COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX00033960 


>j'WlW'' 


R^^\ 


Columtiia  ®[nibergitp 


\^0^ 


department  of  ^urgerp 
iSuU  iilemorial  Jf  unb 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/modernsurgerygen1903daco 


MODERN  SURGERY 

GENERAL  AND  OPERATIVE 


JOHN  CHALMERS  DA  COSTA,  M.D. 

PROFESSOR  OF  THE    PRINCIPLES  OF   SURGERY    AND    OF   CLINICAL  SURGERY,    JEFFERSON 

MEDICAL   COLLEGE,    PHILADELPHIA;    SURGEON   TO  THE   PHILADELPHIA 

HOSPITAL   AND   TO  ST.    JOSEPH'S    HOSPITAL,    PHILADELPHIA 


Fourth  Edition,  Rewritten  and  Enlarged 

with 
707  Illustrations,  some  of  them  in  Colors 


PHILADELPHIA,    NEW   YORK.    LONDON 

W.    B.    SAUNDERS   &   COMPANY 
1903 


Set  up,  electrotyped.  printed,  and  copyrighted  October,  1894.    Reprinted  March,  1895,  and  August,  1896. 
Revised,  entirely  reset,  reprinted,  and  recopyrighted,  June,  1898.     Reprinted  October, 
1898,  and  June,  1899.      Revised,  reprinted,  and  recopyrighted  August, 
1900.    Reprinted  August,  1901 ;  August,  1902,  and  Novem- 
ber, 1902.    Revised,  entirely  reset,  reprinted, 
and  recopyrighted,  August,  1903. 


Copyright,   1903,   by  W.    B.    Saunders   &   Company 


Registered  at  Stationers'  Hall,  London,  England. 


THIS   VOLUME   IS 
DEDICATED,   WITH   AFFECTIONATE   REGARD,    TO 

DR.  ORVILLE    HORWITZ, 

THE  FELLOW-STUDENT,   THE   HOSPITAL  ASSOCIATE,   AND 
THE  TRUSTED   FRIEND   OF 

THE  AUTHOR. 


PREFACE  TO  THE  FOURTH  EDITION 


The  progress  of  surgery  in  ever}-  department  is  one  of  the  most  notable 
phenomena  of  the  present  day.  The  third  edition  of  this  book  was  pubHshed 
in  I  goo,  but  numerous  improvements,  discoveries,  and  observations  made 
since  that  date  render  a  new  edition  necessary.  The  entire  book  has  been 
revised  and  much  new  matter  has  been  added. 

The  author  regrets  that  in  the  section  on  spinal  anesthesia  he  failed  to 
record  the  observation  from  which  the  method  really  springs.  This  observa- 
tion was  made  by  Dr.  J.  Leonard  Corning,  of  New  York,  in  1S85  ("N.  Y. 
Med.  Jour., "  Oct.  31,  1885).  He  discovered  that  cocain  injected  between  the 
spines  of  the  eleventh  and  twelfth  dorsal  vertebrae  produced  analgesia  of  the 
limbs. 

The  author  wishes  to  record  his  gratitude  to  the  late  Mr.  T.  F.  Dagney, 
of  the  firm  of  W.  B.  Saunders  and  Co.,  for  generous  and  invaluable  aid  during 
the  course  of  many  months,  and,  further,  to  express  his  grief  and  sense  of 
personal  loss  at  the  untimely  death  of  this  brilliant  and  lovable  young  man. 

2045  Walnut  Street,  Philadelphia, 
September,  igo^. 


PREFACE  TO  THE  FIRST  EDITION 


The  aim  of  this  Manual  is  to  present  in  clear  terms  and  in  concise  form 
the  fundamental  principles,  the  chief  operations,  and  the  accepted  methods 
of  modern  surgery.  The  work  seeks  to  stand  between  the  complete  but 
cumbrous  text-book  and  the  incomplete  but  concentrated  compend. 

Obsolete  and  unessential  methods  have  been  excluded  in  favor  of  the 
living  and  the  essential.  There  has  been  no  attempt  to  exploit  fanciful  theories 
nor  to  defend  unprovable  hypotheses,  but  rather  the  effort  has  been  to  present 
the  subject  in  a  form  useful  alike  to  the  student  and  to  the  busy  practitioner. 

The  opening  chapter  is  devoted  to  Bacteriology  because  the  author  pro- 
foundly believes  that  without  some  knowledge  of  the  vital  principles  of  this 
branch  of  science  the  vast  importance  of  its  truths  will  be  ill-appreciated,  and 
there  will  be  inevitable  failure  in  the  application  of  aseptic  and  antiseptic 
methods. 

Ophthalmology,  gynecology,  rhinology,  otology,  and  laryngology  have 
not  been  considered,  because  of  the  obvious  fact  that  in  the  advanced  state  of 
specialized  science  only  the  specialist  is  competent  to  write  upon  each  of  these 
branches. 

In  Orthopedic  Surgery  are  discussed  those  conditions  which  must  in  the 
verv  nature  of  things  often  be  cared  for  by  the  surgeon  or  the  general  prac- 
titioner (such  as  hip-joint  disease,  club-foot.  Pott's  disease  of  the  spine,  liat- 
foot,  etc.).  The  limited  space  at  command  precluded  the  introduction  of  a 
special  division  on  diseases  of  the  female  breast.  A  large  amount  of  space 
has  been  devoted  to  Fractures  and  Dislocations,  the  enormous  practical  im- 
portance of  these  subjects  calhng  for  their  full  discussion.  Operative  Sur- 
gery is  considered  in  separate  sections,  the  most  important  procedures  being 
fully  described,  giving  also  the  instruments  necessary,  and  the  positions  as- 
sumed by  patient  and  operator.  This  method  has  been  adopted  to  fit  the 
work  for  use  in  surgical  laboratories. 

Many  systems,  manuals,  monographs,  lectures,  and  journal  articles  have 
been  consulted,  and  credit  has  been  given  in  the  te.xt  for  statements  and  quota- 
tions. Special  acknowledgment  is  due  to  the  American  Text-Book  of  Surgery, 
edited  by  Keen  and  White;  to  the  surgical  works  of  Ashhurst,  Agnew,  the 
elder  Gross,  Duplay  and  Reclus,  Esmarch,  Albert,  Koenig,  Wyeth,  and 
Brvant;  to  the  Manual  of  Surgery,  edited  by  Treves;  to  the  International 
Encyclopo'dia  of  Surgery,  edited  by  Ashhurst;  to  the  Surgical  Pathology  of 
Billroth  and  of  Bowlby;  to  the  Diagnosis  of  A.  Pearce  Gould;  to  the  Surgical 
Dictionary  of  Heath;  to  the  Rest  and  Pain  of  Hilton;  to  the  works  on  opera- 
tive surgerv  of  Barker,  Jacobson,  Treves,  Stephen  SmHh,  and  Joseph  Bell; 
to  the  Minor  Surgery  of  Wharton;  to  the  dictionary  of  Foster  and  of  Gould; 
to  the  Principles  oj  Surgery  of  Senn;  to  the  orthopedic  writings  of  Sa\Te; 


12  Preface  to  the  First  Edition 

to  the  work  on  Diseases  of  the  Male  Generative  Organs  of  Jacobson;  to  the 
System  oj  Genito-urinary  Diseases,  edited  by  Morrow;  and  to  the  treatises  on 
Fractures  and  Dislocations  of  Sir  Astley  Cooper,  Malgaigne,  Hamihon,  Stim- 
son,  and  T.  Pickering  Pick. 

The  Author  returns  his  thanks  to  the  numerous  writers  who  courteously 
authorized  the  reproduction  of  special  illustrations,  and  particularly  to  Pro- 
fessors Keen  and  White  for  their  free  permission  to  draw  upon  the  American 
Text-Book  of  Surgery,  from  which  a  number  of  pictures  have  been  taken, 
distinctively  those  referring  to  Bandaging;  to  Mr.  John  Vansant  for  the 
great  amount  of  labor  so  ably  and  cheerfully  performed;  and  to  Dr.  Howard 
Dehoney  for  the  preparation  of  the  Index. 


CONTENTS 


PAGE 

I.  Bacteriology 17 

II.  Asepsis  and  Antisepsis 42 

III.  Inflammation 57 

IV.  Repair 92 

V.  Surgical   Fevers 105 

VI.  Suppuration  and  Abscess 109 

VII.  Ulceration  and  Fistula 12S 

VIII.  Mortification  or  Gangrene 138 

IX.  Thrombosis  and  Embolism 155 

X.  Septicemia  and  Pyemia 161 

XI.  Erysipelas  (St.  Anthony's  Fire) 166 

XII.  Tetanus  or  Lockjaw 170 

XIII.  Tuberculosis  and  Scrofula 177 

XIV.  Rickets 187 

XV.  Contusions  and  Wounds 191 

XVI.  Syphilis 223 

XVII.  Tumors,  or  Morbid  Growths 244 

XVIII.  Diseases  and  Injuries  of  the  Heart  and  Vessels 283 

1.  Hemorrhage  or  Loss  of  Blood _ 308 

2.  Operations  on  the  Vascular  System 32S 

3.  Ligation  of  Arteries  in  Continuity 334 

XIX.  Diseases  and  Injuries  of  Bones  and  Joints 364 

1.  Diseases  of  the  Bones 364 

2.  Fractures 377 

3.  Diseases  of  the  Joints 469 

4.  Luxations  or  Dislocations 499 

5.  Operations  upon  Bones 528 

XX.       Diseases  and  Injuries  of  Muscles,  Tendons,  and  Burs.e 553 

Operations  upon  Muscles  and  Tendons 565 

XXI.  Orthopedic  Surgery 569 

XXII.  Diseases  and  Injuries  of  Nerves 577 

1.  Diseases  of  Nerves 577 

2.  Wounds  and  Injuries  of  Nerves 578 

3.  Operations  upon  Nerves 586 

XXIII.  Diseases  and  Injuries  of  the  Head 595 

1.  Diseases  of  the  Head 595 

2.  Injuries  of  the  Head 602 

XXIV.  Surgery  of  the  Spine 635 

XXV.  Surgery  of  the  Respiratory  Organs 655 

1.  Diseases  and  Injuries  of  the  Nose  and  Antrum 655 

2.  Diseases  and  Injuries  of  the  Larynx  and  Trachea 656 

3.  Operations  on  the  Larynx  and  Trachea 659 

4.  Diseases  and  Injuries  of  the  Chest,  Pleura,  and  Lungs 661 

5.  Operations  on  Pleura  and  Lung 671 


14  Contents 

PAGE 

XXVI.  Diseases  and  In'jueies  of  the  Upper  Digestive  Tract 677 

XXVII.  Dise.ases  and  Injuries  of  the  Abdomen 695 

1.  Stomach  and  Intestines 704 

2.  The    Peritoneum 740 

3.  The  Liver  and   Gall-bladder 747 

4.  The  Pancreas 764 

5.  The  Spleen 770 

6.  Operations  upon  the  Abdomen 772 

XXVIII.  Diseases  and  Injuries  of  the  Rectum  and  Anus - 851 

XXIX.  Anesthesia  and  Anesthetics 869 

XXX.  Burns  and  Scalds 892 

XXXI.  Diseases  of  the  Skin  and  Nails 896 

XXXII.  DisE.'^sES  -AND  Injuries  of  the  Thyroid  Gland 900 

XXXIII.  Diseases  .and  Injuries  of  the  Lymphatics 909 

XXXIV.  B.^nd.ages 913 

XXXV.  PL.A.STIC  Surgery 922 

XXXVI.  Diseases  and  Injuries  of  the  Genito-urinary  Organs 927 

1.  Diseases  and  Injuries  of  the  Kidney  and  Ureter 933 

2.  Diseases  and  Injuries  of  the  Bladder    953 

3.  Diseases  and  Injuries  of  the  Urethra,  Penis,  Testicles,  Prostate, 

Seminal  Vesicles,  Prostatic  Cord,  and  Tunica  Vaginalis 976 

XXXVn.  Amputations 1023 

Special  Amputations 1028 

XXXVIII.  Diseases  of  the  Breast 1046 

XXXIX.  Skiagraphy,  or  the  Employment  of  the  Rontgen  Rays 1057 

XL.  Injuries  by  Electricity 1067 


INDEX 1071 


MODERN    SURGERY 


MODERN  SURGERY. 


I.   BACTERIOLOGY. 

Bacteriology  is  the  science  of  micro-organisms.  Though  a  science  in 
the  youth  of  its  years,  bacteriology  has  not  only  profoundly  altered,  but  it 
has  also  revolutionized,  pathology,  and  our  views  of  surgery  would  be  in- 
complete, misleading,  and  erroneous  without  its  aid. 

Micro=organisms,  or  microbes,  are  minute  non-nucleated  vegetable 
cells  closely  connected  with  fungi  and  algae,  many  of  them  being  visible  only 
by  means  of  a  highly  powerful  microscope  and  after  they  have  been  brightly 
stained.  The  contents  of  these  cells  are  protoplasm  and  nuclear  chromatin 
enclosed  by  a  structure  containing  cellulose. 

Even  in  the  most  remote  times  some  have  believed  that  "the  mysterious 
cause  of  contagious  and  epidemic  diseases  must  be  sought  in  living  entities" 
(Monti  on  "  Modern  Pathology  ") .  Bacteria  were  discovered  by  Leeuwenhoek 
in  1675,  but  definite  knowledge  of  these  minute  bodies  and  of  their  actions 
dates  from  the  study  of  fermentation  by  the  celebrated  Frenchman  Pasteur, 
who  in  1858  asserted  that  every  fermentation  has  invariably  its  specific 
ferment;  that  this  ferment  consists  of  living  cells;  that  these  cells  produce 
fermentation  by  absorbing  the  oxygen  of  the  substance  acted  upon;  that 
putrefaction  is  caused  by  an  organized  ferment;  that  all  organized  ferments 
are  carried  about  in  the  air;  and  that  entirely  to  exclude  air  prevents  putre- 
faction or  fermentation. 

In  i860  Pasteur  published  the  observation  that  sterile  liquids  will  not 
be  contaminated  by  air  if  the  air  gains  entry  only  through  a  long  curved 
tube,  the  reason  being  that  dust  and  growths  fall  from  the  entering  air  by 
gravity  ("  Comptes  rendus,"  i860). 

In  1863  Pasteur  published  his  experiments  which  proved  that  beer  cannot 
ferment  without  yeasts  and  that  wine  received  in  sterile  vessels  and  kept 
from  external  contamination  will  not  undergo  ammoniacal  change. 

The  views  of  Pasteur,  which  were  radical  departures  from  accepted  belief, 
inaugurated  a  bitter  controversy,  and  in  that  controversy  were  born  the 
microbic  theory  of  disease,  the  doctrine  of  preventive  inoculation,  antiseptic 
surgery,  and  serum-therapy. 

The  word  microbe,  which  signifies  a  small  li\ing  being,  was  introduced 
in  1878  by  the  late  Professor  Sedillot,  of  Paris.  At  that  time  the  nature  of 
these  bodies  was  in  doubt;  some  thought  them  animal,  and  called  them 
tnicrozoarici;  others  thought  them  vegetable,  and  called  them  micro pJi via:  the 
designation  "  microbe"  does  not  commit  us  to  either  view.  We  now  know 
them  to  be  vegetable,  but  the  term  "microbe"  has  remained  in  use. 

The  micro-organisms  connected  with  disease  in  man  are  divided  into: 

I.  Yeasts,  Saccharomyces,  or  Blastomycetes; 
2  17 


1 8  Bacteriology 

2.  Moulds,  or  Hyphomycetes ; 

3.  Bacteria,  or  Schizomycetes. 

Yeasts  or  budding  fungi  include  most  of  those  fungi  which  can  cause 
alcoholic  fermentation  in  saccharine  matter.  They  consist  of  small  cells 
which  can  live  without  free  oxygen,  and  which  multiply  by  gemmation  or 
budding.  When  a  cell  multiplies  a  small  bud  of  protoplasm  projects  from 
or  near  the  end  of  the  cell.  This  bud  increases  progressively  in  size  and  a 
constriction  appears  between  the  bud  and  the  parent-cell.  The  constriction 
deepens  as  the  projection  enlarges,  until  the  bud  attains  the  size  of  the  parent. 
Thus  a  chain  or  series  of  rounded  yeast-cells  is  formed.  These  cells  contain 
spores  when  nourishment  is  insufficient.  Under  certain  conditions  yeast 
fungi  can  form  mycelial  threads. 

Moulds  or  filamentous  fungi  consist  of  filaments,  each  filament  being 
composed  of  a  single  row  of  cells  arranged  end  to  end,  and  all  filaments 
springing  from  a  germinal  tube  which  grows  from  a  germinating  spore.  The 
yeast  fungi  are  the  common  but  not  the  only  cause  of  fermentation.  Mould 
fungi  are  connected  with  processes  of  decomposition.  Putrefaction  is  due 
to  bacteria  and  retards  the  growth  of  yeasts  and  moulds. 

Most  yeasts  and  moulds  grow  best  upon  dead  organic  matter,  some  attack 
plants,  a  few  the  lower  animals,  and  a  very  few  grow  upon  or  in  the  tissues 
of  the  human  body. 

The  oidiiim  albicans  is  a  yeast  fungus  which  by  growing  in  the  mucous 
membrane  produces  the  disease  known  as  thrush.  This  disease  attacks 
especially  the  mucous  membrane  of  the  mouth  and  pharynx,  but  occasionally 
the  growth  takes  place  upon  the  esophagus,  the  vocal  cords,  the  stomach, 
the  vagina,  the  respiratory  tract,  and  the  areola  of  the  breast  of  a  nursing 
woman.  The  prohferating  fungus  presents  the  appearance  of  milky  white 
spots  which  by  thickening  and  coalescence  form  curd-like  masses,  the  super- 
ficial layer  of  epithelium  being  raised  and  cast  off. 

Blastomycetes  dermatitis  is  an  inflammation  of  the  skin  due  to  yeast  fungi 
and  bearing  a  resemblance  to  tuberculosis  or  syphilis.  Sanfelice  and  others 
maintain  that  yeasts  are  responsible  for  the  growth  of  malignant  tumors.  It 
is  certain  that  yeasts  may  exist  in  a  carcinoma  and  can  be  cultivated,  but 
proof  is  entirely  lacking  that  they  are  anything  but  a  contamination.  Many 
skin  diseases  are  due  to  fungi;  among  them  should  be  mentioned:  Favus,  pityr- 
iasis versicolor,  herpes  tonsurans,  parasitic  sycosis,  and  eczema  marginatum. 

Actinomycosis  is  due  to  the  ray  fungus 
(see  page  221).  It  is  uncertain  in  which 
group  the  ray  fungi  should  be  placed;  it  is 
quite  certain  that  more  than  one  variety 
exists,  and  they  seem  to  occupy  a  place 
between  moulds  and  bacteria.  Madura- 
joot,  or  mycetoma,  is  due  to  the  streptothrix 

Fig.  I.— Actinomyces  (Ziegler).  Madurcc. 

Schizomycetes  or  bacteria  chiefly  claim 
our  attention.  It  is  important  to  remember  that  the  term  "bacteria," 
though  applied  to  the  class  schizomycetes,  has  also  a  more  restricted  ap- 
plication— that  is,  to  a  division  of  the  class;  it  may  mean  either  schizo- 
mycetes in  general,  or  rod-shaped  schizomycetes,  whose  length  is  not  more 


Forms  of  Bacteria  19 

than  twice  their  breadth.  In  this  work  it  is  employed  to  designate  schizo- 
mycetes  as  a  class. 

Bacteria  are  minute,  unbranched,  non-nucleated,  vegetable  cells,  free 
from  chlorophyl,  varying  in  shape  and  occasionally  presenting  locomotive 
flagella.  The  cell  consists  of  a  cell  membrane,  a  layer  of  protoplasm,  and 
some  central  fluid.  No  true  nucleus  has  yet  been  demonstrated,  but  granules 
are  found  within  the  cells  which  some  call  metachromatic  bodies  (Babes) 
and  others  nuclei  (Ernst).  The  cell  membrane  varies  greatly  in  thickness, 
and  when  it  is  very  thick  the  cell  is  said  to  have  a  capsule.  The  round  cells 
have  a  smooth  outer  surface,  but  some  of  the  rod-shaped  cells  show  many 
flagella  or  at  the  end  a  single  flagellum.  Flagella  enable  some  bacteria  to 
move  (motile  bacteria),  but  all  organisms  which  contain  them  are  not  motile, 
and  under  certain  conditions  bacteria  without  flagella  may  develop  them,  or 
organisms  which  possess  flagella  may  lose  the  power  to  develop  them. 

Some  of  the  schizomycetes  induce  certain  fermentations;  others  grow  upon 
dead  organic  matter,  but  are  not  able  to  invade  living  tissues,  and  are  called 
saprophytes  or  non- pathogenic  bacteria;  still  others,  known  as  the  pathogenic, 
invade  living  tissue  and  cause  various  diseases.  Parasitic  bacteria  can  grow 
on  or  in  the  tissues  of  the  body.  Obligate  parasites  are  those  which  have  not 
been  cultivated  outside  of  the  body  (as  the  bacilli  of  leprosy).  Facultative 
parasites  usually  live  outside  the  body,  but  may  enter  into  the  body  and 
produce  disease.  The  schizomycetes  vary  much  in  shape,  size,  color,  arrange- 
ment, mode  of  growth,  and  action  upon  the  body.  One  form  cannot  be 
transformed  into  another,  but  each  maintains  its  specific  identity.  Every 
organism  comes  from  a  pre-existing  organism,  this  being  true  of  all  forms. 
Pasteur  proved  that  spontaneous  generation  is  impossible.  The  protoplasm 
of  these  cells  can  be  stained  with  anilin  colors,  and  the  cell-wall  is  more 
readily  detected  after  treating  it  with  water,  which  causes  it  to  swell. 

Many  bacteria  are  colored;  others  are  colorless.  Some  move  {motile 
bacteria);  others  do  not  move  (amotile  bacteria).  The  bacilli  of  anthrax 
and  tuberculosis  and  all  cocci  are  amotile.  Most  bacteria  can  change  from 
motile  to  amotile,  or  from  amotile  to  motile,  when  subjected  to  certain  changes 
of  soil  and  environment.  The  oscillations  of  cocci  are  physical  in  nature, 
not  vital;  they  are  Brunonian  or  Brownian  movements,  movements  due  to 
alterations  in  equilibrium  because  of  currents  or  changes  of  level  in  the  fluid 
in  which  the  micro-organisms  are  contained.  Bacteria  seem  to  possess  the 
power  of  attracting  elements  necessary  for  their  nutrition  (positive  cJiemiotaxis 
or  chemotaxis)  and  of  repeUing  harmful  elements  (negative  chemiotaxis  or 
chemotaxis) . 


Fig.  2. — Micrococcus.  Fig.  3. — Bacillus.  Fig.  4. — Spirillum. 

Forms  of  Bacteria. — The  three  chief  forms  of  bacteria  are— 
I.  The  Coccus  or  Micrococcus — berry-shaped,  oval,  or  round  bacterium 
(Fig.  2); 


20 


Bacteriology 


2.  The  Bacillus — rod-shaped  bacterium  (Fig.  3); 

3.  The  Spirillum  or  Vibrio — corkscrew-shaped  or  spiral  bacterium  (Fig. 
4).     A  short  spiral  organism  is  called  a  comma  bacillus. 

De  Bary  compares  these  forms,  respectively,  to  the  billiard-ball,  the  lead- 
pencil,  and  the  corkscrew. 

Cocci  and  Bacilli. — We  have  to  do  only  with  cocci  and  bacilli.  Cocci 
may  be  designated  according  to  their  arrangement  with  one  another;  namely, 
when  existing  singly  they  are  called  monococci;  in  pairs  they  are  called  diplo- 
cocci  (Fig.  5,  a);  arranged  end  to  end  in  a  chain  they  are  called  streptococci 
(Fig.  5,  c) ;  in  a  group  side  by  side  clustered  like  a  bunch  of  grapes  they  are 
called  staphylococci  (Fig.  5,  b)  ;  in  groups  of  four  they  are  called  plate  cocci, 
tetracocci:  in  cubical  groups  they  are  called  sarcince  or  wool-sack  cocci.  Irregu- 
lar masses,  resembling  frog-spawn,  constitute  zooglea  masses  (Fig.  6).  The 
gelatinous  matter  in  such  a  mass  is  formed  by  a  transformation  in  the  walls 
of  the  bacteria.  The  term  ascococci  is  applied  to  a  group  of  cocci  enclosed 
in  a  capsule  (G.  S.  Woodhead). 


^m. 


.^"""^^i^^ 


''  J 


Fig.  5. — Forms  of  cocci. 


Fig.  6.— Zooglea  (Ball). 


The  cocci  are  often  named  according  to  their  function,  as,  for  example, 
"pyogenic,"  or  pus-forming.  Cocci  may  be  named  according  to  the  color  of 
the  culture.  The  name  may  embody  the  form,  arrangement,  color,  and 
function;  for  instance.  Staphylococcus  pyogenes  aureus  signifies  a  round, 
golden-yellow  micro-organism,  which  arranges  itself  with  its  fellows  in  the 
form  of  a  bunch  of  grapes,  and  which  produces  pus. 

The  bacilli  are  long,  staff-shaped  organisms.  Long,  delicate,  jointed 
bacilli  having  wavy  outlines  are  known  as  leptolhrix  forms.  Chain-like 
bacilli  are  called  slreplobacilli.     Bacilli  give  origin  to  many  surgical  diseases. 

Multiplication  of  Bacteria.— Bacteria  multiply  with  great  rapidity 
when  placed  under  suitable  conditions.  They  can  multiply  by  fission  or 
by  spore-formation.  Some  bacteria  multiply  by  both  methods.  In  fission, 
or  .segmentation,  a  bacillus  undergoes  an  increase  in  size:  a  coccus  does 
not  increase  in  size  but  elongates.  In  either  case  about  the  middle  of  the 
cell  a  transverse  constriction  begins,  which  deepens  until  the  cell  has  divided 
into  two  parts,  each  of  which  soon  grows  as  large  as  its  parent  (Figs.  7,  8). 
As  a  rule,  the  micro-organisms  separate  after  division  of  the  cell;  but 
they  may  not  do  so;  and  if  they  do  not  separate,  the  special  grouping  receives 


Spores 


21 


a  particular  name  (diplococci,  streptococci,  etc.).  If  the  division  is 
invariably  in  the  same  direction,  and  if  the  new  cells  remain  in  con- 
tact, streptococci  or  streptobacilli  are  formed.  Tetracocci  and  sarcinae  are 
formed  when  a  number  of  cocci  "divide  in  two  or  three  successively 
vertical  directions"  ("Clinical  Bacteriology,"  by  Levy  and  Klemperer), 
forming  four  quadrants   {tetracocci)   or  eight  octants   (sarcince).      All    cocci 


Fig.  8. — Divisions  of  a  bacillus  (after  Mace). 

and  some  bacilli  multiply  by  fission.  If  segmentation  of  a  single  cell  and 
the  growth  to  maturity  of  its  products  require  one  hour  (it  really  takes  place 
in  less  time,  the  cholera  bacillus  requiring  but  twenty  minutes  to  divide),  a 
single  cell  in  a  single  day,  if  the  conditions  for  increase  were  ideally  favorable, 
would  have  sixteen  million  descendants,  and  in  three  days  the  mass  of  new 
cells  would  weigh  7500  tons  (Cohn).  In  order,  however,  for  such  enormous 
multiplication  to  occur  conditions  would  have  to  be  absolutely  favorable  to 
the  cells,  and  conditions  are  never  absolutely  favorable.  Were  it  otherwise, 
all  other  forms  of  life  would  be  destroyed. 

Spores. — A  spore  is  a  germ,  and  corresponds  with  the  seed  of  a  plant. 
Some  bacilli,  a  few  spirilla,  and  it  may 
be  sarcina;,  multiply  by  spore-formation. 
Cocci  do  not  undergo  spore-formation 
after  the  manner  of  bacilli,  though 
some  observers  maintain  that  cocci 
occasionally  undergo  an  alteration  that 
makes  them  very  resistant  to  any 
destructive  influences  (arthros  pores). 
When  spore-formation  is  about  to  occur 
in  a  bacillus,  a  point  of  cloudiness  or 
an  area  of  bright  refraction  appears 
in  the  protoplasm  and  the  cell  generally 
elongates.  When  a  row  of  cells  sporu- 
late,  the  segments,  each  of  which  con- 
tains a  lustrous  area  or  a  region  of 
cloudiness,  look  like  parts  of  a  necklace 

of  beads  (Fig.  9).  The  spore  enlarges,  the  spore  membrane  bursts,  and  the 
young  bacillus  emerges  through  the  opening.  A  cell  usually  contains  but 
one  spore,  which  may  be  situated  at  the  end  of  the  cell  (endspore)  or  in  the 
middle  of  the  cell  (endospore).     Sometimes   a  single  cell  contains    several 


Fig.  9. — Sporulation  (after  De  Barj-). 


22  Bacteriology 

spores.  If  an  endspore  exists,  the  end  of  the  cell  containing  the  spore 
is  swollen  or  club-shaped  {drumstick  bacterium).  If  an  endospore  exists, 
the  cell  becomes  spindle-shaped  {Clostridium).  When  multiplication  is  by  a 
single  endospore,  the  bacillus  does  not  elongate.  When  multiplication  takes 
place  by  a  process  of  combined  spore-formation  and  fission,  the  mother-cell 
divides  into  a  number  of  daughter-cells,  which  are  called  arthrospores.  Organ- 
isms which  when  active  multiply  by  fission  take  on  spore-formation  when 
subjected  to  certain  conditions. 

Spore-formation  tends  to  occur  when  bacilli  are  about  to  die  for  want 
of  nourishment  or  when  there  is  an  excess  of  oxygen  present.  The  spore 
has  a  dense  envelope  or  covering  which  is  very  resistant  to  destructive  agents. 
So  resistant  is  the  covering  that  twice  the  amount  of  heat  is  necessary  to  kill 
a  spore  as  to  kill  an  active  adult  cell.  Spores  when  placed  under  conditions 
unfavorable  for  development  may  remain  inactive  for  an  indefinite  period, 
just  as  seeds  remain  inactive  when  unplanted.  When  spores  encounter 
favorable  conditions,  they  at  once  develop  into  adult  cells,  just  as  seeds 
develop  when  planted.  It  seems  probable  that  spores  occasionally  remain 
dormant  in  the  human  body  for  long  periods,  and  finally  awaken  into  activity 
because  of  injury  or  disease  of  the  tissue  in  which  they  lie. 

Life=COnditions  of  Bacteria. — In  order  to  grow  and  to  multiply, 
bacteria  require  a  suitable  soil  and  the  favoring  influences  of  heat  and  moisture. 
The  soil  demanded  consists  of  highly  organized  compounds  rather  than  crude 
substances,  and  slight  modifications  in  it  may  prove  fatal  to  some  forms  of 
bacterial  life,  but  highly  advantageous  to  others.  Some  organisms  require 
albuminous  matter,  others  need  carbohydrates;  they  all  require  water,  carbon, 
nitrogen,  oxygen,  hydrogen,  and  certain  inorganic  materials,  especially  lime 
and  potassium  (Woodhead).  All  organisms  require  water.  If  dried,  no 
micro-organisms  will  multiply,  and  many  forms  will  die.  The  fluid  and 
tissues  of  the  individual  may  or  may  not  afford  a  favorable  soil  for  the  germs 
of  a  disease,  or,  in  the  same  person,  may  afford  it  at  one  time  and  not  at 
another.  Some  individuals  seem  to  possess  indestructible  immunity  from, 
and  others  are  especially  prone  to,  certain  contagious  diseases.  Impairment 
of  health,  by  altering  some  subtle  condition  of  the  soil,  may  make  a  person 
liable  who  previously  was  exempt. 

The  presence  of  oxygen  influences  microbic  growth.  Most  organisms 
thrive  best  when  exposed  to  the  oxygen  of  the  air,  and  they  are  known  as 
aerobic.  The  term  anaerobic  is  employed  to  designate  organisms  that  can 
grow  and  multiply  and  produce  particular  products  only  when  air  is 
absent,  free  oxygen  being  fatal  to  them.  Tetanus  bacilli  and  the  bacilli  of 
malignant  edema  are  anaerobic.  An  organism  which  can  grow  indifferently 
where  oxygen  is  abundant  or  where  free  oxygen  is  absent  is  called  a  jaculta- 
tive-aerobic  bacterium.  It  may  need  oxygen;  but  if  it  does,  it  is  able  to 
obtain  it  from  the  tissues  when  air  is  excluded.  A  .sensitive  organism  which 
dies  when  the  amount  c)f  oxygen  is  even  slightly  diminished  is  called  an 
obli gate-aerobic  bacterium.  Most  microbic  disea.ses  in  man  are  due  to  facul- 
tative-aerobic bacteria. 

Effect  of  Motion,  Sunlight,  the  X=rays,  Cold,  and  Heat.— The 

majority  of  jun^^i  gnnv  best  when  at  rest;  violent  agitation  retards  the  growth 
of  some.     Sunlight  antagonizes  the  growth  of  certain  bacteria,   especially 


Placental  Transmission  23 

tubercle  bacilli  and  the  bacilli  of  typhoid  fever.  It  is  claimed  by  some  that 
the  .r-rays  retard  bacterial  growth.  Temperature  influences  bacterial  growth. 
Some  organisms  will  grow  only  within  narrow  temperature-limits,  while 
others  can  sustain  sweeping  alterations,  but  most  grow  best  between  the 
limits  of  from  86°  to  104°  F.  Freezing  renders  bacteria  motionless  and 
incapable  of  multiphcation,  but  it  does  not  kill  them:  they  again  become 
active  when  the  temperature  is  raised.  The  absurdity  of  employing  cold 
as  a  germicide  is  evident  when  the  fact  is  known  that  a  temperature  of  200° 
F.  below  zero  is  not  fatal  to  germ-life,  cell-activities  by  such  a  temperature 
only  being  rendered  dormant.  Bacteria  have  been  placed  in  hermetically 
sealed  tubes  and  the  tubes  immersed  in  liquid  air  for  seven  days.  The 
germs  were  thus  subjected  to  a  temperature  of  — 190°  C,  but  there  was  no 
change  produced  in  their  virulence  (A.  MacFayden  and  S.  Roland  in  "  Lancet," 
March  24,  1900).  High  temperatures  are  fatal  to  bacteria;  moist  heat  is 
more  destructive  than  dry  heat,  and  adult  cells  are  more  easily  killed  than 
spores.  A  temperature  less  than  212°  F.  will  kill  many  organisms,  and 
boiling  will  kill  every  pathogenic  organism  that  does  not  form  spores.  Some 
spores  are  not  destroyed  after  prolonged  boiling,  and  some  will  withstand  a 
temperature  of  120°  C.  As  a  practical  fact,  however,  boiling  water  kills  in 
a  few  minutes  all  cocci,  most  bacilli,  and  all  pathogenic  spores;  though  the 
spores  of  anthrax,  tetanus,  and  malignant  edema  are  harder  to  kill  than  are 
the  spores  of  other  bacteria. 

Effect  of  Bacteria  upon  Bacteria. — Some  bacteria  are  antagonistic 
to  others,  some  are  synergistic  to  others.  The  streptococcus  of  erysipelas  is 
antagonistic  to  the  bacillus  of  anthrax  and  also  to  syphilis,  tuberculosis,  and 
sarcoma.  The  growth  of  some  microbes  in  culture-media  makes  a  soil 
favorable  or  unfavorable  for  other  microbes,  and  the  same  process  may  occur 
in  the  human  body.  We  are  not  yet  able  to  cure  a  microbic  disease  by 
inoculating  the  sufferer  with  antagonistic  microbes,  on  the  principle  of 
sending  a  thief  to  catch  a  thief. 

Mixed  Infection. — A  fact  of  practical  importance  to  the  surgeon  is 
that  an  area  infected  by  one  form  of  micro-organism  may  be  invaded 
by  another  form.  This  is  known  as  a  mixed  infection,  and  consists  in  a 
primary  infection  with  one  variety  of  organism,  and  a  secondary  infection  with 
another,  or  in  an  infection  at  the  same  time  with  different  micro-organisms. 
Koch  found  both  bacilli  and  micrococci  in  the  same  lesion  of  tuberculosis. 
A  soil  filled  with  pneumococci  favors  the  growth  of  pus  cocci  and  tubercle 
bacilli.  Tuberculous  or  syphilitic  lesions  may  be  attacked  by  erysipelas. 
Chancre  and  chancroid  can  exist  together.  A  syphilitic  ulcer  is  a  good 
cuiture-soil  for  tubercle  bacilli  (Schnitzler).  Suppuration  in  lesions  of 
tuberculosis  is  due  to  secondary  infection  with  pus  organisms.  Occasionally 
in  empyema  and  other  conditions  pus  organisms  may  have  lost  much  of 
their  virulence,  but  a  mixed  infection  with  some  germ  usually  harmless  mav 
break  down  surrounding  barriers  and  intensify  the  virulence  of  bacteria. 

Placental  Transmission. — The  direct  transmission  of  bacteria  from 
parent  to  fetus  is  a  problem  still  in  course  of  solution.  Certain  it  is  that 
some  diseases  (as  syphilis)  are  due  to  the  direct  carrying  of  the  microbes  by 
sperm-cell  to  germ-cell,  or  to  the  transmission  of  the  micro-organism  through 
the  septum  of  separation  between  the  circulations  of  the  mother  and  child. 


24  Bacteriology 

In  many  other  diseases  the  microbe  is  not  directly  transmitted  (as  in  phthisis), 
but  a  patient  born  with  weakened  tissue-cells  is  prone  to  fall  a  prey  to  the 
latter  malady. 

Chemical  Antiseptics  and   Germicides.— It  is  necessary  to  make 

a  distinction  between  deodorizers,  antiseptics,  and  germicides. 

A  deodorizer  is  an  agent  which  destroys  an  offensive  odor.  It  is  true  that 
an  offensive  odor  may  be  due  to  microbic  growth.  It  is  also  true  that  nasty 
odors  may  prove  injurious  to  those  who  inhale  them.  But,  nevertheless,  the 
odor  is  the  result  of  microbic  action,  and  destroying  an  odor  does  not  render 
harmless  the  bacteria  which  caused  it.     Charcoal  is  a  well-known  deodorizer. 

An  antiseptic  is  an  agent  which  retards  or  prevents  putrefaction.  It  acts 
by  weakening  or  killing  saprophytic  organisms,  but  is  not  fatal  to  spores. 

A  germicide  or  disinfectant  is  an  agent  which  is  fatal  to  adult  bacteria 
and  spores.  The  destruction  of  the  germs  of  the  disease  in  clothing,  in 
excreta,  in  a  wound,  etc.,  is  known  as  disinfection.  Disinfection  of  a  wound, 
dressings,  or  instruments  is  called  also  sterilization. 

Antiseptics  and  germicides  should  not  be  used  in  clean  wounds.  Repair 
will  occur  more  quickly  if  they  are  not  used.  Tillmanns  has  pointed  out 
that  when  antiseptics  are  used  cell-division  is  late  in  beginning  and  is  slow 
in  progress.  Neither  should  they  be  used  in  fatty  tissue,  as  bacteria  sur- 
rounded with  oil  cannot  be  reached  by  the  drug,  and  the  chemical  is  irritant 
and  apt  to  cause  fat  necrosis  (Haenel,  in  "  Deutsch.  med.  Woch.,"  1895, 
No.  8). 

Corrosive  Sublimate. — Many  chemical  agents  will  kill  bacteria,  one  of 
the  most  certain  of  them  all  being  corrosive  sublimate.  Koch  showed  that 
corrosive  sublimate  is  an  efficient  test-tube  germicide  when  present  in  the 
proportion  of  only  i  part  to  50,000.  It  is  used  in  surgery  in  strengths  of  i 
part  of  the  salt  to  1000,  2000,  3000,  or  more  parts  of  water.  Badly  infected 
wounds  are  occa.sionally  irrigated  with  solutions  of  a  strength  of  i  to  500. 
Contact  with  albumin  precipitates  from  a  solution  of  corrosive  subhmate  an 
insoluble  albuminate  of  mercury  which  forms  a  white  layer  upon  the  surface 
of  the  wound,  is  not  a  germicide,  and  prevents  deep  diffusion  of  the  mer- 
curial fluid.  In  surgical  operations  by  the  antiseptic  method  the  mercurial 
salt  should  be  combined  with  tartaric  acid  in  the  proportion  of  i  to  5, 
which  combination  prevents  the  formation  of  the  insoluble  albuminate  of 
mercury. 

But  though  corrosive  sublimate  under  certain  conditions  is  e.xtremely  pow- 
erful, it  is  not  always  absolutely  reliable.  Many  spores  are  very  resistant  to  its 
action.  Even  a  i  per  cent,  solution  of  bichlorid  of  mercury  is  not  certainly 
destructive  of  the  spores  of  anthrax.  Geppert  tells  us  that  anthrax-spores 
may  be  active  after  a  twenty-five-hour  immersion  in  a  i  :  100  solution  of 
sublimate  (Schimmelbusch).  In  the  presence  of  hydrogen  sulphid  corrosive 
sublimate  is  useless,  inert  and  insoluble  sulphid  of  mercury  being  precipitated; 
hence  corrosive  sublimate  is  without  value  as  a  rectal  antiseptic;  in  fact, 
Gerloczy  has  proved  that  a  concentrated  aqueous  solution  of  sublimate  will 
not  disinfect  an  equal  quantity  of  feces.  Corrosive  sublimate  contained  in 
dressings  after  a  time  undergoes  decomposition  and  ceases  to  be  a  germicide. 
It  is  not  germicidal  in  fatty  tissues  because  it  is  unable  to  attack  bacteria 
which  are  coated  with  oil.     Corrosive  sublimate  is  very  irritating  to  the  tissues 


Carbolic  Acid  25 

and  causes  copious  exudation.  Hence,  after  tissues  have  been  irrigated  with 
this  agent  drainage  must  be  employed.  In  some  cases  the  irritated  tissues 
lose  to  a  great  extent  their  power  of  resistance,  and  infection  may  be  actually 
facilitated  by  irrigation  with  sublimate.  In  rare  instances  corrosive  sublimate 
is  absorbed  and  produces  poisoning.  In  spite  of  these  shortcomings  and 
drawbacks  it  is  a  valuable  aid  to  the  surgeon  and  must  be  frequently  used, 
especially  upon  the  skin  of  the  patient  and  the  hands  of  the  operator  and  his 
assistants.  It  should  be  dissolved  in  distilled  water,  because  ordinary  water 
causes  a  precipitate  to  form  (common  salt  prevents  the  formation  of  this 
precipitate). 

Because  of  the  fact  that  corrosive  subhmate  is  poisonous  and  very  irritant, 
it  should  not  be  used  upon  serous  membranes.  It  is  absorbed  quickly  from 
serous  membranes  and  destroys  the  endothehal  cells,  and  should  not  be 
introduced  into  the  pleural  sac,  into  joints,  or  into  the  peritoneal  cavity. 
It  should  never  be  put  within  the  dura,  and  should  not  be  apphed,  in  strong 
solution  at  least,  to  mucous  membranes.  It  is  better  to  make  the  solution 
when  it  is  needed,  so  as  to  have  it  fresh,  for  in  old  solutions  much  of  the 
soluble  corrosive  sublimate  has  been  converted  into  insoluble  oxychlorid,  and 
the  fluid  has  ceased  to  be  germicidal.  In  order  to  make  up  fresh  solutions 
use  tablets,  each  of  which  contains  about  7^  grains  of  the  drug — one  of  these 
tablets  added  to  a  pint  of  water  makes  a  solution  of  a  strength  of  i  to  1000. 
Tablets  which  also  contain  ammonium  chlorid  are  more  soluble  than  those 
which  contain  corrosive  sublimate  only.  Hot  solutions  of  the  drug  are  more 
powerfully  germicidal  than  cold  solutions.  As  corrosive  sublimate  is  irritant, 
leads  to  profuse  exudation,  and  may  produce  tissue-necrosis,  it  should  never 
be  introduced  into  an  aseptic  wound.  In  such  a  wound  it  can  do  no  good 
and  may  do  much  harm. 

Griffin,  in  Foster's  "Practical  Therapeutics,"  sets  forth  the  strengths  of 
solutions  applicable  to  different  regions: 

For  disinfection  of  the  surgeon's  hands  and  the  patient's  skin,  i  :  1000; 
for  irrigating  trivial  wounds,  i  :  2000;  for  irrigating  larger  wounds  and 
cavities,  i  :  10,000  to  i  :  5000;  for  irrigating  vagina,  i  :  10,000  to  i  :  5000; 
for  irrigating  urethra,  i  :  40,000  to  i  :  20,000;  for  irrigating  conjunctiva, 
I  :  5000;   for  gargling,  i  :  ic,ooo  to  i  :  5000. 

Instruments  cannot  be  placed  in  corrosive  sublimate  without  being  dulled, 
stained,  and  corroded. 

Corrosive  Sublimate  Poisoning. — Corrosive  sublimate  may  be  absorbed 
from  a  wound,  a  serous  surface,  or  a  mucous  membrane,  ptyalism  and  diar- 
rhea resulting.  The  absorption  of  bichlorid  of  mercury  may  be  followed  by 
cramp  in  the  limbs  and  belly,  feeble  pulse,  cold  skin,  extreme  restlessness,  and 
even  collapse  and  death.  At  the  first  sign  of  trouble  withdraw  the  drug  and 
treat  the  ptyalism  (page  238). 

Carbolic  acid  is  a  valuable  germicide  in  the  strength  of  from  i  :  40  to 
I  :  20.  It  is  certainly  fatal  to  pus-organisms,  but  weak  solutions  fail  to  kill 
most  bacteria  and  do  not  destroy  spores.  Unfortunately,  this  acid  attacks 
the  hands  of  the  surgeon;  consequently  in  the  United  States  it  is  chiefly  em- 
ployed as  an  antiseptic  medium  in  which  to  place  the  sterilized  operating- 
instruments,  or  as  a  germicide  to  prepare  the  skin  of  the  patient  before  the 
operation  is  performed. 


26  Bacteriology 

Carbolic  Acid  Poisoning. — Carbolic  acid  is  very  irritant  to  tissues, 
and  carbolized  dressings  may  be  responsible  for  sloughing  of  the  wound 
or  dry  gangrene.  Because  of  its  irritant  properties  wounds  which  have 
been  irrigated  with  it  should  be  well  drained.  Carbolic  acid,  like  cor- 
rosive sublimate,  is  inert  in  fatty  tissues.  Carbolic  acid  is  readily 
absorbed,  and  may  thus  produce  toxic  symptoms.  Absorption  is  not 
uncommon  when  the  weaker  solutions  are  used,  but  rarely  occurs  when 
a  wound  has  been  brushed  over  with  pure  acid,  because  the  pure  acid 
at  once  forms  an  extensive  zone  of  coagulation,  which  acts  as  a  barrier 
to  absorption.  One  of  the  early  indications  of  the  absorption  of  carbolic 
acid  is  the  assumption  by  the  urine  of  a  smoky,  greenish,  or  blackish 
hue.  This  hue  appears  a  little  time  after  the  urine  has  been  voided,  whereas 
the  smoky  hue  of  hematuria  is  noted  in  urine  at  once  lafter  it  has  been  passed. 
The  condition  produced  by  carbolic  acid  is  known  as  carboluria,  and  exam- 
ination of  such  urine  shows  a  great  diminution  or  entire  absence  of  sulphates 
when  the  acidulated  urine  is  heated  with  chlorid  of  barium.  The  diminution 
of  precipitable  sulphates  is  explained  by  the  fact  that  these  salts  are  combined 
with  carbolic  acid,  forming  soluble  sulphocarbolates  (Griffin).  Such  urine 
is  apt  to  contain  albumin.  If  during  the  use  of  carbolized  dressing  or  the 
employment  of  carbolic  solutions  the  urine  becomes  smoky,  the  use  of  the 
drug  in  any  form  must  be  at  once  discontinued,  otherwise  dangerous  symp- 
toms will  soon  appear.  These  symptoms  are  subnormal  temperature,  feeble 
pulse  and  respiration,  muscular  weakness,  and  vertigo.  If  death  occurs,  it 
is  due,  as  a  rule,  to  respiratory  failure.  The  treatment  of  slow  poisoning 
by  carbolic  acid  consists  in  at  once  withdrawing  the  drug,  giving  stimulants 
and  nourishing  food,  administering  sulphate  of  sodium  several  times  a  day 
and  atropin  in  the  morning  and  evening. 

Pure  carboHc  acid  is  a  rehable  disinfectant  for  certain  conditions.  It  is 
used  to  destroy  chancroids,  to  purify  infected  wounds  and  abscess  cavities, 
to  disinfect  the  medullary  cavity  in  osteomyehtis,  to  stimulate  granulation  after 
the  open  operation  for  hydrocele,  or  to  purify  sloughing  burns  or  ulcerated 
areas.  The  pure  acid  rarely  produces  constitutional  symptoms,  but  it  occa- 
sionally causes  sloughing.  Its  application  causes  pain  for  a  moment  only, 
and  then  analgesia  ensues.  Even  dilute  solutions  of  carbolic  acid  greatly 
relieve  pain  when  applied  to  raw  surfaces.  The  local  action  of  carbolic  acid 
can  be  at  once  antidoted  by  the  application  of  alcohol  (Seneca  D.  Powell). 
When  carbolic  acid  is  applied  to  a  wound,  the  area  about  the  wound  should 
first  be  moistened  with  alcohol.  After  the  application  of  pure  carbolic  acid  to 
a  joint,  a  wound,  the  medullary  canal,  or  an  infected  area,  wait  about  one 
minute  and  then  apply  alcohol. 

Carbolic  acid  acts  more  slowly  and  less  certainly  than  corrosive  sublimate. 
It  requires  twenty-four  hours  for  a  5  per  cent,  solution  to  kill  anthrax-spores. 
Pus  or  blood  (albuminous  matter)  greatly  weakens  the  germicidal  power  of 
carh)olic  acid,  and  fatty  tissue  cannot  be  disinfected  by  it.  It  is  not  even 
the  best  of  agents  in  which  to  place  instruments,  as  it  dulls  them.  After 
operation  upon  the  mouth  it  is  used  as  a  wash  or  gargle,  i  to  2  per  cent. 
being  a  suitable  strength.  It  is  used  sometimes  to  irrigate  the  bladder  and 
often  to  cleanse  sinuses,  but  is  not  employed  in  the  ])eritoneal  cavity,  the 
pleural  sac,  or  the  brain.  It  is  occa.sionally  injected  into  tuberculous  joints. 
Never  a[)ply  carbolic  solutions  to  clean  wounds. 


Iodoform  27 

Creolin,  which  is  a  preparation  made  from  coal-tar,  is  a  germicide  without 
irritant  or  toxic  effects.  It  is  less  powerful  than  carbolic  acid,  but  acts  similarly, 
and  is  used  in  emulsion  of  a  strength  of  from  i  to  5  per  cent.,  and  does  not 
irritate  the  skin  like  carbolic  acid. 

Peroxid.  of  hydrogen  is  an  excellent  agent  for  cleansing  a  purulent  or 
putrid  area,  but  it  is  never  applied  upon  an  aseptic  wound.  It  comes  in  a 
lo-volume  solution,  which  should  be  diluted  one-half  or  two-thirds.  It 
probably  destroys  the  albuminous  element  upon  which  bacteria  live,  and 
starves  the  fungi.  When  peroxid  of  hydrogen  is  applied  to  a  purulent  area 
ebullition  occurs,  liberated  oxygen  bubbling  up  through  the  fluid  and  the 
pus  being  oxidized.  The  peroxid  of  hydrogen  is  not  fatal  to  tetanus  bacilli; 
in  fact,  tetanus  bacilli  can  be  cultivated  in  a  strong  solution  of  it.  Some 
surgeons  use  it  to  wash  out  appendicular  abscesses  (R.  T.  Morris).  It  must 
not  be  injected  into  a  deep  abscess  in  any  region  unless  a  large  opening  exists, 
as  otherwise  the  evolved  gas  may  tear  apart  structures  and  dissect  up  the 
cellular  tissue.  The  use  of  peroxid  should  not  be  too  long  continued,  for 
if  used  for  a  considerable  period  it  makes  the  granulations  edematous  and 
retards  healing.  In  fact,  its  continued  use  may  actually  prevent  a  sinus 
closing. 

Iodoform  is  largely  used;  it  is  not  truly  a  germicide,  as  bacteria  will  grow 
upon  it,  but  it  hinders  the  development  of  bacteria  and  directly  antagonizes  the 
action  of  the  toxic  products  of  germ-life.  Iodoform  stimulates  the  production 
of  connective  tissue.  It  is  of  the  greatest  value  when  applied  to  putrid  foci, 
infected  areas,  and  tuberculous  processes.  The  laboratory  workers  who  con- 
demn it  have  in  many  cases  used  nutrient  material  in  which  it  does  not  dissolve 
(P.  F.  Lomry,  "  Archiv  fiir  klin.  Chir.,"  1896).  Its  use  in  suppurating  tissues 
retards  the  growth  and  attenuates  the  virulence  of  pus  cocci  and  organisms 
of  putrefaction.  Clinically,  no  real  substitute  for  it  has  yet  been  found.  It 
can  be  rendered  sterile  by  washing  with  a  solution  of  corrosive  sublimate. 
It  need  not  be  applied  to  clean  wounds,  but  the  powder  is  very  useful  when 
dusted  into  infected  wounds.  It  prevents  wound-discharges  from  decom- 
posing and  distinctly  allays  pain.  Gauze  impregnated  with  iodoform  is  used 
to  keep  abscesses  open  after  evacuation,  to  drain  the  belly  after  certain  opera- 
tions, to  pack  aside  the  intestines  and  prevent  their  infection  during  some 
abdominal  operations,  and  as  packing  to  arrest  intracranial  hemorrhage. 
Iodoform  gauze  will  drain  serum  well,  but  will  not  drain  pus.  In  fact,  it 
blocks  up  a  pus-cavity,  and  if  retained  long  leads  to  the  collection  of  purulent 
matter  behind  and  about  the  supposed  drain.  If  used  in  an  abscess,  it  must 
be  removed  in  twenty-four  or  thirty-six  hours.  Tuberculous  joints  and  cold 
abscesses  are  injected  with  iodoform  emulsion,  which  is  made  by  adding  the 
drug  to  sterile  glycerin  or  olive  oil.  The  emulsion  contains  10  per  cent,  of 
iodoform.  A  solution  in  ether  of  a  strength  of  10  per  cent,  may  be  used  to 
inject  the  cavity  of  a  cold  abscess. 

lodojorm-poisoning. — The  drug  must  be  used  with  some  caution.  Ab- 
sorption from  a  wound  sometimes  happens,  producing  toxic  symptoms. 
These  symptoms  are  frequently  misinterpreted,  being  usually  attributed 
to  infection.  R.  T.  Morris  has  pointed  out  that  in  iodoform-poisoning 
the  wound  seems  to  be  in  excellent  condition,  whereas  in  sepsis  the 
wound  is  unhealthy.     The  symptoms  in   some   cases   are   acute  and    arise 


28  Bacteriology 

suddenly,  and  consist  of  hallucinatory  delirium,  nausea,  fever,  watery 
eyes,  contracted  pupils,  metallic  taste  in  mouth,  yellowness  of  the  skin 
and  eyes,  an  odor  of  iodoform  upon  the  breath,  the  presence  of  the 
drug  in  the  urine,  the  outbreak  of  a  skin  eruption  resembling  measles 
or  one  which  is  erythematous,  vesicular,  bullous,  or  petechial  (see  Stel- 
wagon  on  "Diseases  of  the  Skin").  There  is  often  nephritis  and  always 
excessive  loss  of  flesh  and  strength.  Patients  with  such  acute  symptoms 
usually  pass  into  coma  and  die  within  a  week.  Such  attacks  are  most  apt 
to  arise  in  those  beyond  middle  hfe  (see  Gerster  and  Lilienthal,  in  Foster's 
"Practical  Therapeutics").  lodin  can  be  recognized  in  urine  by  adding  a 
few  drops  of  commercial  nitric  acid  and  a  little  chloroform.  When  the  mixture 
is  shaken  the  chloroform  will  take  up  the  free  iodin  and  become  purple,  and 
on  standing  the  purple  layer  will  settle  to  the  bottom  of  the  tube.  Another 
method  is  as  follows:  Put  a  little  urine  in  a  saucer,  add  a  httle  calomel,  and 
stir.  If  the  urine  contains  iodoform  a  brown  color  will  be  noted  (R.  T. 
Morris).  The  finding  of  iodin  in  the  urine,  however,  is  not  proof  that  the 
patient  is  poisoned.  We  may  find  it  when  no  sign  of  poisoning  exists.  In 
chronic  cases  of  iodoform-poisoning  the  first  symptoms  usually  observed  are 
moroseness,  bewilderment,  and  irritability,  followed  by  depression,  with  un- 
systematized persecutory  delusions,  delirium,  coma,  and  even  death. 

In  systemic  poisoning  by  iodoform,  discontinue  the  use  of  the  drug, 
sustain  the  strength  of  the  patient,  and  favor  the  elimination  of   the  poison. 

Iodoform  sometimes  produces  greal  local  irritation  of  the  cutaneous 
surface,  the  dermatitis  being  eczematous  or  else  being  manifested  by  crops 
of  vesicles  filled  with  turbid  yellow  serum  or  even  bloody  serum.  These 
vesicles  rupture  and  expose  a  raw  oozing  surface,  looking  not  unlike  a  burn. 
The  use  of  the  drug  must  be  at  once  abandoned,  for  to  continue  it  will  not 
only  increase  the  dermatitis,  but  will  produce  constitutional  symptoms. 
Wash  the  vesiculated  area  with  ether  to  remove  iodoform,  open  each  vesicle, 
and  dress  the  part  for  several  days  with  gauze  wet  with  normal  salt  solution. 
After  acute  inflammation  ceases  apply  zinc  ointment  or  cosmolin. 

Aristol  is  an  odorless  iodin  compound  used  by  some  as  an  antiseptic 
dusting-powder. 

Loretin  is  an  antiseptic  powder  which  is  odorless,  germicidal,  non-irritant, 
and  which  is  said  to  be  non-toxic. 

Europhen  is  a  powder  containing  iodin,  and  the  iodin  separates  from 
it  slowly  when  the  powder  is  applied  to  wounds  or  burns.  It  does  not  produce 
toxic  symptoms  readily,  if  at  all,  and  is  a  valuable  substitute  for  iodoform. 
It  is  used  especially  in  the  treatment  of  ulcers  and  burns. 

Nosophen  is  a  pale  yellow  powder  containing  60  per  cent,  of  iodin.  Its 
bismuth  salt  is  known  as  antinosin.  Nosophen  is  not  toxic,  is  free  from 
odor,  and  is  the  best  of  the  sut)stitutes  for  iodoform. 

Acetanilid  is  frequently  used  as  a  substitute  for  iodoform.  It  is  of 
value  when  applied  to  suppurating,  ulcerating,  or  sloughing  areas,  but  it 
does  not  benefit  tuberculous  conditions.  Sometimes  absorption  takes  place  to 
a  sufficient  extent  to  cause  cyanosis,  sweating,  and  weakness  of  the  pulse 
and  respiration.  If  cyanosis  arises,  suspend  the  administration  of  the  drug 
and  administer  stimulants  by  the  stomach. 

Airol  is  a  substitute  for  pure  iodoform,  and  is  composed  of  gallic  acid, 
bismuth,  and  iodofcjrm.     It  is  non-irritant  and  non-toxic. 


Mustard  29 

Among  other  powders  we  may  mendon  iodol,  amyloform,  subiodid  of 
bismuth,  and  dermatol  or  subgallate  of  bismuth. 

Silver  is  a  valuable  antiseptic.  Halsted  and  Bolton  have  shown  that 
metallic  silver  exerts  an  inhibitive  action  upon  the  growth  of  micro-organisms 
and  does  not  irritate  the  tissues.  Crede  has  also  demonstrated  the  same  facts. 
These  statements  indicate  one  great  reason  why  silver  wire  is  such  a  useful 
suture-material.  Halsted  is  accustomed  to  place  silver  foil  over  wounds 
after  thev  have  been  sutured,  and  Crede  employs  as  a  dressing  a  fabric  in 
which  metallic  silver  is  intimately  incorporated. 

Crede  considers  silver  lactate  (actol)  an  admirable  antiseptic.  It  does 
not  form  an  insoluble  albuminate  when  introduced  into  the  tissues  and  is 
not  an  irritant.  Silver  citrate  (itrol)  is  said  to  be  even  a  better  preparation 
than  silver  lactate,  and  it  is  a  useful  dusting-powder.  A  preparation  of 
metallic  silver  is  made  which  is  soluble  in  water  and  in  albuminous  fluids; 
it  remains  as  metaUic  silver  when  in  solution,  and  is  said  to  be  powerfully 
germicidal.  A  i  per  cent,  solution  is  used  and  can  be  injected.  Crede's 
ointment  of  silver  is  used  in  septic  diseases.  In  a  child  15  grains  of  the 
ointment  is  rubbed  in  the  skin  at  one  time,  in  an  adult  45  grains,  and  the 
rubbing  should  be  kept  up  from  ten  to  thirty  minutes.  There  is  said  to  be 
no  risk  of  argyria.  Protargol  is  a  silver  salt  much  used  in  gonorrhea. 
Argyrol  is  a  new  and  valuable  preparation  of  silver  which  I  have  used  fre- 
quently with  much  satisfaction.  It  is  known  as  silver  vitelline,  is  not  irritant, 
and  contains  30  per  cent,  of  metallic  silver.  In  a  strength  of  5  per  cent,  it 
is  a  very  useful  injection  for  gonorrhea,  as  it  has  powerful  gonococcidal  proper- 
ties. In  some  types  of  chronic  cystitis  several  drams  of  a  3  per  cent,  solution 
may  be  injected  into  the  bladder  from  time  to  time,  and  much  stronger  solu- 
tions can  be  used  with  safety.  Inflamed  mucous  membranes  may  be  painted 
with  a  solution  of  a  strength  of  from  20  to  50  per  cent.  A  sinus  or  a  sluggish 
area  of  granulation  may  be  stimulated  by  touching  with  a  solution  of  a  strength 
of  from  25  to  50  per  cent.     I  have  found  it  of  much  service  in  sinuses. 

Formaldehyd,  or  formic  aldehyd,  has  valuable  antiseptic  properties. 
Formalin  is  a  40  per  cent,  solution  of  the  gas  in  water.  Solutions  of  this 
strength  are  very  irritant  to  the  tissues,  but  2  per  cent,  solutions  can  be  used 
to  disinfect  wounds.  A  solution  of  a  strength  of  0.5  per  cent,  is  used  to 
irrigate  sinuses,  tuberculous  areas,  abscess-cavities,  and  suppurating  joints. 
A  strong  solution  is  used  to  asepticize  chancroids  and  other  ulcers.  The 
vapor  of  formalin  can  be  so  applied  as  to  disinfect  wounds,  and  Wood  suggests 
its  employment  in  septic  peritonitis  as  a  means  of  disinfection  after  the  abdo- 
men has  been  opened.  The  vapor  of  formalin  thoroughly  disinfects  catheters. 
A  2  per  cent,  solution  disinfects  instruments  satisfactorily. 

Formalin-gelatin  has  recently  been  introduced  by  Schleich  as  an  anti- 
septic powder.  When  applied  to  a  clean  wound  it  gives  off"  formalin  and  keeps 
the  wound  aseptic.  When  it  is  applied  to  a  sloughing  surface  it  will  not 
give  off  formalin  unless  it  is  mixed  with  pepsin  and  hydrochloric  acid.  The 
commercial  preparation  is  known  as  glutei.  Formalin-gelatin  has  been  used 
to  replace  bone-defects. 

Lysol  is  a  valuable  germicidal  agent.  It  is  saponified  phenol  and  is 
used  in  a  solution  of  a  strength  of  from  i  to  3  per  cent. 

Mustard  is  an  excellent  emergency  germicide.     Its  value  has  been  demon- 


30  Bacteriology 

strated  by  Roswell  Park.  A  mixture  of  soap,  cornmeal,  and  mustard  flour 
is  used  to  scrub  the  surgeon's  hands  or  the  patient's  skin  (Park).  Mustard 
removes  the  odor  of  decay  at  once. 

Commercial  gasoline  is  used  by  Riordan  and  others  to  clean  wounds 
and  ulcers,  and  to  prepare  the  field  of  operation.  Its  vapor  is  so  inflammable 
that  the  material  must  not  be  used  when  an  artificial  light  is  necessary,  and 
it  is  used  only  in  the  daytime  and  on  free  surfaces  where  evaporation  is  rapid. 
It  is  sterile,  non-irritant,  and  on  evaporation  leaves  a  dry,  clean  surface. 

Tincture  of  iodin  may  be  applied  to  an  infected  wound  in  the  same 
manner  as  is  pure  carbolic  acid;  its  use  is  advocated  by  Carl  Beck.  In 
dilute  solution  it  is  used  to  irrigate  sinuses.  The  proper  dilution  for  irrigation 
is  obtained  when  the  fluid  is  the  color  of  sherry  wine. 

Nucleins,  especially  protonuclein,  possess  germicidal  powers.  Proto- 
nuclein  is  of  value  in  treating  areas  of  infection,  particularly  when  sloughing 
exists. 

Among  other  antiseptics  and  germicides  of  more  or  less  value  we  may 
mention  trichlorid  of  iodin,  chlorid  of  zinc,  chlorid  of  iron,  salol,  oxycyanid  of 
mercury,  fluorid  of  sodium,  argonin,  sugar,  lannaiol,  bichlorid  of  palladium 
(in  very  dilute  solution),  thymol,  potash  soap,  sahcylic  acid,  boric  acid, 
camphor,  eucalyptol,  cinnamon,  bromin,  chlorin  (as  gas  or  as  chlorin-water), 
cinnamic  acid,  permanganate  of  potassium  or  of  calcium,  chlorate  of  potas- 
sium, alcohol,  normal  salt  solution,  and  oxalic  acid. 

The  best  germicide  is  heat,  and  the  best  form  in  which  to  apply  heat  is. 
by  means  of  boiling  water  (even  better  than  steam).  One  can  use  boiling 
water  upon  instruments  and  dressings,  but  rarely  upon  a  patient.  Jeannel, 
of  Toulouse,  uses  boiling  salt  solution  in  abscess-cavities,  and  some  other 
surgeons  employ  steam  or  boiling  water  to  disinfect  the  medullary  canal  in 
osteomyeUtis.  Nevertheless,  boiling  water  is  rarely  applied  to  the  patient, 
and  in  many  cases  a  chemical  germicide  must  be  used.  The  surgeon  should 
always  scrub  his  hands  in  a  germicidal  solution. 

Distribution  of  Bacteria. — Microbes  are  very  widely  distributed  in 
nature.  They  are  found  in  all  water  except  that  which  comes  from  very 
deep  springs;  in  all  soil  to  the  depth  of  three  feet;  and  in  air,  except  that  of 
the  desert,  that  over  the  open  sea,  and  that  of  lofty  mountains. 

Microbes  may  be  useful.  Some  of  them  are  scavengers,  and  clean  the 
surface  of  the  earth  of  its  dead  by  the  process  known  as  "putrefaction,"  in 
which  complex  organic  matter  is  reduced  to  harmless  gases  and  to  a  mineral 
condition.  The  gases  are  taken  up  from  the  air  by  vegetables,  and  the 
mineral  matter  is  dissolved  in  rain-water  and  passes  into  the  soil  from  which 
it  came,  there  again  to  be  food  for  plants,  which  plants  will  become  food 
for  animals.  Other  organisms  purify  rivers;  others  cause  bread  to  rise; 
still  others  give  rise  to  fermentation  in  liquors.  Microbes  may  be  harmful. 
They  may  poison  rivers  and  soils;  they  may  be  parasites  on  vegetable  life; 
they  cause  diseases  of  the  growing  vine,  and  also  of  wine;  they  produce  the 
mould  on  stale,  damp  bread;  they  occasionally  form  poisonous  matter  in 
sausages,  in  ice-cream,  and  in  canned  goods;  and  they  produce  many  diseases 
among  men  and  the  lower  animals. 

With  so  universal  a  distribution  of  these  jungi,  man  must  constantly  take 
them  into  his  organism.     They  are  upon  the  surface  of  his  body,  he  inhales 


Toxins  3 1 

them  with  every  breath,  and  he  swallows  them  \\-ith  his  food  and  drink. 
Most  of  them,  fortunately,  are  entirely  harmless;  others  cannot  act  on  the 
living  tissues ;  but  some  are  virulent,  and  these  are  generally,  but  not  always, 
destroyed  by  the  cells  of  the  human  body.  The  alimentary  canal  always 
contains  bacteria  of  putrefaction,  which  act  only  upon  the  dead  food,  and  not 
upon  the  living  body;  but  when  a  man  dies  these  organisms  at  once  attack 
the  tissues,  and  post-mortem  putrefaction  begins  in  the  abdomen. 

Koch's  Circuit. — To  prove  that  a  microbe  is  the  cause  of  a  disease 
it  must  fulfil  Koch's  circuit.  It  must  always  be  found  associated  with  the 
disease;  it  must  be  capable  of  forming  pure  cultures  outside  the  body;  these 
cultures  must  be  capable  of  reproducing  the  disease;  and  the  microbe  must 
again  be  found  associated  with  the  artificially  produced  morbid  process. 

Disease  Production. — Disease-producing  organisms  which  enter  the 
body  are  usually  rapidly  destroyed.  They  cannot  dwell  there  long  without 
inducing  disease,  but  spores  can  lie  dormant  in  the  system  for  years,  only 
waking  into  activity  when  they  come  in  contact  with  some  damaged,  weakened, 
or  diseased  part  where  the  circulation  is  abnormal — a  so-called  point  of 
least  resistance  (a  locus  minoris  resistentm) — which  affords  a  nest  for  them 
to  develop  and  to  multiply,  the  cellular  activities  of  the  weakened  part 
being  unable  to  cope  with  the  activities  of  the  germs.  Even  large  num- 
bers of  pathogenic  organisms  may  induce  no  trouble  in  a  healthy  man; 
but  let  them  reach  a  damaged  spot,  and  mischief  is  apt  to  arise.  Kocher 
established  subcutaneous  bone-injuries  in  dogs,  and  these  injuries  pursued 
a  healthy  course  until  the  animal  was  fed  upon  putrid  meat,  whereupon 
suppuration  took  place.  This  e.xperiment  proves  that  micro-organisms  can 
reach  a  damaged  area  by  means  of  the  blood,  and  it  enables  us  to  understand 
how  a  knee-joint  can  suppurate  when  we  merely  break  up  adhesions,  and 
how  osteomyelitis  can  follow  trauma  when  the  skin  is  intact.  A  given  number 
of  organisms  might  produce  no  effect  on  a  healthy  man,  whereas  the  same 
number  might  produce  disease  in  an  individual  who  was  weak  or  ill  nourished, 
suffering  from  depression  or  fear,  or  debilitated  by  the  habitual  use  of  alcohol. 
The  personal  equation  plays  a  great  part  in  disease-production.  Some  indi- 
viduals seem  to  be  immune  to  certain  diseases;  others  seem  especiallv  liable 
to  develop  certain  diseases;  and  these  immunities  and  liabilities  mav  be 
hereditary  or  acquired,  temporary  or  permanent. 

Enzymes. — Bacteria  contain  and  e.xcrete  ferments,  and  these  ferments 
are  known  as  enzymes.  Bacterial  ferments  resemble  pepsin  and  trypsin,  the 
digestive  ferments.  The  digestive  ferments  convert  albumin  into  peptone, 
starch  into  sugar,  and  break  up  fat.  When  microbic  infection  of  the  tissues 
occurs  the  enzymes  of  the  bacteria  act  upon  the  tissues  just  as  the  digestive 
ferments  act  upon  the  food,  and  form  microbic  albumoses.  The  enzymes 
are  the  weapons  of  micro-organisms.  By  means  of  these  ferments  bacteria 
not  only  prepare  substances  for  assimilation,  but  seek  to  destroy  antagonists 
and  cell  enemies.  It  is  probable  that  enzymes  when  absorbed  are  fre- 
quently productive  of  to.xemia. 

Toxins. — The  action  of  pathogenic  bacteria  upon  the  tissues  is  of  great 
importance.  In  the  first  place,  they  abstract  from  the  blood,  the  lymph, 
and  the  cells  certain  elements  necessary  to  the  body, — as  water,  o.xygen, 
albumins,  carbohydrates,  etc., — and  thus  cause  body-wasting  and  exhaustion 


32  Bacteriology 

from  want  of  food.  In  the  second  place,  bacteria  produce  a  vast  number 
of  compounds,  some  harmless  and  others  highly  poisonous.  The  symptoms 
of  a  microbic  disease  are  largely  due  to  the  absorption  of  poisonous  materials 
from  the  area  of  infection.  These  poisons  may  be  formed  from  the  tissues 
by  the  action  upon  them  of  the  bacteria  (toxins  and  peptones)  or  may  be 
liberated  from  the  bodies  of  degenerating  microbes  (bacterial  proteid).  Bac- 
teria contain  and  secrete  ferments ;  and  as  albumoses  are  formed  in  the  alimen- 
tary canal  by  the  action  of  digestive  ferments  upon  proteids,  sugars,  and 
starches,  so  microbic  albumoses  are  formed  by  the  action  of  microbic  ferments 
upon  tissues.  Just  as  the  albumoses  formed  in  digestion  are  poisonous  when 
injected,  so  the  albumoses  of  microbic  action  are  poisonous  when  ab- 
sorbed. The  albumoses  of  microbic  action  are  called  toxallmmins,  and 
these  albumoses  often  operate  as  virulent  poisons  to  the  body-cells. 

A  number  of  compounds  formed  by  the  microbic  destruction  of  tissue  are 
alkaloidal  in  nature.  These  poisonous  alkaloids  are  readily  diffusible  and, 
many  of  them,  very  virulent.  It  is  probable  that  every  pathogenic  organism 
has  its  own  special  toxin  which  produces  its  characteristic  effects,  although 
the  effects  are  modiiied  by  the  nature  of  the  soil — that  is  to  say,  by  the  condi- 
tion of  the  tissues.  The  absorption  of  toxins  may  be  very  rapid;  for  instance, 
the  toxins  of  cholera  may  kill  a  man  before  the  bacilli  have  migrated  from 
the  intestine.  Brieger  uses  the  term  toxin  to  designate  all  of  the  poisonous 
products  of  bacterial  action.  He  divides  toxins  into  alkaloidal  or  crystallizable 
and  amorphous,  the  latter  being  called  toxalbumins. 

Ptomains. — By  many  writers  the  term  "ptomain"  is  used  to  designate 
these  toxins,  but  in  reahty  a  ptomain  is  a  form  of  toxin  produced  by  the 
action  of  saprophytic  bacteria.  A  ptomain  is  a  putrefactive  alkaloid,  and  a 
toxin  is  any  poison  of  microbic  origin.  Among  these  putrefactive  alkaloids 
may  be  mentioned  tetanin,  typhotoxin,  sepsin,  putrescin,tyrotoxicon,  muscarin, 
and  spasmotoxin.  The  poison  which  occasionally  forms  in  cheese,  ice-cream, 
sausage,  and  canned  goods  is  composed  of  ptomains.  Poisoning  by  any 
putrid  food  is  called  ptomain-poisoning. 

Leucomains  must  not  be  confounded  with  the  above-mentioned  bodies. 
Leucomains  are  alkaloidal  substances  existing  normally  in  the  tissues,  and 
arising  from  physiological  fermentations  or  retrograde  chemical  changes. 
They  are  natural  body-constituents,  in  contrast  to  toxins,  which  are  morbid 
constituents.  Leucomains  are  found  in  expired  air,  saliva,  urine,  feces, 
tissues,  and  the  venom  of  serpents.  If  not  excreted,  these  bodies  may  induce 
illness,  and  when  injected  may  act  as  poisons.  Ordinary  colds  and  some 
fevers  result  from  leucomains;  they  play  a  great  part  in  uremia,  and  when 
excretion  is  deficient  the  retained  leucomains  make  the  system  a  hospitable 
host  for  pathogenic  bacteria.  Sickness  due  to  the  retention  and  absorption 
of  leucomains  is  known  as  autointoxication.  Among  leucomains  may  be 
mentioned  adenin,  hypoxanthin,  and  xanthin,  aUied  to  uric  acid,  and  other 
substances  allied  to  creatin  and  creatinin.  The  surgeon  should  never  forget 
the  yjossibility  of  harm  being  done  by  retained  leucomains,  and  should  endeavor 
to  prevent  autointoxication  in  all  cases  by  keeping  the  skin,  the  bowels,  and 
the  kidneys  active. 

Immunity. — If  a  person  will  not  contract  and  cannot  be  infected  with 
a  certain  disease,  he  is  said   to  be  immune.      It  has  long  been  known  that 


Alexins   and   Antitoxins  t,^ 

when  a  person  recovers  from  certain  diseases  he  has  become  immune  to  the 
disease  from  which  he  suffered.  Immunity  may  be  transitory,  prolonged,  or 
permanent.  Immunity  may  be  compared  to  fermentation.  When  fermen- 
tation ceases,  the  addition  of  more  ferment  is  without  result.  When  a  person 
recovers  from  certain  diseases,  the  addition  to  his  blood  of  more  of  the  causa- 
tive bacteria  is  also  void  of  result.  Some  persons  seem  naturally  immune  to 
certain  diseases.     Immunity  to  some  diseases  may  be  produced  artificially. 

Alexins  and  Antitoxins. — Immunity  was  long  believed  to  arise  from 
the  e.xhaustion  of  some  unknown  constituent  of  tissue  necessary  to  the  life  oi 
the  bacteria.  This  theory  was  advanced  by  Pasteur.  It  has  been  abandoned 
because  of  the  demonstration  that  though  an  animal  may  be  immune  to  certain 
bacteria,  these  bacteria  will  grow  in  its  blood  or  tissue.  A  theory  proposed 
by  Chauveau  is  known  as  the  "retention  theory,"  and  is  the  opposite  of  Pas- 
teur's "exhaustion  theory."  According  to  Chauveau,  bacteria  growing  within 
the  body  leave  as  a  legacy  excrementitious  material,  and  the  accumulation 
and  retention  of  excrementitious  products  produce  immunity. 

At  the  present  time  there  are  two  notable  theories  of  immunity,  and  it  is 
probable  that  each  is  at  least  partly  true.  The  first  theory  is  that  of  phago- 
cytosis, which  assumes  that  certain  body-cells  attack,  consume,  and  destroy 
bacteria  (see  below) .  The  other  theory  is  founded  on  the  discovery  of  Nuttal 
that  normal  blood-serum  is  germicidal.  \'aughan  and  others  have  shown 
that  the  germicidal  agent  is  probably  a  nuclein  furnished  chiefly  by  the  \vhite 
cells  and  held  in  solution  by  the  alkaline  serum.  This  germicidal  agent 
Buchner  called  "alexin"  or  defensive  proteid,  and  explained  immunity  by 
its  presence.  This  theory  is  known  as  the  "humoral  theory."  According 
to  this  theory,  when  an  animal  is  naturally  immune  to  a  bacterial  disease  it 
is  assumed  that  the  blood-serum  and  body-fluids  contain  enough  of  this 
alexin  to  destroy  the  bacteria. 

Since  the  above  discoveries  were  made  it  has  been  found  that  when  an 
animal  recovers  from  a  bacterial  disease  the  blood-serum  and  body-fluids 
contain  a  new  protective  substance  which  is  not  an  alexin,  but  which  has  the 
power  of  destroying  the  toxins  of  the  bacteria.  It  is  known  as  an  antitoxin 
and  is  produced  by  the  body-cells  under  the  stimulation  of  bacterial  toxins. 
It  is  thus  seen  that  bacteria  not  only  produce  poisons,  but  also  stimulate  the 
body-cells  to  ])roduce  antidotes  to  these  poisons.  Alexins  exist  in  normal  blood 
and  kill  bacteria.  Antitoxins  exist  in  blood  of  animals  rendered  immune  and 
do  not  kill  bacteria,  but  sim])ly  neutralize  their  toxins.  It  was  pointed  out 
by  Kitasato  and  Behring  that  animals  can  be  rendered  immune  to  tetanus 
by  artificial  means  and  that  the  blood-serum  of  immune  animals  wifl,  if 
injected  into  other  animals,  render  them  immune,  or  will  cure  the  disease 
if  injected  into  animals  suffering  from  tetanus.  The  same  statements  were 
soon  after  proved  to  be  true  of  diphtheria.  Now  many  experimenters  are 
endeavoring  to  find  the  antitoxin  of  each  microbic  disease  for  the  purpose  of 
using  it  therapeutically  and  also  as  a  preventive  agent. 

The  real  mechanism  of  antitoxin-formation  is  unknown,  although  it  seems 
certain,  as  Roux  maintains,  that  it  is  secreted  by  the  body-cells. 

Ehrlich's  theory  of  the  mechanism  of  immunity  is  at  present  attracting 
much  interest.  His  theory  may  be  explained  in  the  words  of  D.  H.  Bergey 
("American  Medicine,"  Oct.  ii,  1902). 


34  '    Bacteriology 

"In  the  light  of  our  later  knowledge  upon  the  subject,  Ehrlich,  in  1898, 
formulated  his  hypothesis  of  the  mechanism  of  immunity  which  is  receiving 
very  general  acceptance  by  scientists  to-day.  His  theory  of  the  mechanism 
of  immunity  is  based  upon  Weigert's  teaching  of  the  process  of  tissue  repair. 
It  is  a  matter  of  universal  observation  that  nature  is  prodigal  in  her  attempts 
to  repair  an  injury.  This  is  shown  in  the  healing  process  in  an  ordinary 
wound.  A  much  larger  amount  of  material  is  thrown  out  to  bridge  the 
chasm  than  is  really  utilized  in  the  formation  of  new  tissue.  The  presence 
of  an  excessive  amount  of  new  material  is  shown  by  the  fact  that  the  part 
is  raised  above  the  level  of  the  surrounding  sound  tissue,  and  this  excess  is 
removed  gradually  as  the  new-formed  tissue  becomes  stronger  and  stronger, 
until  finally  the  wound  is  marked  by  a  hne  of  white  scar-tissue,  the  excess 
gradually  passing  into  the  blood-current. 

"  Ehrlich  believed  that  the  mechanism  of  immunity  was  explainable  on 
a  similar  basis.  It  had  become  evident  from  the  experiments  of  Wasserman 
with  the  tetanus  bacillus  that  its  toxin  had  an  especial  affinity  for  the  cells 
of  the  central  nervous  system.  Experiments  with  other  bacteria  pointed  to 
the  fact  that  the  to.xins  of  different  species  of  bacteria  had  an  especial  affinity 
for  the  cells  of  different  organs  of  the  body.  When  the  amount  of  poison 
entering  the  body  is  insufi&cient  to  destroy  the  cells  which  have  an  especial 
affinity  for  it,  these  cells  may  be  injured  only  to  such  an  extent  as  to  permit 
subsequent  repair.  In  order  to  comprehend  Ehrlich's  hypothesis  it  is  neces- 
sary to  conceive  the  cells  of  the  body  as  having  a  complex  structure  which 
may  be  stated  diagrammatically  as  consisting  of  a  central  mass  or  nucleus 
from  which  radiate  a  number  of  'lateral  chains,'  or  bonds,  each  of  which 
serves  to  bind  the  cell  to  other  substances.  In  the  case  of  the  cells  of  the 
central  nervous  system  one  of  these  lateral  bonds  has  an  especial  afifinit}- 
for  tetanus  toxin  and  suffers  destruction.  The  cell  now  finds  itself  in  unstable 
equilibrium,  and  at  once  proceeds  to  repair  the  damage  wrought.  As  in  the 
case  of  tissue  repair,  the  new  material  produced  is  far  in  excess  of  the  required 
amount.  The  excess  finds  its  way  into  the  blood-current.  This  material 
now  circulating  in  the  blood-current  has  the  same  affinity  for  tetanus  toxin  as 
when  united  with  the  central  mass  of  a  cell  as  its  lateral  bond,  and  can,  there- 
fore, combine  with  tetanus  toxin  floating  in  the  blood-current,  thus  preserving 
other  cells  from  injury.  The  union  formed  between  the  lateral  bond  of  the 
cell  (which  is  really  the  antitoxin)  and  the  tetanus  toxin  results  in  the  forma- 
tion of  a  compound  which  is  physiologically  inert.  According  to  Ehrlich's 
idea,  therefore,  the  antitoxin  is  simply  the  excess  of  lateral  bonds  floating 
in  the  blood-current.  This  substance  can  neutralize  the  effect  of  the  tetanus 
toxin  in  a  test-tube  just  as  readily  as  it  does  within  the  body." 

Phagocytes. — The  tendency  of  the  white  blood-cells,  and  in  a  less  de- 
gree fjf  the  endothelial  cells  of  the  vessels,  to  destroy  organisms  is  undoubted. 
This  process  of  destruction  is  known  as  phagocytosis,  and  the  destroying  cells 
are  called  phagocytes.  When  infection  occurs,  the  white  blood-cells  gather 
in  enormous  numbers  at  the  seat  of  disease,  encompass  and  surround  the 
bacteria,  and  build  a  barrier  to  prevent  dissemination  of  the  microbes  and 
general  infection  of  the  organism.  The  force  which  draws  leukocytes  to  a 
region  of  infection  also  tends  to  draw  them  to  an  area  where  there  is  cellular 
degeneration  or  death.     This  force  is  called  positive  chemiotaxis.     In  very 


Protective  and  Preventive   Inoculations 


03 


10. — Phagocytosis 


A,  Successful  ; 
(Senn). 


B,  Unsuccessful 


virulent  infections  the  leukocytes  may  fail  to  collect  and  may  actually  be 
repelled  and  scattered  under  the  influence  of  what  has  been  called  negative 
chemiotaxis.  Phagocytes  at  the  seat  of  infection  try  to  eat  up,  carry  aw-ay  to  a 
gland,  and  there  digest  and  destroy  bacteria.  A  battle  royal  occurs,  the  mi- 
crobes fighting  the  body-cells  with  most  active  ferments;  the  body-cells  endeav- 
oring to  devour  and  destroy  the  bacteria  (Fig.  lo).  In  some  cases  the  bacteria 
win  absolutely  and  the  patient 
dies.  In  other  cases  they  win 
for  a  time  and  overwhelm  the 
organism;  but  presently  the 
body-cells,  whose  movements 
were  inhibited  by  the  poison, 
regain  their  activity  and  suc- 
cessfully recur  to  the  attack. 
It  is  probable  that  the  de- 
fensive proteids  thrown  out 
by  the  white  cells  tend  to 
destroy  enzymes,  to  kill  bac- 
teria, and  to  neutralize  toxic 
bacterial  products.  Those 
which  kill  bacteria  are  known 
as  alexins,  and    those  which 

neutralize  toxic  products  are  known  as  antitoxins.  After  the  attack  of 
disease  has  passed  away  the  body-cells  have  been  educated  to  withstand 
this  poison,  and  new  cells  in  the  future  retain  this  capacity;  the  weak 
cells  were  killed,  the  fittest  survived.  The  new  cells  formed  by  the  organism 
are  insusceptible  to  the  poison  and  the  individual  is  said  to  be  insusceptible 
or  immune.  The  theory  of  phagocytosis  immunity  assumes  an  educated 
white  corpuscle  and  body-cell.  This  view  originated  with  Sternberg,  but  it 
is  usually  accredited  to  Metschnikoff.  Lankester  gave  us  the  term  "  educated 
corpuscle." 

Protective  and  Preventive  Inoculations.— Our  knowledge  of  pro- 
tective inoculations  for  contagious  diseases  dates  from  Jenner's  discovery  in 
1798.  Preventive  inoculations  with  attenuated  virus  are  due  to  the  experi- 
ments of  Pasteur.  This  observer  discovered  the  cause  of  chicken-cholera, 
and  cultivated  the  micro-organism  of  this  disease  outside  the  body.  He 
found  that  by  keeping  his  cultures  for  some  time  they  became  attenuated  in 
virulence,  and  that  these  attenuated  cultures,  inoculated  in  fowls,  caused  a 
mild  attack  of  the  disease,  which  attack  was  protective,  and  rendered  the 
fowl  immune  to  the  most  virulent  cultures.  Cultures  can  be  attenuated  by. 
keeping  them  for  some  time,  by  exposing  them  for  a  short  period  to  a  tempera- 
ture just  below  that  necessary  to  kill  the  organisms,  or  by  treating  them  with 
certain  antiseptics.  It  has  further  been  shown  that  injection  of  the  blood- 
serum  of  an  animal  rendered  immune  by  inoculation  is  capable  of  making 
a  susceptible  animal  also  immune. 

A  most  important  fact  is  that  animals  may  be  rendered  immune  to  certain 
diseases  by  inoculating  them  with  filtered  cultures  of  the  microbes  of  the 
disease,  the  filtrate  containing  microbic  products,  but  not  living  microbes. 
By  this  method  animals  can  be  rendered  immune  to  tetanus  and  diphtheria. 


36  Bacteriology 

Pasteur's  protective  inoculations  against  hydrophobia  owe  their  power  to 
microbic  products,  and  Koch's  lymph  contains  them  as  its  active  ingredients. 
The  chief  feature  in  acquired  immunity  is  the  presence  in  the  blood  and 
tissues  of  elements  which  can  neutralize  the  toxic  products  of  or  which  can 
kill  bacteria.  These  elements  are  "antitoxins"  and  "alexins."  The  knowl- 
edge of  them  arose  from  the  discovery  of  Nuttall  and  Buchner  that  fresh 
blood-serum  is  germicidal,  the  power  varying  for  different  bacteria  and  being 
hmited.  A  fi.xed  amount  of  serum  is  capable  of  destroying  a  fixed  number 
of  bacteria  only.  It  has  been  said  that  in  tetanus  injections  of  the  serum  of 
an  immune  animal  may  cure  the  disease.  The  above  facts  are  of  immense 
importance,  for  on  these  lines  may  be  solved  the  problems  of  the  prevention 
and  treatment  of  microbic  maladies. 

Orrhotherapy,  or  serum=therapy,  is  an  attempt  to  utilize  therapeu- 
tically the  germicidal  properties  of  blood-serum.  It  is  believed  that  when 
a  person  recovers  from  an  infectious  disease  the  alkaline  blood-serum  is 
saturated  with  protective  material.  If  this  belief  is  true,  it  is  a  proper  de- 
duction that  blood-serum  containing  protective  material  should  cure  the  dis- 
ease if  injected  into  a  patient  suffering  from  an  attack.  Instead  of  using 
the  blood-serum  itself,  some  observers  have  precipitated  the  curative  mate- 
rial from  the  serum,  and  used  the  material  in  solution  in  fixed  amounts. 
Instead  of  using  the  serum  of  persons  rendered  immune  by  an  attack  of  the 
disease,  many  physicians  have  employed  the  serum  of  animals  rendered 
artificiallv  immune  by  injections  of  attenuated  cultures  of  the  bacteria. 
Some  experimenters  have  employed  even  the  serum  of  animals  naturally 
immune  to  the  disease.  That  Pasteur  has  devised  a  method  which  will 
usually  prevent  hydrophobia  is  certain  (page  220),  and  that  Murri,  of 
Bologna,  has  cured  a  case  of  hydrophobia  seems  proved  (page  220).  Hosts 
of  observers  believe  in  the  utility  of  tetanus  antitoxin  and  diphtheria 
antitoxin. 

Inconclusive  experiments  have  been  made  in  the  treatment  of  syphilis 
by  the  serum  of  dog's  blood,  and  by  the  blood-serum  of  men  laboring  under 
tertiary  syphilis;  in  the  treatment  of  pneumonia  with  the  blood-serum  of 
jjersons  convalescent  from  pneumonia;  and  in  the  treatment  of  sufferers 
from  septic  diseases  with  antistreptococcic  serum — blood-serum  of  animals 
rendered  immune  to  septic  infections.  The  real  value  of  antistreptococcic 
serum  is  as  yet  uncertain.  Occasionally  it  seems  to  do  great  good;  at  other 
times  it  appears  to  produce  no  benefit  whatever.  Tavel,  in  a  recent  elaborate 
re.search  ("  Klinische-therapeutische  Wochenschrift"  (Vienna),  August,  1902), 
states  that  he  obtained  brilliant  results  in  some  cases,  but  no  re.sults  in  others. 
He  does  not  undertake  to  explain  this  variability  of  action.  He  thinks  the 
serum  benefits  .staphylococcus  as  well  as  streptococcus  infections.  Malignant 
tumors  (both  sarcomata  and  carcinomata)  have  been  treated  with  the  blood- 
serum  of  dogs,  which  animals  had  been  injected  with  fluid  expressed  from 
malignant  growths  (Richet  and  Hericourt).  Von  I^eyden  and  Blumenthal 
obtain  a  serum  by  compression  of  a  recent  cancerous  growth  and  treat  human 
victims  of  cancer  with  it.  They  claim  that  the  results  are  encouraging 
("Deutsche  medicinische  Wochenschrift,"  September  4,  1902).  Many 
claims  made  for  serum-therayjy  in  surgical  diseases  are  exaggerated,  .sensa- 
tional, and  unscientific.     That  there  is  truth  in  the  method  seems  highly 


Special  Surgical   Microbes  37 

probable,  but  how  much  of  it  is  true  is  not  yet  definitely  ascertained.  It  is 
our  duty  to  study,  experiment,  and  observe,  and  to  reach  a  conclusion  only 
after  honest,  careful,  and  thorough  investigation.  A  little  skepticism  is  as 
yet  a  safe  rule. 

Special  Surgical  Microbes.— Suppuration  is  caused  by  microbes. 
Can  it  exist  without  them  ?  The  answer  is,  Xo.  Injection  of  a  fluid  con- 
taining dead  organisms  will  form  a  limited  amount  of  pus;  injection  of  an 
irritant  forms  a  thin  fluid  which  may  resemble  pus,  but  which  is  not  pus.  In 
surgery  pus  is  not  met  with  without  the  micro-organisms,  and  the  presence 
of  pus  proves  the  presence  of  micro-organisms.  Pus  microbes,  or  pyogenic 
microbes,  possess  the  property  of  peptonizing  albumin,  and  thus  forming  pus. 
The  peptonizing  action  is  brought  about  by  bacterial  ferments  or  enzymes. 
The  inflammation  which  surrounds  an  area  of  pyogenic  infection  is  caused 
by  the  irritant  products  of  bacterial  action  (toxalbumins,  ammonia,  etc.). 
In  the  presence  of  the  pyogenic  peptones  the  coagulation  of  inflammatory 
exudate  is  retarded  or  prevented.  The  most  usual  causes  of  suppuration 
are  the  following  micro-organisms. 

Staphylococcus  pyogenes  aureus  (Plate  i.  Fig.  i,  and  Fig.  11),  the  golden- 
yellow  coccus.  This  is  the  most  usual  cause  of  abscesses  (circumscribed 
suppurations);   77   per   cent,    of   acute   abscesses   are   due   to   staphvlococci 

m 

Fig.   II. — Micrococcus    pyogenes    aureus  Fig.    12. — Streptococcus    pyogenes 

(X  1000).  (X  700). 

(W.  Watson  Cheyne).  Staphylococci  are  found  also  in  osteomyelitis,  in  a 
carbuncle,  and  in  a  boil.  The  staphylococcus  pyogenes  aureus  is  a  facul- 
tative aerobic  parasite  which  is  widely  distributed  in  nature,  and  is  found  in 
the  soil,  the  dust  of  air,  w'ater,  the  alimentary  canal,  under  the  nails,  on  and 
in  the  superficial  layers  of  skin,  especially  in  the  axillie  and  perineum.  It 
forms  the  characteristic  color  only  when  it  grows  in  air.  It  is  killed  in  ten 
minutes  by  a  moist  temperature  of  58°  C,  and  is  instantly  killed  by  boiling 
water.  Carbolic  acid  (i  :  40)  and  corrosive  sublimate  (i  :  2000)  are  quicklv 
fatal  to  this  coccus. 

Staphylococcus  pyogenes  a/bus,  the  white  staph}-lococcus,  acts  like  the 
aureus,  but  is  more  feeble  in  power.  When  this  organism  is  found  upon 
and  in  the  skin  it  is  called  the  staphylococcus  epidermidis  albus,  an  organism 
which  Welch  proved  to  be  the  usual  cause  of  stitch-abscesses. 

Staphylococcus  pyogenes  citreus,  the  lemon-yellow  coccus,  is  found  occa- 
sionally in  acute  circumscribed  suppurations,  but  far  more  rarely  than  the 
other  two  forms.     Its  pyogenic  power  is  even  weaker  than  that  of  the  albus. 

Staphylococcus  cereus  albus  is  found  occasionallv  in  acute  abscesses. 


38  Bacteriology 

Staphylococcus  cereus  flavus  is  found  occasionally  in  acute  abscesses. 

Staphylococcus  flavescens  is  occasionally  found  in  abscesses.  Is  inter- 
mediate between  the  aureus  and  albus  (Senn). 

Micrococcus  pyogenes  tenuis  rarely  takes  the  form  of  a  bunch  of  grapes. 
Is  occasionally  found  in  the  pus  of  acute  abscesses. 

Streptococcus  pyogenes  (Fig.  12)  is  found  in  spreading  suppuration.  Wood- 
head  tells  us  (Treves'  "  System  of  Surgery  ")  that  six  organisms,  each  of  which 
bears  a  separate  name,  are  discussed  under  this  designation.  Three  of  these 
organisms  he  places  in  one  group,  two  in  another,  and  says  the  sixth  may 
be  a  separate  species. 

ist  Group. — Streptococcus  pyogenes,  found  especially  in  spreading  suppura- 
tion and  in  very  acute  abscesses.  Cheyne  says  that  16  per  cent,  of  acute 
abscesses  contain  streptococci.  Is  easily  killed  by  boiling,  and  can  be  de- 
stroved  by  carbolic  acid  and  corrosive  sublimate.  These  organisms  are 
normally  present  in  the  nasal  passages,  vagina,  mouth,  and  urethra. 

Streptococcus  pyogenes  maligmis,  an  uncommon  organism  found  in  splenic 
abscess. 

Streptococcus  septicus  has  a  strong  tendency  to  break  up  into  diplococci. 

2d  Group. — Streptococcus  of  erysipelas,  is  found  in  the  capillary  lymph- 
spaces  in  erysipelas.  Many  bacteriologists  believe  it  to  be  identical  with  the 
streptococcus  pyogenes. 

Streptococcus  oj  Septicemia  and  Pyemia. — Most  observers  maintain  that 
it  is  identical  with  the  streptococcus  pyogenes  and  the  streptococcus  of  ery- 
sipelas. 

3d  Group. — Streptococcus  articuloruvi,  found  in  the  false  membrane  of 
diphtheria  fsee  the  article  by  Woodhead  in  the  ''System  of  Surgery"  by  Sir 
Frederick  Treves). 

The  micrococcus  tetragenus  is  thought  to  be  the  bacterium  chiefly  respon- 
sible for  the  suppuration  of  tubercular  pulmonary  lesions. 

Bacillus  pyogenes  fa'tidns,  found  especially  in  the  pus  of  ischiorectal 
abscesses. 

Bacillus  pyocyaneus,  found  by  Ernst  in  blue  pus 

The  gonococcus,  the  pneumococcus,  the  bacillus  of  typhoid  fever,  and 
the  colon  bacillus  have  pyogenic  power. 

Other  Surgical  .'Vlicrobes. — Streptococcus  oj  erysipelas  (Fehleisen's 
coccus),  as  stated  before,  is  thought  by  many  to  be  identical  with  the  strepto- 
coccus pyogenes.  Their  difference  in  action  is  believed  by  Sternberg  to  be 
due  to  difference  in  virulence  induced  by  external  conditions  and  by  the 
state  of  the  tissues  of  the  host.  The  coccus  of  erysipelas  is  somewhat  larger 
than  the  ordinary  form  of  streptococcus  pyogenes.  Infection  takes  place 
by  a  wound,  often  a  very  trivial  wound  of  the  skin  or  mucous  membrane. 
The  organism  multiplies  in  the  small  lym|)h-channels.  This  organism  will 
cause  puerperal  fever  in  a  woman  in  childbed  when  it  gains  access  to  "  an 
absorbing  surface  in  the  genital  tract  "  (Senn).  The  streptococcus  may  cause 
suppuration  in  erysipelas,  mixed  infection  not  being  necessary  to  induce  pus- 
formation. 

The  gonococcus  (Fig.  13,  the  bacillus  of  Neisser),  the  dij)l(Jcoccus  which 
causes  gonorrhea.  Bumm  proved  the  causative  influence  of  the  gonococcus. 
He  reproduced  the  disease  in  a  healthy  female  urethra  by  inoculation  with 


BACTERIOLOGY. 


Plate  i. 


1.  Staphylococcus  pyogenes  aureus. 

2.  Staphylococcus  pyogenes  albus. 

3.  Bacillus  tuberculosis  on  glycerin -agar. 

(Warren's  Surgical  Pathology. ) 


Other  Surgical   Microbes  39 

the  twentieth  generation  in  descent  from  a  pure  culture.  Diplococci  are  found 
often  in  the  secretions  of  apparently  healthy  mucous  membranes,  and  simulate 
very  closely  gonococci.  Gonococci  cannot  be  cultivated  upon  ordinary  media 
but  grow  best  upon  human  blood-serum.  In  gonorrhea  the  organisms  are 
found  both  within  and  outside  of  pus-cells  and  mucus-cells.  It  seems  reason- 
ably certain  that  the  gonococcus  is  pyogenic,  although  it  is  possible  that  the 
pus  formed  in  gonorrhea  is  due  to  mixed  infection.  Gonococci  stain  easily 
and  are  readily  decolorized  by  Gram's  method. 


Fig.  13. — Gonococci  from  gonorrheal  pus. 

Streptococci  are  found  in  noma.  No  specific  organism  has  been  isolated 
for  traumatic  spreading  gangrene  or  hospital  gangrene. 

The  bacillus  of  tetanus  (Fig.  14,  Nicolaier's  bacillus),  an  anaerobic  organ- 
ism, found  especially  in  the  soil  of  gardens,  in  the  dust  of  old  buildings,  in 


\ 


I'ig.  14. — Bacillus  of  tetanus,  with  spores. 

street  dirt,  and  in  the  sweepings  of  stables.  Spores  develop  at  thfe  ends  of 
these  bacilli.  The  bacilli  are  capable  of  producing  to.xins  of  deadly  power. 
The  spores  are  very  resistant  and  it  is  difficult  to  kill  them.  The  drug  which 
is  most  certainly  fatal  to  tetanus  bacilli  is  bromin. 

The  bacillus  tuberculosis  (Koch's  bacillus,  Plate  i.  Fig.  3),  the  cause  of 
all  tuberculous  processes,  is  met  with  especiall\'  in  dusty  air  which  contains 


40  Bacteriology 

the  dried  sputum  of  victims  of  phthisis.  This  infected  air  is  the  chief  means 
of  transmission  of  the  disease,  though  it  may  be  conveyed  by  the  milk  of 
tuberculous  cows  and  the  meat  of  tuberculous  animals.  Wounds  may  open 
a  gateway  for  infection.     Fig.  15  shows  tubercle  bacilli  in  sputum. 

Bacillus  anthracis  (Fig.  16),  the  cause  of  malignant  pustule,  or  splenic 
fever. 

Bacillus  mallei,  the  cause  of  glanders. 

Bacilhis  oj  syphilis  (Lustgarten's  bacillus).  That  syphilis  is  due  to  a 
micro-organism   is  highly  probable,   but  that  we  have  found  the  causative 

%  Xs   \        '^  \- 


\ 


\ 


V 


Fig.  15. — Tubercle  bacilli  in  sputum  (Ziegler). 

organism  in  Lustgarten's  bacillus  is  by  no  means  sure.  A  fact  which  points 
strongly  against  its  causative  power  is  that  it  is  found  rather  in  non-contagious 
tertiary  lesions  than  in  contagious  secondary  lesions. 

Diplococcus  pneumoni(e  is  believed  to  be  the  cause  of  pneumonia  and  acute 
meningitis.  It  is  found  normally  in  the  human  saliva.  This  organism  is 
often  spoken  of  as  Frankel's  bacillus  and  also  as  the  diplococcus  lanceolatus. 

The  bacillus  coli  communis,  called  also  the  bacterium  coli  commune,  the 
colon  bacillus,  or  the  bacillus  of  Escherich  (Fig.  17).     Feces  invariably  con- 


Fip.  16.— ^Bacillus  anthracis.     V  lono.  Fig.  17. — Pacilliis  of  maligtiatit  edema. 

tain  this  organism.  It  is  believed  b\'  many  observers  to  be  the  cau.se  of 
appendicitis,  peritonitis,  abscesses  about  the  intestine,  many  ischiorectal 
abscesses,  some  perirenal  abscesses,  certain  ca.ses  of  cystitis,  cholangitis,  and 
cholecystitis,  l-'rom  the  j)us  of  appendicitis  we  may  obtain  a  pure  culture 
of  Escherich's  bacillus,  but  usually  find  also  streptococci,  staphylococci,  or 
pneumococc  i.     The  colf)n  bacillus  has  pyogenic  |)ower. 

The  bacillus  oj  malii^udiil  edema  (Fig.   17)  (the  vibrione   septicjue   of  Pas- 


Infections  with  Protozoa  41 

teur),  found  especially  in  stagnant  water  and  certain  varieties  of  soil.  In 
the  disease  known  as  malignant  edema  there  is  a  mixed  infection  with  the 
bacilli  of  malignant  edema  and  saprophytic  organisms,  and  the  latter  form 
considerable  quantities  of  gas  in  the  tissues.  The  bacilli  of  malignant 
edema  may  cause  spreading  gangrene. 

The  bacillus  0}  typhoid  fever  (Eberth's  bacillus)  is  responsible  for  some 
cases  of  gangrene,  some  of  embolism,  and  not  a  few  of  bone  and  joint  disease. 
It  has  pyogenic  power. 

We  may  mention,  in  conclusion,  as  of  occasional  surgical  importance,  the 
bacillus  of  iniiuenza,  bacillus  of  diphtheria,  bacillus  of  bubonic  plague, 
bacillus  of  leprosy,  bacillus  of  rhinoscleroma,  bacillus  of  fetid  ozena,  bacillus 
of  hemorrhagic  septicemia,  bacillus  lactis  aerogenes  (an  occasional  cause  of 


i^^. 


-''  r 


^'y 

'\ 

A,«' 

% 

/' 

4 

'<    ^ 

I 

ir 

\ 

- 

w; 

'n 

.< 

• " 

\/ 

^/ 

f^ 

X 

Fig 

.  i8. — Bacillus 

coli  communis. 

peritonitis),  and  the  bacillus  aerogenes  capsulatus.  The  latter  organism 
causes  gangrenous  celluHtis,  a  spreading  gangrene  accompanied  by  gas- 
formation. 

The  putrefactive  organisms  are  responsible  for  many  septic  intoxications. 

Infections  with  Protozoa.— Protozoa  is  a  name  given  to  the  lowest 
forms  of  animal  life.  The  protozoa  are  minute  unicellular  organisms.  The 
cell  has  a  definite  nucleus  and  is  composed  of  protoplasm  and  a  more  or  less 
dense  cell-wall.  Many  species  have  organs  of  locomotion  (cilia  or  flagella). 
Protozoa  are  known  to  cause  malaria  and  dysentery.  Some  observers  main- 
tain that  they  cause  cancer,  and  it  is  thought  probable  that  they  may  produce 
smallpox. 


42  Asepsis  and    Antisepsis 


II.  ASEPSIS  AND  ANTISEPSIS. 

The  effort  in  all  operations  is  to  secure  and  maintain  scrupulous  surgical 
cleanliness.  What  is  known  as  the  antiseptic  method  we  owe  to  the  splendid 
labors  of  Lord  Lister,  and  the  aseptic  method  is  but  a  natural  evolution  of 
the  antiseptic  method.  It  is  true  that  Agostino  Bassi,  over  half  a  century  ago, 
convinced  that  various  maladies  were  due  to  parasites,  treated  wounds  with 
a  solution  of  corrosive  subhmate.  It  is  also  true  that  Semmelweis  in  1847 
demonstrated  the  infectiousness  of  puerperal  fever  and  the  method  of  prevent- 
ing it;  that  Jules  Lemaire  in  1863  published  a  treatise  on  carbolic  acid  and 
advocated  the  use  of  this  drug  in  the  treatment  of  wounds  in  order  to  destroy 
living  germs,  and  that  Bottini  in  1866  employed  carbolic  acid  in  the  treatment 
of  putrid  and  suppurating  wounds  because  he  believed  germs  to  be  responsible 
for  such  conditions  (Monti  on  "Modern  Pathology").  In  spite  of  the  above 
facts,  Lister  is  the  real  father  of  asepsis  and  taught  all  nations  how  to  prevent 
infection.  Monti  says:  "But  Lister,  with  that  practical  spirit  which  forms 
one  of  the  best  characteristics  of  English  genius,  from  the  scientific  studies 
of  Pasteur,  deduced  the  general  laws  of  antisepsis  and  the  rules  for  their 
methodical  application  to  practical  surgery."  Lister  called  the  attention  of 
the  profession  to  a  new  method  of  treating  wounds,  compound  fractures, 
and  abscesses  in  1867.*  The  processes  first  employed  were  extremely  com- 
plicated, but  have  been  made  in  the  last  few  years  simple  and  easy  of  per- 
formance. Lister  believed  the  chief  danger  to  be  from  air.  It  is  now  belie\'ed 
that  the  chief  danger  is  from  actual  contact  of  hands,  instruments,  dressings, 
or  foreign  bodies  with  a  wound.  Air  carries  but  few  micro-organisms  unless 
it  is  filled  with  dust.  Infection  through  air  is  most  apt  to  occur  if  the  air  is 
dusty,  and  is  more  common  after  an  aseptic  than  an  antiseptic  operation. 

Of  course,  some  bacteria  from  the  air  must  settle  in  every  wound,  but 
the  majority  of  air  fungi  are  harmless.  Comparatively  few  reach  the  wound 
unless  the  air  is  dusty,  and  these  few  the  tissues  are  usually  able  to  destroy. 
Schimmelbusch  made  experiments  in  von  Bergmann's  clinic  when  the  stu- 
dents were  present.  He  found  that  "  the  number  of  bacteria  which  settle 
upon  the  surface  of  a  wound  a  square  decimeter  in  extent,  in  the  course  of  half 
an  hour,  is  about  60  or  70,"  and  thousands  are  usually  required  to  produce 
infection. 

There  is  no  danger  of  the  breath  alone  producing  infection.  Air  which 
comes  from  the  lungs  is  germ-free,  and  even  a  large  class  will  not  infect  the 
air  by  breathing,  but  will  rather  help  free  it  from  bacteria,  for  the  lungs  are 
filters  for  air  laden  with  micro-organisms. 

In  performing  any  surgical  operation  cutting  is  better  than  tearing  by 
blunt  dissection.  The  former  method  makes  an  incised  wound,  the  latter  a 
lacerated  wound,  and  a  lacerated  wound  is  much  more  apt  to  become  infecterl 
than  is  an  incised  wound. 

Surgical  cleanliness  may  be  obtained  by  either  the  aseptic  or  the  antiseptic 
method.  In  the  aseptic  method  heat,  chemical  germicides,  or  both  are  used 
to  cleanse  the  instruments,  the  field  of  operation,  and  the  hands  of  the  surgeon 
and  his  assistants,  the  surface  being  freed  from  the  chemical  germicide  by 

*The  Lancet. 


Asepsis  and  Antisepsis.  43 

washing  with  boiled  water  or  with  saline  solution.  After  the  incision  has 
been  made  no  chemical  germicide  is  used,  the  wound  being  simply  sponged 
with  gauze  sterilized  by  heat ;  if  irrigation  is  necessary,  boiled  water  or  normal 
salt  solution  is  used,  and  the  wound  is  dressed  with  gauze  which  has  been 
rendered  sterile  by  heat.  The  effort  of  the  surgeon  is  simply  to  prevent  the 
entrance  of  micro-organisms  into  the  tissues.  Some  micro-organisms  must 
enter,  but  the  number  will  be  so  small  that  healthy  tissues  will  destroy  them. 
The  aseptic  method  should  be  used  only  in  non-infected  areas.  If  chemical 
germicides  are  not  used,  the  amount  of  wound-fluid  will  be  small,  the  surgeon 
can  often  dispense  with  drainage,  and  repair  will  be  rapid.  If  a  wound  is 
to  be  closed  without  drainage,  every  point  of  bleeding  must  be  hgated.  It 
is  often  advisable  to  sew  up  the  wound  with  Halsted's  subcuticular  stitch. 
If  this  stitch  is  employed,  the  skin  staphylococcus  does  not  obtain  access  to 
stitch-holes,  and  stitch-abscesses  are  not  apt  to  arise.  This  suture  may 
consist  of  catgut,  silk,  or,  preferably,  silver  wire,  this  latter  agent  being  capable 
of  certain  sterilization  by  heat  and  exercising  a  powerful  inhibitory  action 
on  micro-organisms.  If  a  wound  is  closed  without  drainage,  firm  compression 
is  applied  over  the  wound  to  obliterate  any  cavity  which  may  exist.  Drainage 
must  be  used  if  the  wound  is  very  large,  if  its  shape  or  structure  prevents  the 
obliteration  of  the  cavity  by  pressure,  if  there  is  any  doubt  as  to  the  perfect 
cleanliness  of  the  part,  if  the  patient  is  very  fat,  for  in  such  individuals  fat 
necrosis  predisposes  to  sepsis  and  to  fat  embolism,  and  if  the  skin  is  so  thin 
that  we  fear  pressure  will  produce  sloughing  ("  A  Manual  of  Surgical  Treat- 
ment," by  Cheyne  and  Burghard).  In  some  regions  of  the  body  wounds 
are  sealed  with  collodion  or  iodoform-collodion.  If  irrigation  is  not  practised 
and  the  wound  is  dressed  with  dry  sterile  gauze,  the  procedure  is  said  to  be 
by  the  "  dry  "  aseptic  method.  In  the  antiseptic  method  the  same  preparations 
are  made  for  the  operation  as  in  the  aseptic  method,  but  during  the  operation 
sponges  impregnated  with  a  chemical  germicide  are  used,  and  the  wound 
is  dressed  with  gauze  containing  corrosive  sublimate  or  some  other  chemical 
germicide.  If  the  wound  is  not  flushed  with  a  chemical  germicide,  and  is 
dressed  with  dry  antiseptic  gauze,  the  operation  is  said  to  be  by  the  "dry" 
antiseptic  method.  The  antiseptic  method  is  preferred  in  infected  areas. 
Dry  dressings  are  usually  preferable  to  moist  dressings,  because  they  are 
more  absorbent  and  do  not  act  as  poultices,  and  dry  dressings  may  be  used, 
even  when  the  wound  has  been  flushed.  Some  surgeons  question  the  value 
of  antiseptic  irrigation  in  a  septic  wound,  but  we  believe  it  removes  many 
bacteria  and  much  poisonous  matter  and  also  antidotes  toxic  material.  In 
suppurating  areas  it  is  often  best  to  use  moist  dressings  in  the  form  of  anti- 
septic fomentations.  Year  by  year  the  aseptic  method  becomes  more  popular. 
Surgeons  have  learned  that  the  most  important  factor  in  asepsis  is  mechanical 
cleansing  bv  means  of  soap  and  water.  The  chemical  germicide  plays  a 
secondarv  rather  than  a  vital  part.  By  mechanical  cleansing  great  numbers 
of  micro-organisms  are  removed  along  with  dirt,  grease,  and  epithelium. 
Manv  organisms  remain,  but  vast  hordes  are  washed  away,  and  the  danger 
of  infection  is  greatly  lessened  by  thus  diminishing  the  number  of  bacteria. 
If  a  chemical  germicide  is  used  without  preliminary  mechanical  cleansing,  it 
is  useless,  because  it  cannot  destroy  bacteria  in  the  epithelium  and  in  masses 
of  oilv  matter.     After  the  use  of  mechanical  cleansing  the  germicide  is  active 


44  Asepsis  and  Antisepsis 

in  destroying  the  comparatively  few  bacteria  which  are  naked  on  the  surface. 
In  many  regions  a  strong  chemical  germicide  must  not  be  used  (in  the  abdo- 
men, in  the  brain,  in  joints,  in  the  pleural  sac,  and  in  the  bladder),  and  in 
other  regions  (mucous  surfaces  and  fatty  tissue)  it  is  productive  of  harm 
rather  than  good. 

Preparation  for  an  Operation. — If  the  operation  is  to  be  performed 
in  a  hospital,  a  particular  room  is  always  ready.  If  it  is  to  be  done  in  a  private 
house,  much  careful  preparation  is  desirable.  A  room  in  which  an  operation 
is  to  be  performed  should  be  well  lighted  and  well  ventilated.  It  is  ad- 
vantageous to  have  an  open  grate  in  the  room,  for  then  a  fire  can  be  quickly 
made  to  take  a  chill  off  the  air  and  ventilation  is  improved.  The  morning 
before  the  operation  furniture  should  be  removed,  the  carpet  taken  up,  and 
curtains  and  hangings  taken  down.  If  the  ceiling  and  walls  are  papered, 
they  must  be  thoroughly  brushed.  If  they  are  painted,  they  must  be  washed 
with  soap  and  water.  Dust  is  thus  removed,  and  the  danger  of  dust 
falUng  into  the  wound  is  averted.  The  floor  is  scrubbed  with  soap  and 
water.  The  windows  should  be  opened  for  many  hours  to  thoroughly  dry 
and  freshen  the  room.  On  the  morning  of  the  operation  the  patient's  bed 
is  brought  into  the  room  and  placed  in  a  position  where  there  will  be  plenty 
of  light  for  future  dressings,  and  where  the  surgeon  will  have  access  from 
either  side.  Never  use  a  big  broad  bed;  use  a  narrow  bed.  Never  have  a 
feather  bed,  but  insist  on  Treves's  advice  being  followed,  and  employ  a  metal 
bed  with  a  wire  netting  and  hair  mattress. 

A  piece  of  carpet  or  rug  is  spread  upon  a  portion  of  the  floor  and  the  table 
is  set  upon  it.  The  table  should  be  so  placed  that  there  will  be  a  good  Hght 
on  the  field  of  operation.  A  kitchen  table  does  very  well.  On  the  table  is 
placed  a  folded  comfortable  or  several  folded  blankets. 

Around  the  operating-table  at  proper  distances  are  arranged  a  table  for 
instruments,  a  table  for  dressings,  a  table  for  sponges  and  a  basin  of  bichlorid, 
and  a  table  for  soap  and  a  basin  of  water.  A  couple  of  buckets  should  be 
placed  on  the  floor  near  at  hand.  The  nurse  and  assistants  should  have 
ready  the  ether  cone,  wrapped  in  a  clean  towel,  sterile  sheets,  sterile  gowns,- 
sterile  towels,  sterile  gauze  for  sponges  and  dressings,  trays  for  instruments, 
iodoform  gauze,  catgut,  silk,  silkworm-gut,  etc.,  according  to  the  nature  of 
the  operation.  The  surgeon  should  pick  out  the  instruments  required. 
The  anesthetizer  should  lay  out  a  mouth-gag,  tongue-forceps,  a  hypodermatic 
syringe  in  working  order,  ether  or  chloroform,  brandy,  tablets  of  strychnin, 
and  also  of  atropin. 

If  the  operation  is  to  be  performed  in  a  hospital,  it  is  desirable  to  have 
the  patient  admitted  two  or  three  days  before.  He  adjusts  himself  to  his 
surroundings,  becomes  accustomed  to  diminished  activity,  forms  an  acquaint- 
ance with  his  nurses  and  physicians,  and,  as  a  rule,  becomes  less  ner- 
vous and  more  calmly  confident  of  the  result.  The  patient  is  prepared  the 
day  before  the  operation,  except  in  an  emergency  case. 

When  the  time  for  the  operation  arrives,  the  surgeon  and  his  assistants 
remove  their  coats,  roll  up  their  sleeves,  and,  after  sterilizing  the  hands  and 
forearms,  envelop  their  bodies  in  aseptic  or  antiseptic  sheets  or  gowns,  to 
protect  the  patient  and  themselves.  It  is  a  good  plan  for  the  surgeon  and 
his  assistants  to  wear  sterile  musUn  caps.     The  caps  prevent  hair,  dandruff. 


Mechanical   Cleansing  45 

and  sweat  falling  into  the  wound.  Mikulicz  and  some  other  operators  wear 
over  the  mouth  and  nose  a  respirator  or  piece  of  gauze  in  order  to  prevent 
saliva  or  mucus  being  projected  into  the  wound  while  the  surgeon  talks. 

It  is  a  difficult  or  impossible  matter  to  absolutely  sterilize  the  hands,  but 
it  is  fortunate,  as  Mikulicz  and  Fliigge  say,  that  most  of  the  bacteria  of  the 
skin  are  harmless.  The  staphylococcus  epidermidis  albus,  howe\er,  is  con- 
stantly present  in  the  epidermis.  The  hands  of  some  persons  are  more 
easilv  sterilized  than  those  of  others.  For  instance,  a  hairy,  creased  hand 
is  more  difficult  of  sterilization  than  a  smooth  and  almost  hairless  one;  a 
hand  grossly  neglected,  than  one  reasonably  clean.  Germs  abound  in  the 
epidermis,  in  the  fissures  and  creases,  under  and  around  the  nails,  on  hairs, 
and  in  the  ducts  of  glands.  The  surface  of  the  hands  may  be  thoroughly 
sterile  at  the  beginning  of  an  operation  and  become  infected  later,  because 
germs  in  gland  ducts  are  forced  to  the  surface.  Hence,  in  a  prolonged  opera- 
tion, the  surgeon  should  stop  from  time  to  time  and  wash  his  hands,  first 
in  alcohol  and  then  in  corrosive  sublimate  solution  (Leonard  Freeman). 

In  view  of  the  difficulty  of  cleansing  the  hands,  every  student  must  be 
taught  how  to  do  it,  and  he  must  become  impressed  with  the  fact  that  the 
surgical  hand  is  to  be  regarded  as  reaching  to  the  elbow.  The  more  hands 
used  in  an  operation,  the  greater  is  the  danger  of  infection  of  the  wound. 
The  surgeon  u.ses  retractors  and  forceps  whenever  possible,  but  his  fingers 
must  enter  the  wound.  The  fingers  of  no  other  person  should  enter  unless 
absolutely  necessary.  The  basis  of  all  plans  of  sterilization  and  the  most 
important  part  of  any  plan  is  mechanical  cleansing  by  scrubbing  with  soap 
and  water.  By  this  means  a  quantity  of  loose  epidermis  is  removed  and  with 
it  great  numbers  of  bacteria. 

Mechanical  Cleansing. — The  hands  and  forearms  may  be  sterilized  in 
several  ways.  Any  method  is  preceded  by  mechanical  cleansing,  which  is 
carried  out  as  follows:  Scrub  for  five  minutes  with  soap  and  hot  sterile 
water,  giving  special  attention  to  the  nails  and  creases  in  the  skin.  The 
brush  is  rubbed  in  the  long  axis  of  the  extremity  and  also  transversely. 
The  creases  on  the  back  of  the  hands  and  fingers  will  be  partially  opened 
bv  flexing  the  fingers,  and  transverse  scrubbing  will  clean  the  furrows. 
The  furrows  on  the  palmar  surface  will  be  opened  by  extending  the  fingers, 
and  will  be  best  cleaned  by  transverse  scrubbing  (George  Ben  Johnston). 
The  best  soap  is  the  ethereal  soap  of  Johnston,  which  is  a  solution  of 
castile  soap  in  ether.  Green,  or  castile,  or  synol  soap  can  be  used.  The 
brush  employed  should  be  kept  in  a  i  :  1000  solution  of  corrosive  sublimate 
or  should  have  been  recently  sterilized  with  steam.  The  nails  are  cut  short, 
are  cleansed  with  a  knife,  and  the  hands  are  again  scrubbed. 

Fiirbringeys  Method:  After  washing  oft"  the  soap  in  sterile  water  the  hands 
are  dipped  in  95  per  cent,  alcohol  and  held  there  for  two  or  three  minutes  while 
the  forearms  are  being  rubbed  with  alcohol.  Alcohol  removes  the  soap  which 
has  entered  into  follicles  and  creases,  removes  desquamated  epitheHum,  enters 
under  and  about  the  nails,  and  favors  the  diffusion  of  the  corrosive  sublimate 
under  the  nails  and  into  the  follicles,  when  the  hands  are  placed  later  in  the 
mercurial  solution.  After  using  the  alcohol  the  hands  are  then  dipped  in 
a  hot  solution  of  corrosive  sublimate  (i  :  1000).  and  with  the  forearms  are 
scrubbed  for  at  least  a  minute,  the  nails  receiving  especial  care. 


46  Asepsis  and  Antisepsis 

The  Welch-Kelly  Method:  After  the  hands  or  forearms  have  been  cleaned 
mechanically  and  have  been  rinsed  in  sterile  water  they  are  immersed  for 
two  minutes  in  a  warm  solution  of  permanganate  of  potassium  (a  saturated 
solution  in  distilled  water)  and  are  then  immersed  in  a  warm  saturated  solution 
of  oxalic  acid  and  are  held  there  until  decolorized.  They  are  then  to  be  well 
washed  in  sterile  water,  are  next  immersed  for  two  minutes  in  a  i  :  500  solu- 
tion of  corrosive  sublimate,  and  finally  are  rinsed  in  sterile  water  and  dried 
on  a  sterile  towel.  The  solutions  for  use  in  the  above  method  should  be 
contained  in  jars  of  the  shape  of  a  druggist's  percolator  so  that  both  the  hands 
and  forearms  can  be  immersed  at  the  same  time. 

The  Weir-Stimson  Method:  The  hands  should  be  cleansed  mechanically 
as  previously  directed  or,  as  Weir  prefers,  by  scrubbing  with  a  brush  and 
green  soap  and  in  running  hot  water  and  cleaning  under  the  nails  with  a 
piece  of  soft  wood.  Place  about  a  tablespoonful  of  chlorinated  lime  in  the 
palm  of  the  hand,  place  upon  the  lime  an  equal  amount  of  crystalline  washing- 
soda,  add  a  little  water,  and  rub  the  creamy  mixture  over  the  arms  and  hands 
until  the  rough  granules  of  sodium  carbonate  are  no  longer  felt.  Place  the 
paste  under  and  around  the  nails  by  means  of  a  bit  of  sterile  orange- wood. 
Wash  the  arms  and  hands  in  hot  sterile  water.*  The  combination  forms 
nascent  chlorin,  a  most  efficient  germicide.  This  method  has  proved  extremely 
satisfactory  in  the  clinic  of  the  Jefferson  Medical  College  Hospital.  It  is 
important  that  crystalline  washing-soda  be  employed.  If  the  bicarbonate 
is  used,  nascent  chlorin  will  not  be  produced,  but  hydrochloric  acid  gas  will 
be  formed,  and  the  latter  gas  irritates  the  skin  and  is  not  a  satisfactory  germi- 
cide. 

The  Use  of  Gloves. — Some  surgeons  are  so  impressed  with  the  impos- 
sibility of  sterilizing  the  hands  that  they  wear  gloves  in  operations.  Hunter 
Robb  is  said  to  have  suggested  the  use  of  gloves  in  1894,  but  Halsted  began 
to  use  rubber  gloves  in  1889.  Mikuhcz  uses  white  cotton  gloves.  Lockett 
has  proved  that  cotton  and  silk  are  not  impervious  to  micro-organisms,  but 
that  rubber  is.  The  thin,  seamless  rubber  gloves  which  are  now  made  are 
very  satisfactory.  They  are  sterilized  by  boiling,  are  then  dried,  and  are 
wrapped  in  a  sterile  towel.  In  order  to  insert  the  hand  in  them,  the  interior 
of  the  glove  should  be  first  dusted  with  sterile  starch  or  talc  powder,  and 
then  the  nurse  should  hold  the  glove  while  the  surgeon  inserts  his  fingers 
into  the  proper  compartments  and  pushes  the  hand  in. 

If,  during  an  operation,  a  glove  becomes  infected,  a  clean  one  can  be 
substituted  for  it.  Gloves  somewhat  impair  the  sense  of  touch,  but  a  surgeon 
soon  learns  to  work  with  them.  If  they  are  to  be  used,  the  hands  should  be 
sterilized  just  as  carefully  as  when  they  are  not  to  be  used,  because,  during 
the  operation,  the  gloves  may  tear  or  be  punctured  by  a  needle.  That  it  is 
absolutely  necessary  to  wear  gloves  in  all  cases  has  not  been  y)roved.  Their 
use  does  contribute  to  success  in  brain  operations,  abdominal  operations, 
and  joint-operations.     They  are  of  great  value  in  military  surgery. 

When  a  surgeon  is  obliged  to  place  his  fingers  in  an  area  of  virulent  infec- 
tion he  may  be  poisoned.  Gloves  will  save  him  from  this  danger.  Again, 
a  surgeon  should  try  to  avoid  bringing  his  hands  unnecessarily  in  contact 
with  putrid  or  y)urulent  matter.  Though  it  may  not  poison  him,  it  grossly 
*  Medical  Record,  April  3,  1897. 


Disinfection  of  Instruments 


47 


infects  the  surface,  renders  subsequent  cleansing  difficult,  and  endangers 
other  patients.  Gloves  will  prevent  this  danger.  A  surgeon  should  wear 
gloves  if  he  is  making  an  examination  or  performing  an  operation  which  is 
sure  to  infect  the  bare  hands,  and  he  should  wear  gloves  in  an  operation  if  in  a 
previous  operation  his  hands  were  infected.* 

Instruments  are  disinfected  by  subjecting  them  to  the  action  of  steam 
in  a  special  sterilizer,  or  better  by  boiling  them  for  fifteen  minutes  in  a  i  per 

cent,   solution   of    carbonate    of    sodium. 

a 

They  are  wrapped  into  a  bundle  by 
means  of  a  towel  or  piece  of  gauze  and 
are  dropped  into  the  solution.  The 
blades  of  knives  should  first  be  wrapped 
in    cotton    to    prevent    scratching    and 


Fig.  19. — a,  Schimmelbusch's  gas-heated  apparatus  for  sterilizing  instruments  ;  b,  wire  basket. 

dulhng.  After  boiling,  the  instruments  should  be  rinsed  in  hot  sterile  water 
or  in  a  5  per  cent,  solution  of  carbolic  acid  and  be  kept  until  needed  in  a  pan 
of  sterile  water.  The  carbonate  of  sodium  prevents  rusting.  In  a  clinic 
the  boiling  is  carried  out  in  a  Schimmelbusch  sterilizer  (Fig.  19).  In  a 
private  house  it  can  be  done  in  a  sterilizer  such  as  that  shown  in  Fig.  20,  or 
in  a  pan,  a  kettle,  or  a  wash-boiler.  A  sterilizer  with  a  tray  is  better  than 
an  ordinary  pan  or  kettle,  because,  when  the  latter  is  used,  the  metal  instru- 
ments lie  in  the  bottom  of  the  vessel,  where  the  heat  is  very  great,  and  the 
temper  may  be  impaired. 
Boiling  unfortunately  destroys 
to  some  extent  the  keenness  of 
cutting  instruments,  the  ebul- 
lition throwing  them  about. 
Hence  the  kni\'es  should  be 
wrapped  in  cotton  to  pre- 
serve the  edges.  After  ster- 
ilization  the   instruments    are 

placed  in  trays  containing  boiled  water.  After  the  completion  of  the 
operation  the  instruments  should  be  scrubbed  with  soap  and  water, 
boiled  in  soda  solution,  and  dried  and  placed  in  a  closet  with  glass  shelves 
so  they  will  not  gather  dust.  Instruments  can  be  partially  disinfected  by 
keeping  them  for  thirty  minutes  in  a  5  per  cent,  solution  of  carbolic  acid 
or  in  a  2  per  cent,  solution  of  formalin.  Instruments  with  handles  of 
wood  must  not  be  boiled.  If  such  instruments  are  used,  thev  can  be 
disinfected  by  the  use  of  carbolic  acid,  but  they  should  not  be  used. 
Metal  instruments,  whenever  possible,  should  consist  of  one  smooth  piece. 
Grooves  and  letters  are  objectionable,  as  dirt  gathers  in  such  depressions. 
Ivory  handles  cannot  be  boiled. 

*A  review  of   the    literature  of  disinfection  of   the  hands,  bv  Martin    B.    Tinker   and 
A.  B.  Craig,  will  be  found  in  the  Phila.  Med.  journal,  Feb.  15,  1902. 


ar.  20. — P.  rtable  sterilizer. 


48  Asepsis  and  Antisepsis 

Preparation  of  the  Patient. — Whenever  possible,  give  the  patient  some 
davs'  rest  in  bed  before  a  severe  operation.  During  this  preliminar}-  rest 
studv  the  disease,  and  study  the  individual  in  order  to  learn  his  tendencies, 
peculiarities,  etc.  The  condition  of  the  lungs,  the  heart,  the  blood,  and  the 
kidneys  should  be  accurately  determined.  The  amount  of  urine  passed  in 
twenty-four  hours  should  be  ascertained,  and  the  percentage  of  urea  should 
be  estimated  from  a  sample  of  the  twenty-four  hours'  urine.  The  urine  is 
carefuUv  examined  for  sugar,  albumin,  casts,  etc.  By  the  above  examinations 
we  may  be  able  to  anticipate  and  provide  against  certain  calamities:  We  ma}' 
be  led  to  postpone  or  abandon  an  operation,  and  we  will  be  made  able  to 
intelligently  select  the  proper  anesthetic.  Constipation  must  be  amended 
bv  mild  laxatives  or  enemas.  The  diet  should  be  nutritious  but  not  bulky. 
The  night  before  the  operation  give  a  saline  cathartic,  and  the  morning  of 
the  operation  employ  an  enema.  Empt\ing  the  bowels  lessens  the  danger 
of  sepsis  after  operation.  It  is  desirable  that  the  rectum  be  empty,  because 
in  shock  the  absorbing  power  of  the  stomach  is  greatly  diminished  or  is  even 
abolished  for  the  time,  and  we  may  wish  to  utilize  the  absorbing  power  of 
the  rectum  and  give  stimulants  by  enema.  When  a  patient  is  under  the 
influence  of  an  anesthetic,  or  when  he  is  j^rofoundly  shocked,  of  course  no 
attempt  is  made  to  give  stimulants  by  the  mouth.  Whenever  posssible,  give 
a  general  warm  bath  the  day  before  the  operation.  The  evening  before  the 
operation  shave  the  region  if  hairy,  scrub  the  entire  field  of  0])eration,  as  well 
as  the  adjoining  regions,  with  ethereal  soap  and  water;  wash  with  ether  or 
alcohol;  scrub  with  hot  corrosive  sublimate  solution  (i  :  1000) ;  apply  a  layer  of 
moist  corrosive  sublimate  gauze,  and  place  over  this  dry  antiseptic  gauze,  a 
rubber  dam,  and  a  bandage.  Many  surgeons  apply  a  poultice  of  green  soap 
for  many  hours  before  applying  a  chemical  germicide,  in  order  to  separate 
masses  of  epithelium  and  with  them  many  germs.  This  method  is  particu- 
larly useful  in  cleansing  the  scalp.  On  removing  the  dressings  to  perform 
the  operation,  scrub  the  part  with  soap  and  water,  wash  it  with  sterile  water 
and  then  with  alcohol,  surround  the  field  of  operation  with  dry  sterile  sheets 
and  towels  and  scrub  the  exposed  area  with  a  hot  solution  of  corrosive  sub- 
limate (i  :  1000).  Murphy  prevents  infection  from  the  cutaneous  surface 
by  spreading  a  specially  prepared  rubber  dam  over  the  sterilized  operation 
area.  The  dam  is  sterile  and  sticks  to  the  skin.  The  incisions  are  made 
through  the  artificial  skin  of  rubber  and  the  dam  is  removed  when  the  surgeon 
is  ready  to  introduce  the  sutures.  Thus  infection  of  the  wound  with  con- 
taminated sweat  is  prevented,  for,  as  Murphy  says,  this  elastic  covering  is 
"in  reality  a  non-secreting,  sterile,  artificial  derma,  for  the  |)eriod  of  opera- 
tion" ("General  Surgery,"  edited  by  John  B.  Murphy).  The  i)atient  must 
be  carefully  ])rotected  from  cold  by  wrapjjing  him  in  blankets  and  often  l)y 
having  him  wear  specially  prepared  drawers  with  feet.  After  the  completion 
of  an  operation  and  the  application  of  the  dressings  the  patient  is  returned 
to  his  room  or  the  ward,  care  being  taken  to  protect  him  from  cold  or  draughts. 
In  emergency  cases  disinfection  can  only  be  ]jractised  just  previous  to  the 
operation.  Disinfection  in  such  cases  can  be  thoroughly  effected  by  scrub- 
bing with  soap  and  water  and  then  using  chlorinated  lime  and  washing 
soda. 

Disinfection  of  Mucous  Membranes. — it  is  impossible  to  thf)roughly 


Litjatures  and  Sutures 


49 


disinfect  mucous  membranes.  We  cannot  scrub  forcibly,  and  we  must  not 
use  powerful  antiseptics  because  they  are  irritant  and  also  because  they  may 
be  absorbed.  The  best  that  can  be  done  in  the  vagina  is  to  rub  hghtly, 
when  possible,  with  a  bit  of  moist  absorbent  cotton  and  irrigate  with  a  solution 
of  boric  acid  or  with  normal  salt  solution.  Another  method  is  to  sponge  the 
vagina  with  creolin  and  Johnston's  ethereal  soap  (i  and  i6)  and  irrigate  with 
hot  saline  fluid  or  boracic  acid. 

The  rectum  is  prepared  by  washing  out  all  retained  feces  by  the  use  of 
copious  high  injections  and  by  irrigating  with  salt  solution  or  boracic  acid. 

The  mouth  is  prepared  by  having  snags  of  teeth  removed  and  decayed 
teeth  plugged.  For  several  days  before  the  operation  scrub  the  teeth  twice 
a  day  with  a  brush  and  castile  soap;  and  every  three  hours,  when  the  patient 
is  awake,  rinse  the  mouth  with  peroxid  of  hydrogen  and  spray  the  nares  and 
nasopharynx  with  boracic  acid  solution. 

The  urethra  is  prepared  by  the  administration  for  several  days  of  salol  or 
urotropin  and  by  frequent  irrigation  of  the  urethra  and  bladder  with  boracic 
acid  solution  or  normal  salt  solution  or  a  solution  of  permanganate  of  potash 
(i  :  6000). 

Irrigation  is  often  practised  in  septic  wounds,  but  is  not  required  in 
aseptic  wounds.  In  a  septic  wound  gentle  irrigation  with  an  antiseptic  is 
advisable.  It  removes  bacteria  and  toxins  and  antidotes  retained  toxins. 
It  must  never  be  forcible  for  fear  it  may  disseminate  infection.  Among 
irrigating  fluids  we  may  mention  corrosive  sublimate,  carbolic  acid,  peroxid 
of  hydrogen,  boric  acid  solution,  and  normal  salt  solution.  Hot  normal 
salt  solution  is  the  best  agent  with  which  to  irrigate  the  peritoneal  cavity,  the 
pleural  sac,  the  interior  of  joints,  and  the  surface  of  the  brain.  This  solution 
contains  0.6  per  cent,  of  sodium  chlorid. 

Many  surgeons  employ  Landerer's  dry  method  in  operadng  aseptically. 
No  fluid  is  applied  to  the  wound.  As  the  wound  is  enlarged  gauze  sponges 
are  packed  in  to  arrest  hemorrhage.  On  the  completion  of  the  operation  the 
sponges  are  removed,  any  bleeding  points  are  ligated,  and  the  wound  is  often 
closed  without  drainage. 

Ligatures  and  Sutures. — In  using  sutures  always  remember  that  they 
must  be  tied  firmly,  but  never  tightly.  A  tight  suture  will  cut  when  the 
wound  swells  and  will  thus  fail  of  its  purpose;  further,  it  produces  an  area 
of  tissue  necrosis,  which  is  a  point  of  least  resistance  in  and  about  which, 
infection  is  prone  to  occur. 

Catgut. — The  favorite  ligature  material  is  catgut.  Catgut  undergoes  ab- 
sorption in  the  tissues.  Years  ago  attempts  were  made  by  Scarpa,  Crampton, 
and  Physick  to  use  absorbable  ligatures.  Sir  Astley  Cooper  tried  catgut. 
These  attempts  failed  because  the  material  employed  was  septic,  suppuration 
ensued,  the  wound  gaped,  and  the  Hgature  was  cast  off  prematurely.  Surgeons 
remained  content  with  non-absorbable  ligatures  of  silk  or  linen.  These 
ligatures  were  not  cut  short,  but  a  long  end  was  left  to  each  one,  and  the 
ends  were  allowed  to  hang  out  of  the  wound.  The  ligatures  were  lightly 
pulled  upon  from  time  to  time,  and  when  they  loosened  or  cut  through  were 
removed.  Catgut  is  the  submucous  coat  of  the  intestine  of  the  sheep,  and 
is  the  material  from  which  violin  strings  are  made.  It  was  reintroduced  into 
surgery  by  Lister.     It  is  obtained  in  the  following  manner:  The  small  intestine, 

4 


50  Asepsis  and  Antisepsis 

after  separation  from  the  mesentery,  is  washed  in  water,  laid  upon  a  board, 
and  scraped  with  a  metal  instrument.  Thus  the  mucous  coat  and  the  muscular 
coat  are  scraped  away,  and  the  submucous  coat  only  remains.  The  sub- 
mucous coat  is  cut  into  strips,  and  each  strip  is  twisted  into  a  coil.  Raw  cat- 
gut is  an  infected  material.  It  is  difficult  to  sterilize  it,  because  in  the  twisting 
many  organisms  get  into  the  interior  of  the  strand,  where  it  is  difficult  for 
antiseptics  to  reach  them.  Raw  catgut  obtained  from  animals  dead  of 
splenic  fever  contains  spores  of  anthrax.  If  not  thoroughly  disinfected,  catgut 
is  dangerous,  and  some  surgeons  consider  its  cleanliness  always  a  matter 
of  grave  question  and  will  not  use  it.  Surgeon's  catgut  can  be  bought  from 
the  dealer  in  skeins  containing  thirty  yards.  It  should  be  rough  and  yellow. 
The  smooth  white  variety  should  not  be  gotten.  It  has  been  rubbed  smooth 
with  a  piece  of  glass  and  bleached  with  a  chemical,  and  in  consequence  is 
weak  and  unreliable.  The  smallest  size  is  known  as  double  zero,  then  come 
single  zero,  No.  i.  No.  2,  No.  3,  and  No.  4.  The  usual  Hgature  size  is  No. 
2.  Nos.  3  and  4  are  only  used  for  tying  thick  pedicles.  Nos.  i  and  2  are 
used  for  suturing  the  dura  and  peritoneum,  and  for  tying  small  vessels  in  the 
brain.  McBurney  and  Collins  state  that  when  catgut  is  used  to  tie  delicate 
tissue  (omental  masses,  intestinal  surfaces,  etc.),  it  must  first  be  softened  by 
immersing  for  half  a  minute  in  normal  salt  solution.  If  this  precaution  is 
neglected  and  wiry  catgut  is  used,  the  ligature  or  suture  will  cut  and  hemor- 
rhage will  occur.* 

If  catgut  is  thoroughly  freed  from  bacteria,  and  the  wound  in  which  it  is 
used  is  aseptic,  it  is  a  most  satisfactory  hgature  material,  is  absorbed  in  the 
wound  after  being  cut  off  short,  and  produces  no  trouble  although  it  does  in- 
crease slightly  wound  secretion.  The  smaller  sizes  are  absorbed  in  four  or  five 
days,  No.  2  lasts  from  nine  to  ten  days,  Nos.  3  and  4  from  ten  days  to  three 
weeks. 

One  of  the  following  methods  of  preparation  may  be  used:  The  catgut  is 
soaked  in  ether  for  twenty-four  hours  to  remove  fat.  It  is  then  wound  on 
glass  spools,  transferred  to  alcohol,  and  boiled  under  pressure.  The  boiling 
is  conducted  in  a  heavy  metal  jar  with  a  well-ffiting  screw-top.  The  jar  is 
half  filled  with  alcohol.  The  spools  of  catgut  are  placed  in  the  jar,  the  Hds 
screwed  down,  and  the  apparatus  is  immersed  in  boiling  water  for  half  an 
hour.  The  gut  is  kept  in  this  jar  until  needed.  Fowler's  catgut  is  prepared 
by  boiling  in  alcohol.  It  is  placed  in  hermetically  sealed  U-shaped  glass 
tubes.  Each  tube  contains  alcohol  and  twelve  ligatures.  The  alcohol  is 
boiled  by  immersing  the  tube  in  boiling  water.  The  cumol  method  is  employed 
by  Kelly  in  the  Johns  Hopkins  Hospital,  and  is  known  as  Kronig's  method. 
Cumol  is  a  fluid  hydrocarbon  which  boils  at  179°  C.  Catgut  is  wound  upon 
spools  of  glass,  and  these  are  placed  in  a  beaker  glass,  the  bottom  of  which  is 
covered  with  cotton.  A  bit  of  cardboard  is  placed  on  top  of  the  beaker,  and 
through  a  small  perforation  in  the  cardboard  a  thermometer  is  introduced. 
The  beaker  is  placed  in  a  sand-bath  and  the  bath  is  heated  by  means  of  a 
Bunsen  burner.  The  temperature  is  gradually  raised  to  80°  C,  and  is  kept 
at  this  point  for  one  hour,  in  order  entirely  to  remove  moisture  from  the  gut. 
Cumol,  at  a  temperature  of  100°  C,  is  poured  into  the  glass,  and  the  heat  is 
increased  until  the  temperature  of  the  cumol  is  a  few  degrees  below  its  boiling- 
*  "  International  Text-Book  of  Surgery." 


Ligatures  and  Sutures  51 

point  (165°  C.)-  For  one  hour  this  temperature  is  maintained.  Then  the 
cumol  is  poured  off  and  the  catgut  is  allowed  to  remain  for  a  time  in  the  sand- 
bath  at  a  temperature  of  100°  C,  in  order  to  dry.  It  is  transferred  for  keeping 
into  sterile  glass  jars  or  test-tubes.* 

The  formalin  method  is  advocated  by  the  elder  Senn.  The  catgut  is 
wound  on  glass  test-tubes,  and  is  immersed  in  an  aqueous  solution  of  formalin 
(2-4  per  cent.)  for  twenty-four  to  forty-eight  hours.  It  is  placed  in  running 
water  for  twelve  hours  to  get  rid  of  the  formalin.  It  is  boiled  in  water  for 
fifteen  minutes,  is  cut  in  pieces  and  tied  in  bundles,  placed  in  a  glass-stoppered 
jar,  and  is  kept  ready  for  use  in  the  following  mi.xture:  950  parts  of  absolute 
alcohol,  50  parts  of  glycerin,  and  100  parts  of  pulverized  iodoform.  Every 
few  days  the  mixture  should  be  shaken. 

Senn's  process  is  a  modification  of  Hoffmeister's.  Even  sterile  catgut 
contains  a  toxic  substance  which  increases  wound  secretion,  has  a  poisonous 
effect  on  body-cells,  and  favors  to  some  extent  limited  suppuration.  Senn 
maintains  that  to  counteract  this  influence  gut  should  not  only  be  sterile, 
but  should  be  antiseptic,  to  inhibit  the  growth  of  pyogenic  organisms  which 
reach  the  wound  from  without  during  operation  or  subsequently  by  the  blood. 

Boeckman  wraps  catgut  in  paraffin  paper,  seals  it  in  a  paper  envelope, 
puts  it  in  the  sterilizer,  and  subjects  it  to  dry  heat.  For  three  hours  it  is  heated 
to  a  temperature  of  284°  F.,  and  for  four  hours  to  a  temperature  of  290°  F. 
The  envelope  can  be  carried  in  the  pocket  or  the  instrument  bag.  When  the 
gut  is  wanted  the  end  of  the  envelope  is  torn  off,  an  assistant  Avith  sterilized 
hands  unwraps  the  parafl&n  paper,  and  the  gut  is  dipped  for  a  moment  in 
sterile  water  to  make  it  phable.f 

A  method  which  has  been  largely  used  is  to  take  raw  catgut,  keep  it  in 
ether  for  twenty-four  hours,  soak  it  for  twenty-four  hours  in  an  alcoholic 
solution  of  corrosive  sublimate  (i  :  500),  wind  it  on  sterilized  glass  rods,  and 
place  it  for  keeping  in  ether  or  in  alcohol. 

Johnston's  quick  method  of  preparing  catgut  is  as  follows:  Place  it  for 
twenty-four  hours  in  ether;  at  the  end  of  this  period  place  it  in  a  solution 
containing  20  grains  of  corrosive  sublimate,  100  grains  of  tartaric  acid,  and 
6  ounces  of  alcohol.  The  small  gut  is  kept  in  this  for  ten  or  fifteen  minutes, 
the  larger  gut  from  twenty  to  thirty  minutes,  but  never  longer.  It  is  placed 
for  keeping  in  a  mixture  containing  i  drop  of  chlorid  of  palladium  to  8  ounces 
of  alcohol.  This  gut  is  strong  and  reliable.  At  the  time  of  operation  the  gut 
is  placed  in  a  solution  one-third  of  which  is  5  per  cent,  carbolic  acid  solution 
and  two-thirds  of  which  is  alcohol. 

Chromicized  catgut  is  absorbed  less  rapidly  by  the  tissues  than  ordinary 
catgut.  It  is  used  to  tie  thick  pedicles  and  large  arteries,  to  suture  nerves  and 
tendons,  and  as  a  suture  material  in  the  radical  cure  of  hernia.  Chromicized 
gut.  No.  3  and  No.  4,  will  remain  unabsorbed  in  the  tissues  from  four  to  six 
weeks.  The  gut  should  be  soaked  in  ether  for  twenty-four  hours,  and  placed 
for  twenty-four  hours  in  a  4  per  cent,  solution  of  chromic  acid  in  water. 
The  gut  is  then  dried  in  a  hot-air  sterilizer  and  disinfected  by  one  of  the 
several  methods.     The  cumol  method  is  satisfactory. 

*  See  McBurney  and  Collins,  in  "International  Text- Book  of  Surgeiy,"'  and  Clark, 
in    Johns   Hopkins   Ilospital    Bulletin,    March,    1896. 

IJames  E.  Moore,  in  Phila.  Med.  Journal,  June  22,  1898. 


52  Asepsis  and  Antisepsis 

Catgut  is  tied  in  a  reef  knot  (square  knot)  and  distinct  ends  are  left  on 
cutting.  The  second  knot,  if  pulled  too  tightly,  may  break  the  ligature. 
Moist  catgut  is  slippery  and  is  hard  to  tie.  If  a  large  vessel  is  tied  by  catgut, 
a  third  knot  should  be  used  and  the  ends  cut  close  to  the  knot. 

Kangaroo-tendon  is  obtained  from  the  tail  of  the  great  kangaroo.  This 
material  is  especially  useful  for  buried  sutures  in  hernia  operations;  it  will  be 
absorbed  in  the  tissues,  but  only  after  a  long  time  (sixty  to  seventy  days). 
Kangaroo-tendon  is  not  grossly  infected  as  is  catgut.  The  material  is  obtained 
from  a  recently  killed  animal  and  is  promptly  dried  in  the  sun.  This  suture 
material  was  introduced  by  Dr.  Henry  O.  Marcy.  It  can  be  prepared  in  the 
same  manner  as  the  chromicized  catgut,  and  it  ought  always  to  be  chromicized. 
Marcy's  plan  of  preparation  is  as  follows:  Soak  the  dried  tendon  in  a  solution 
of  corrosive  sublimate  (i  :  looo)  and  separate  the  individual  strands.  The 
individual  strands  will  be  of  equal  diameter  and  from  lo  to  20  inches  in  length. 
The  diameter  depends  on  the  size  of  the  animal.  Dry  each  strand  in  an  an- 
tiseptic towel.  Chromicize  the  tendons  and  keep  them  until  needed  in  boiled 
linseed  oil  containing  5  per  cent,  of  carbolic  acid.  Before  using  the  strands 
take  them  out  of  the  oil,  wipe  off  the  oil  with  a  sterile  towel,  and  immerse  the 
tendon  for  half  an  hour  in  a  i  :  1000  solution  of  bichlorid  of  mercury.  This 
immersion  does  not  make  them  swell  and  soften  and  does  not  weaken  them  as 
it  would  catgut. 

The  following  method  of  preparation  is  recommended  by  Charles  Truax 
("Mechanics  of  Surgery"):  Soak  the  dried  tendon  until  it  becomes  supple, 
in  a  I  :  1000  solution  of  corrosive  sublimate.  Separate  the  material  into 
individual  tendons,  place  them  lengthwise  between  two  towels;  dry  them; 
make  them  aseptic  by  soaking  in  a  solution  of  formalin,  as  we  would  do  with 
catgut  (see  page  51).  After  washing  out  the  formalin  chromicize  the  tendon 
by  placing  it  in  a  fresh  5  per  cent,  solution  of  carbolic  acid  containing  i  :  4000 
pans  of  chromic  acid.  When  the  tendons  become  "dark  golden  brown"  in 
color,  they  are  removed  from  the  chromic  acid  solution,  dried  between  sterile 
towels,  and  placed  for  keeping  in  10  per  cent,  carbolized  oil.  When  wanted, 
they  are  removed  from  the  oil,  and  wiped  with  a  sterile  towel  saturated  with 
bichlorid  solution  (i  :  1000).     Kangaroo-tendon  is  tied  in  a  reef  knot. 

Silk.—Thh  material  can  be  used  for  both  ligatures  and  sutures;  many 
sizes  should  be  kept  on  hand.  White  silk  may  be  used,  or  black  silk,  which 
is  more  easily  visible.  Silk  is  encapsuled  in  the  tissues.  It  is  not  absorbed 
at  all  or  only  after  a  very  long  time.  It  is  not  a  good  material  for  buried 
sutures,  as  in  the  long  run  it  may  form  a  sinus.  Sutures  of  silk  should  be 
boiled  for  half  an  hour  before  using,  in  a  i  per  cent,  solution  of  carbonate  of 
sodium.  Some  surgeons  keep  the  silk  after  boiling  in  sublimated  alcohol 
(1  :  looo)  or  carbolic  .solution  (5  per  cent.),  but  it  is  better  to  prepare  it  just 
before  using.  A  convenient  method  of  preparation  is  to  wind  the  silk  on  a 
glass  spool,  place  the  spool  in  a  large  test-tube,  close  the  mouth  of  the  tube  with 
jewelers'  cotton,  introduce  the  tube  into  a  steam  sterilizer,  and  subject  it  to  a 
pressure  of  ten  pounds  for  twenty  minutes,  repeating  the  process  the  next  day. 
These  tubes  are  carried  in  wooden  boxes  sealed  with  rubber  corks.  Silk  is 
very  strong,  soft,  extremely  supple,  and  does  not  swell  or  irritate.  It  can  be 
tied  into  very  firm  knots.  Ordinary  surgical  silk  is  a  form  of  twisted  silk — 
that  is,  several  or  many  strands  are  twisted  into  one. 


Dressings  53 

Cable  twist  or  Tait's  silk  is  very  strong  and  is  used  for  tying  large  pedicles. 
Braided  silk  is  extremely  strong  and  is  made  by  plaiting  together  several 
strands  of  twisted  silk.  Floss  silk  is  "  a  straight  fiber  slightly  twisted  "  (Truax). 
Silk  is  usually  tied  in  a  reef  knot,  but  occasionally  in  a  surgeon's  knot. 

Horsehair. — This  is  used  for  effecting  very  neat  approximation  where 
only  light  sutures  are  required;  for  instance,  in  wounds  of  the  face.  Its 
chief  use  is  for  capillary  drainage.  It  is  prepared  by  washing  and  then  boil- 
ing for  fifteen  minutes  in  a  4  per  cent,  solution  of  carbonate  of  sodium.  It  is 
kept  until  needed  in  sublimated  alcohol  (i  :  1000). 

Silkworm- gut. — This  material  contains  fewer  bacteria  than  catgut  and 
does  not  swell  when  introduced  into  a  wound.  It  is  strong,  solid,  smooth, 
non-irritating,  and  can  be  drawn  through  the  tissues  with  slight  force.  The 
designation  silkworm-gut  is  a  misnomer;  the  material  is  not  gut  at  all.  It 
is  obtained  by  killing  the  silkworm  when  it  is  just  ready  to  spin  the  cocoon, 
and  drawing  out  the  fiber.  It  is  a  very  valuable  suture  material,  but  is 
not  used  for  ligatures.  Silkworm-gut  is  prepared  by  placing  it  in  ether  for 
forty-eight  hours  and  in  a  solution  of  corrosive  sublimate  (i  :  1000)  for  one 
hour,  or  it  can  be  boiled  in  plain  water  for  half  an  hour.  It  is  carried  in  a  long 
tube  filled  with  alcohol.  A  few  minutes  before  using  the  gut  is  placed  in 
carbolic  acid  and  alcohol  (one-third  of  the  solution  is  a  5  per  cent,  solution 
of  acid,  two-thirds  of  it  is  alcohol).  Silkworm-gut  is  tied  by  the  surgeon's 
knot. 

Celluloid  thread  is  warmly  advocated  by  Pagenstecher.  He  calls  it  cellu- 
loid yarn,  and  prepares  it  from  English  gray  linen  thread.  I  have  used  it 
with  much  satisfaction.  It  is  strong,  smooth,  flexible,  and  the  knot  holds 
firmly;  it  can  be  sterilized  by  any  method  used  for  raw  silk,  and  sterilization 
by  dry  heat  actually  increases  its  strength.  Its  one  disadvantage  is  that  it 
absorbs  about  40  per  cent,  of  fluid,  but  does  not  soften.  The  celluloid  is 
added  after  the  thread  has  been  boiled  in  a  i  per  cent,  solution  of  carbonate 
of  soda  wiped  or  wrapped  in  a  sterile  towel  and  dried  in  hot  air  or  steam.  It 
is  then  dipped  in  a  solution  of  celluloid  heated  in  a  hot-air  sterilizer,  and  packed 
in  sterile  boxes  (Schlutius,  in  "Pacific  Med.  Journal,"  Jan.,  1900;  Keen  and 
Rosenberger,  in  "Phila.  Med.  Journal,"  May  10,  1900).  Celluloid  thread 
can  be  used  for  sutures  or  ligatures. 

Silver  wire  is  prepared  by  boiling.  It  is  a  very  useful  suture  material,  as 
it  can  be  thoroughly  sterilized  and  has  an  inhibitory  effect  on  the  growth  of 
bacteria.  Some  surgeons  use  it  for  buried  sutures,  but  many  are  opposed  to 
using  it  thus  on  the  ground  that  it  is  apt  to  lead  to  sinus-formation. 

Most  wounds  are  closed  by  interrupted  sutures  of  silkworm-gut,  but  silk, 
catgut,  chromic  catgut,  or  silver  wire  can  be  used.  The  old  continuous 
suture  (glovers'  stitch)  is  rarely  used.  An  admirable  closure  can  be  eft"ected 
by  Halsted's  subcuticular  stitch,  and  scarcely  any  scar  results.  Marcy's 
buried  tendon  sutures  are  very  valuable,  es]jecially  in  hernia  operations  and 
in  various  operations  upon  the  abdomen. 

Dressings  are  made  of  cheese-cloth.  In  order  to  make  antiseptic  gauze 
the  cheese-cloth  is  boiled  in  a  solution  of  carbonate  of  sodium,  rinsed  out, 
and  dried;  it  is  then  soaked  for  twenty-four  hours  in  a  solution  containing  i 
part  of  corrosive  sublimate,  2  parts  of  table  salt,  and  500  parts  of  water.  It 
is  placed  in  clean  jars  with  glass  lids,  and  it  may  be  kept  moist  or  dry. 


54 


Asepsis  and  Antisepsis 


Sterilized  or  aseptic  gauze  is  prepared  by  boiling  in  carbonate  of  sodium, 
etc.,  as  described  under  Antiseptic  Gauze.  It  is  wrapped  in  a  towel  and  is 
placed  in  a  steam  sterilizer  for  an  hour  (Fig.  21).  It  is  kept  in  sterile  glass 
jars  with  glass  lids.  The  pads  for  sponging  are  made  by  rolling  up  portions 
of  sterile  gauze.     Ashton's  abdominal  pads  are  made  b}'  taking  several  layers 


Fig.  21. — Lautenschlager's  steam  sterilizer  for  dressings  :  A,  Exterior  view  ;  B,  cross-section. 

of  sterile  gauze,  each  piece  about  six  inches  long  and  four  inches  wide,  running 
a  stitch  around  the  margin,  and  sewing  a  piece  of  tape  into  one  corner. 

Sterile  absorbent  cotton  is  prepared  in  the  same  manner  as  gauze.  Cotton 
is  useful  as  a  dressing  to  supplement  gauze,  being  placed  on  the  outside  of  the 
gauze.     It  absorbs  quantities  of  serum,  but  will  take  up  very  little  pus. 

Iodoform  gauze  is  very  useful  for  packing  in  the  brain  and  abdomen,  for 
packing  absces.ses  and  tuberculous  areas,  and  for  dressing  foul  wounds.  It 
is  prepared  as  follows:  Make  an  emulsion  composed  of  equal  parts  by  weight 
of  iodoform,  glycerin,  and  alcohol,  and  add  corrosive  sublimate  in  the  pro- 
portion of  I  part  to  1000  of  the  mixture.  This  mixture  stands  for  three 
days.  Take  moist  bichlorid  gauze,  saturate  it  with  the  emulsion,  let  it  drip 
for  a  time,  and  keep  it  in  sterilized  and  covered  glass  jars  (Johnston). 

Lister's  cyanid  gauze  (double  cyanid  of  zinc  and  mercury)  is  not  certainly 
antiseptic,  and  must  be  dipped  into  a  corrosive  sublimate  solution  ( i  :  2000) 
before  using.  All  forms  of  gauze  can  be  bought  ready  prepared  from  reliable 
firms. 

Some  surgeons  place  silver  joil  upon  a  wound  before  ajjplying  the  gauze 
(Halsted,  page  29).  Small  wounds  in  which  drainage  is  not  employed  may 
often  be  dressed  by  laying  a  film  of  aseptic  absorbent  cotton  over  the 
wound  and  applying,  by  means  of  a  clean  camel's-hair  brush,  iodoform 
collodion  (grs.  xlviij  of  iodoform  to  5j  of  collodion).  Among  other  materials 
sometimes  used  for  dressing  wounds  the  following  should  he  mentioned:  Wood 
wool,  absorbent  wool,  moose  pa[)y)e,  oakum,  jute,  peat,  and  sawdust. 

Protectives. — A  protective  is  a  material  placed  directly  upon  wounds  to 
shield  them  from  irritation  and  infection  and  outside  of  dressings  to  diffuse  and 
prevent  the  escape  of  discharge.     The  commonly  used  protectives  are  Lister's 


Change    of  Dressing  55 

oil  silk  protective,  gutta-percha  tissue,  rubber  dam,  waxed  paper,  paraffin 
paper,  mackintosh,  and  silver  foil.  Undoubtedly,  many  antiseptic  agents 
destroy  young  cells  and  in  this  way  hinder  repair.  The  same  is  true  of  certain 
rough  dressings. 

R.  T.  Morris  maintains  that  gauze  and  particularly  cotton  are  injurious 
to  a  heahng  wound.  A  non-irritant  protective  laid  directly  upon  a  wound 
may  be  useful. 

Among  the  best  protectives  in  common  use  are  Lister's  protective,  gutta- 
percha tissue,  and  silver  foil.  Morris  condemns  gutta-percha  tissue  as  irri- 
tant. He  uses  thin  gold-beaters'  skin  made  from  the  peritoneum  of  the  ox, 
which  material  he  calls  Cargile  membrane,  after  an  Arkansas  physician  who 
introduced  it  into  practice.  The  advantage  of  this  material  is  that  moisture 
cannot  penetrate  and  new  cells  do  not  adhere. 

Silver  foil.  Lister's  protective,  and  gutta-percha  tissue  are  laid  directlv 
upon  a  wound,  the  dressing  being  placed  above  it.  Silver  foil  comes  in  books 
and  is  sterilized  by  dr\-  heat.  Gutta-percha  tissue  is  sterihzed  by  washing 
with  soap  and  water,  rinsing  in  sterile  water,  and  soaking  in  a  solution  of 
corrosive  sublimate.  Lister's  protective  is  employed  to  save  the  wound  from 
the  irritation  of  carbolized  dressings.  In  the  L'nited  States,  if  it  is  desired  to 
place  an  impermeable  material  over  a  dressing,  a  rubber  dam  is  usually  em- 
ployed. A  rubber  dam  before  being  used  should  be  washed  with  soap  and 
water  and  soaked  in  a  solution  of  corrosive  sublimate. 

The  use  of  a  protective  over  a  dressing  is  not  nearly  so  common  as  for- 
merly. In  an  aseptic  wound  dry  dressing  uncovered  by  rubber  is  the  most 
useful.  AMien  a  dressing  is  covered  by  an  impermeable  material  it  becomes 
wet,  acts  as  a  poultice,  and  the  discharges  on  the  dressings  may  undergo 
decomposition. 

Drainage. — Drainage  is  obtained,  when  needed,  by  rubber  or  glass  tubes, 
by  strands  of  horsehair,  silkworm-gut,  or  catgut,  or  by  pieces  of  gauze. 
Rubber  drainage-tubes  (Fig.  22,  B)  are  prepared  by  boiling  in  plain 
water.  They  are  kept  until  wanted  in  a  mercurial  solution.  This  solution 
should  be  changed  ever}-  few  days,  because  the  mercun-  is  apt  to  be  pre- 
cipitated as  sulphid.  Glass  tubes  ^ 
are  prepared  by  boiling.  A  bit 
of  rubber  tissue  is  sometimes 
used  for  drainage.  Gauze,  cat- 
gut,  etc.,  are  known  as  capillary     ^^^^^^^^^^^^^^__ 

badly  or    not   at    all.        Drainage-  Fig.  22.— Drainage-tubes:  .-l.  Glass:  .e.  Rubber. 

tubes    or    strands     are    brought 

out  at  a  portion  of  the  wound  which  will  be  dependent  when  the  patient 
is  recumbent.  Drainage  is  used  in  all  infected  wounds,  in  most  \er\-  large 
wounds,  in  wounds  to  which  irritant  antiseptics  have  been  applied,  in  cases 
in  which  large  abnormal  caWties  exist  in  ver)-  fat  people,  and  in  indixnduals 
with  such  thin  skin  that  we  dare  not  apply  firm  pressure. 

Change  of  Dressing. — Dressings  must  be  changed  as  soon  as  soaking 
is  apparent,  or  if  constitutional  s}Tnptoms  of  wound  infection  arise,  and  the 
change  must  be  effected  with  all  of  the  aseptic  care  employed  in  the  operation. 


^6  Asepsis  and  Antisepsis 

Removal  of  Stitches. — Stitches  may  usually  come  out  from  the  sixth 
to  the  eighth  day,  although  if  there  is  much  tension  on  the  edges  of  the  wound 
they  are  allowed  to  remain  several  days  longer.    In  large  wounds,  half  of  the 

stitches  are  taken  out  at  one  time,  the  remainder 
being  allowed  to  remain  for  a  couple  of  days 
longer.  When  a  stitch  begins  to  cut,  it  is  doing 
no  good,  and  it  should  be  removed,  no  matter 
how  short  a  time  it  has  been  in  place.  If  it 
is  allowed  to  remain,  it  will  cut  into  the  wound, 
make  a  stitch-abscess,  and  cause  an  irregular 
suture-line. 

Artificial  Sponges. — Bits  of  gauze  should 
be  used,  each  piece  being  thrown  away  as  soon 
as  it  is  soaked  with  blood  or  tissue  fluid.  Gauze 
pads  can  be  used,  soaking  them  in  an  anti- 
septic solution  and  squeezing  them  from  time 
Fig.  23.— Mikulicz's  bag;  a,  to  time  during  an  operation. 
Abdominal  sutures;  b,  gauze  bag;  Preparation  of  Marine  sponges.— Marine 

c,   abdominal   wound ;   d,  loops   in  1  j  /^  j 

the  abdominal  wall ;  e,  gauze  strip,  sponges  are  rarely  used.  Gauze  pads  are  pre- 
ferred. Marine  sponges  absorb  admirably,  but 
they  are  hard  to  clean  when  new  and  cannot  be  certainly  sterilized  in  their 
interiors  after  becoming  infected.  They  may  be  prepared  as  follows:  Beat  out 
the  dust;  place  them  for  forty-eight  hours  in  a  solution  of  hydrochloric  acid 
(15  per  cent.);  wash  them  with  water;  place  them  for  one  hour  in  a  solution 
of  permanganate  of  potassium  (giij  to  5  pints  of  water);  soak  for  four  hours 
in  a  solution  containing  10  ounces  of  hyposulphite  of  sodium,  5  ounces  of 
hydrochloric  acid,  and  3  pints  of  water;  wash  with  running  water  for  six 
hours.  Keep  the  sponges  in  a  jar  containing  corrosive  sublimate  solution 
(i  :  1000).  After  using,  wash  in  hot  water,  soak  for  half  an  hour  in  a  solution 
of  sodium  carbonate  (i  132),  wash  again  in  hot  water,  and  replace  in  cor- 
rosive sublimate. 

Senn's  Decalcified  Bone-chips. — Take  the  shaft  of  the  tibia  or  femur 
of  a  recently  killed  ox,  saw  it  into  portions  two  inches  in  length,  remove  the 
marrow  and  periosteum,  and  place  the  fragments  of  bone  in  a  15  per  cent, 
solution  of  hydrochloric  acid.  Change  the  solution  every  twenty-four  hours. 
In  from  two  to  four  weeks  the  bone  will  be  decalcified.  Wash  in  distilled 
water,  place  the  pieces  of  decalcified  bone  for  a  few  minutes  in  a  dilute  solu- 
tion of  potash  to  neutralize  the  acid,  and  then  immerse  for  twenty-four  hours 
in  distilled  water.  The  portions  of  bone  are  cut  into  strips  in  the  direction 
of  the  long  axis  of  the  segments.  Each  strip  is  three-quarters  of  an  inch  wide 
and  should  be  sliced  into  bits  one  millimeter  thick.  These  chips  are  kept  in 
an  alcoholic  solution  of  corrosive  sublimate  (i  :  500). 

Bandages. — For  retaining  dressings  upon  wounds  the  muslin  bandage 
may  be  user],  but  in  most  cases  the  gauze  bandage  is  employed.  The  gauze 
bandage  soaked  in  corrosive  sublimate  solution  is  antiseptic;  it  does  not  partly 
seal  the  dressing  and  act  like  protective;  it  can  be  applied  firmly,  evenly,  and 
rapidly,  and  is  very  comfortable. 


Active  Hyperemia  57 


III.  INFLAMMATION. 

Definition. — When  the  tissues  are  injured  they  react  or  respond,  and 
this  reaction  or  response  is  known  as  inflammation.  The  process  of  inflam- 
mation is  defined  by  Professor  Burdon-Sanderson  as  "  the  succession  of  changes 
which  occur  in  a  Uving  tissue  when  it  is  injured,  provided  that  the  injury  is 
not  of  such  a  degree  as  at  once  to  destroy  its  structure  and  vitahty."  Pro- 
fessor Adami,  in  his  article  upon  inflammation  in  Allbutt's  "  System  of  Medi- 
cine," points  out  that  this  definition  really  includes  too  much.  He  alludes 
to  the  hemorrhage  which  occurs  in  the  liver  after  a  traumatism,  and  the  sub- 
sequent changes  in  the  extravasated  corpuscles,  and  points  out  that  these 
changes  are  not  inflammatory  phenomena.  This  definition,  however,  includes 
all  inflammatory  conditions,  is  largely  employed,  is  very  useful,  indicates  the 
cause,  and,  as  Burdon-Sanderson  says,  makes  clear  that  inflammation  is  a 
process  and  not  a  state  (Adami).  Adami's  definition  is  as  follows:  "The 
series  of  changes  constituting  the  local  manifestation  of  the  attempt  at  repair 
of  actual  or  referred  injury  to  a  part,  or,  briefly,  the  local  attempt  at  repair  of 
actual  or  referred  injury."  The  changes  alluded  to  in  Burdon-Sanderson's 
definition  comprise  (i)  changes  in  the  vessels  and  the  circulation,  (2)  depar- 
ture of  fluids  and  solids  from  the  vessels,  and  (3)  changes  in  the  perivascular 
tissues. 

Vascular   and   circulatory  changes  were   formerly  thought  to   be 

absolutely  essential  to  inflammation  in  both  vascular  and  non-vascular  tissues. 
In  the  former  they  occur  in  the  inflamed  tissues;  in  the  latter  (cornea  and 
cartilage)  they  are  manifest  in  neighboring  tissues  from  which  the  non-^•ascular 
area  derives  its  nutritive  material.  As  a  matter  of  fact,  in  inflammation, 
vascular  changes  are  almost  always  present;  but  in  a  rather  trivial  corneal 
inflammation  the  episcleral  vessels  may  not  dilate,  and  the  only  white  corpus- 
cles which  gather  in  the  damaged  area  are  those  which  come  from  the  lymph- 
spaces  of  the  cornea.  Inflammation  in  any  tissue  will  not  be  accompanied 
by  vascular  dilatation  unless  the  process  reaches  a  certain  stage  of  severity. 

Active  Hyperemia. — When  an  irritant  is  applied  to  tissue  there  may 
be  a  momentary  arterial  contraction  due  to  irritation  of  the  nerves,  but  this 
contraction  is  transitory,  and  is  not  an  inflammatory  phenomenon.  The 
first  vascular  phenomenon  is  dilatation  of  all  the  vessels, — capillaries,  venules, 
and  arterioles, — appearing  first  and  being  mos'c  pronounced  in  the  small 
arteries.  As  a  result  of  the  dilatation  there  are  increased  rapidity  of  circula- 
tion and  increased  determination  of  blood  to  the  part,  and  the  area  of  hyper- 
emia becomes  warmer  than  is  normal.  This  condition  of  increased  circulatory 
activity  is  known  as  "  active  hyperemia"  (Fig.  25). 

Active  hyperemia  is  an  increase  in  the  amount  of  moving  blood  in  a  part. 
Passive  hyperemia  is  an  increase  in  the  amount  of  blood  in  a  part,  but  not  of 
moving  blood,  as  passive  hyperemia  or  congestion  is  due  to  venous  obstruction, 
and  the  blood  is  stagnated.  Diminution  in  the  amount  of  blood  in  a  part  is 
ischemia.  Local  anemia  is  the  complete  cutting-off  of  the  blood-supply  of  a  part. 

In  active  hyperemia  more  blood  goes  to  the  part  and  more  blood  passes 
through  it,  an  increased  amount  of  venous  blood  comes  from  the  hyperemic 
area,  the  venous  tension  is  increased,  and  the  veins  may  even  pulsate.     The 


58 


Inflammation 


Normal  vessels  and  blood-stream. 


capillaries,  which  under  ordinary  circumstances  contain  but  few  blood-cells 
(Fig.  24),  become  tilled  with  corpuscles  (Fig.  25),  and  even  the  smallest  capil- 
laries pulsate.  The  blood  in  the  veins  adjacent  to  the  area  of  inflammation 
is  of  a  much  hghter  red  than  in  health.     Many  capillaries  which  were  invisible 

under  normal  conditions  become  visible 
when  active  hyperemia  exists.  The  capil- 
laries contain  no  muscle-fiber,  and  hence 
these  tubes  cannot  actively  contract,  except 
so  far  as  the  caliber  of  the  tubes  is  altered 
by  the  contraction  or  expansion  of  the 
endothelial  cells  of  the  capillary  w^all. 
Contraction  and  dilatation  of  the  capilla- 
ries depend  chiefly  upon  the  amount  of 
blood  sent  to  or  retained  in  them.  In 
active  hyperemia  the  increased  amount 
of  blood  sent  to  the  part  causes  capillary 
dilatation.  As  a  result  of  the  dilatation 
the  endothelial  cells  become  thinner  than 
before,  the  cells  as  a  result  of  irritation 
lose  some  of  their  power  to  restrain  exu- 
dation, and  some  observers  assert  that 
openings  are  formed  between  the  cells  or 
that  previously  existing  openings  enlarge. 
Fluid  elements  rarely  leave  the  blood-ves- 
sels during  active  hyperemia,  but  they 
occasionally  do.  The  wheals  of  urticaria  are  thus  formed  (Warren).  Active 
hyperemia  is  often  the  first  stage  of  an  inflammation,  but  it  is  not  of  neces- 
sity followed  by  other  inflammatory  changes,  and  it  can  be  caused  by  nerve 
section  or  nerve  stimulation. 

The  duration  of  active  hyperemia  is  variable.  If  the  irritation  was  brief, 
the  hyperemia  is  very  transitory.  If  the  irritation  is  prolonged,  it  may  last 
some  time  before  giving  way  to  retardation.  In  the  web  of  a  frog's  foot,  if  an 
irritant  is  applied,  hyperemia  lasts  from  one-half  hour  to  two  hours  before  it 
is  replaced  by  retardation. 

Clinical  Signs  of  Active  Hyperemia. — A  hyperemic  part,  if  on  or  near 
the  surface,  is  red  in  color,  imparts  a  sense  of  heat  to  the  examining  hand, 
the  color  quickly  disappears  on  pressure  and  quickly  returns  when  pressure 
is  released.  In  a  congested  part  the  temperature  is  diminished,  the  surface 
is  purple,  the  congested  veins  are  visible,  there  are  edema  and  a  sensation  of 
coldness  and  numbness.  'When  congestion  is  purely  local,  the  lividity  dis- 
appears quickly  when  pressure  is  applied  and  returns  quickly  when  pressure 
is  removed.  When  due  to  disease  of  the  heart  or  lungs,  it  disappears  and 
returns  slowly.  When  a  local  congestion  is  about  to  give  way  to  gangrene, 
the  lividity  disappears  very  slowly  on  pressure  and  crawls  back  slowly  when 
pressure  is  released. 

Retardation. — After  active  hyperemia  has  existed  for  a  \ariable  time 
the  blood-current  begins  to  lessen  in  velocity,  until  it  becomes  more  tardy  than 
in  health.  This  is  known  as  "retardation  of  the  circulation."  Retardation 
is  first  noted  in  the  venules,  next  in  the  capillaries,  and  last  in  the  arterioles; 


Oscillation    and   Stagfnation 


59 


but  arterial  pulsation  continues.  The  red  cells  take  the  center  of  the  blood- 
stream, which  is  known  as  the  axial  current.  The  white  corpuscles  drop  out 
of  the  central  stream,  separate  from  the  red,  and  float  lazily  along  near  the 
vessel-wall,  and  they  are  accompanied  by  many  third  corpuscles.  The  white 
cells  show  a  strong  tendency  to  adhere  to  the  venule-walls,  and,  as  a  result, 
accumulate  against  the  inside  of,  and  stick  to,  these  walls  and  to  one  another, 
until  the  venules  are  entirely  lined  with  la\'ers  of  leukocytes  (Fig.  25).  The 
third  corpuscles  act  in  a  similar  man- 
ner and  take  the  peripheral  current.  In 
the  capillaries  some  leukocytes  gather, 
but  not  many.  In  the  arterioles  they 
adhere  during  cardiac  dilatation,  but 
are  swept  away  by  the  force  of  the 
heart's  contractions.  Retardation  is 
believed  to  be  chiefly  due  to  paresis  of 
the  muscular  walls  of  the  arterioles. 
This  causation  seems  probable  when 
we  recall  Lord  Lister's  experiments 
upon  the  pigment-cells  of  the  frog's 
foot.  Lister  proved  that  inflammation 
paralyzes  the  pigment-cells,  and  con- 
cluded that  dilatation  at  the  focus  of 
an  inflammation  is  due  to  the  paralyz- 
ing action  of  an  irritant.  Dilatation 
at  a  distance  from  the  focus  is  a  reflex 
phenomenon  (W.  Watson  Cheyne). 
When  the  vessels  are  weakened  or 
paralyzed,  the  contractions  of  the  arte- 
rioles are  feeble  or  absent,  and  the  blood  is  no  longer  urged  forward  by 
arterial  power.  The  endothelial  cells  of  the  small  vessels  enlarge  distinctly 
and  develop  a  condition  of  stickiness,  which  leads  the  white  cells  to  adhere  to 
them,  and  thus  increases  resistance  to  the  current  of  blood  and  adds  to 
retardation.  Fluids  pass  through  a  vessel  in  this  condition  more  readily  than 
a  healthy  vessel,  and  white  corpuscles  leave  the  vessel  in  large  numbers. 

Oscillation  and  Stagnation. — By  this  accumulation  of  leukocytes 
the  blood-stream  is  progressively  narrowed  and  the  axial  current  is  impeded. 
The  red  blood- cells  begin  to  stick  to  one  another,  forming  aggregations  like 
rouleaux  of  coin,  which  masses  increase  the  difficulty  the  axial  current  has  to 
contend  with,  until  progressive  movement  ceases  and  the  contents  of  the  vessels 
sway  to  and  fro  with  each  heart-beat.  This  is  the  stage  of  oscillation.  In  a 
short  time  oscillation  ceases  and  the  vessels  are  filled  with  blood  which  does 
not  move,  and  the  vessel-walls  become  irregular  in  outline  or  even  pouched. 
This  stage  is  known  as  "stasis"  or  "stagnation"  (Fig.  26).  If  stasis  persists, 
coagulation  occurs,  because  the  vessel-walls  have  been  so  injured  by  the  irritant 
as  to  be  practically  dead  material,  and  they  are  no  longer  able  to  prevent 
clotting  of  their  contents.  Stasis  is  chiefly  due  to  paralysis  and  damage  of 
the  vessel-walls.  Migration  ceases  when  stasis  takes  place.  W^e  can  then 
sum  up  the  vascular  changes  of  inflammation  by  stating  that  they  consist  in  a 
dilatation  of  the  small  vessels  and  a  primary  acceleration,  a  secondary  retarda- 


Fig.  25. — Dilatation  of  the  vessels  in  inflammation. 


6o 


Inflammation 


Fig.  26. — Retardation  of  blood  and  migration  of 
white  corpuscles  in  inflammation. 


tion,  and  a  subsequent  stagnation  of  the  blood-current  with  adhesion  of 
leukocytes  to  the  wails  of  veins  and  capillaries,  migration  of  leukocytes, 
and  the  aggregation  into  masses  of  the  red  blood-cells.      If  stasis  persists, 

the  vessel-walls  become  profoundly  in- 
volved in  the  inflammatory  change, 
and  they  may  rupture  or  be  completely 
destroyed. 

Exudation  of  Fluids.— It  is  to 
be  remembered  that  in  the  process 
of  nutrition  serum  and  even  white  cells 
pass  into  the  tissues  through  the  walls 
of  veins  and  capillaries.  Whenever 
retardation  of  the  circulation  arises, 
there  is  an  increase  in  the  amount  of 
plasma  which  passes  out  of  the  vessels, 
but  in  inflammation  the  exudation  is 
vastly  greater  in  amount  and  is  different 
in  composition.  In  a  slight  inflamma- 
tion, and  in  the  early  stage  of  any  in- 
flammation, there  is  an  increase  in  the 
fluid  exudate,  and  we  speak  of  the  con- 
dition as  "serous  inflammation."  This 
fluid  is  really  not  serum,  but  is  liquor 
sanguinis.  We  find  true  serum  in  pas- 
sive congestion,  not  in  active  inflam- 
mation. The  fluid  in  a  serous  exudation  contains  very  few  white  cells,  and 
hence  little  or  no  fibrin  can  form  in  it,  and  coagulation  does  not  take  place  in 
the  perivascular  tissues;  and  if  the  inflammation  goes  no  further,  the  exudate 
is  absorbed  by  the  lymphatics.  A  blister  is  an  example  of  serous  inflamma- 
tion. If  the  inflammation  continues  to  intensify,  the  exudation  is  altered 
in  character — it  becomes  thicker,  turbid,  and  very  coagulable.  It  contains 
many  white  cells  and  fibrin  elements,  and  coagulates  in  the  tissues,  because 
some  of  the  leukocytes  break  up  and  set  free  fibrin  ferment,  and  fibrin  ferment 
causes  the  union  of  calcium  and  fibrinogen  and  the  formation  of  fibrin.  This 
fluid  is  known  as  "lymph,"  or  plastic  exudation,  and  when  it  is  present  we 
speak  of  the  condition  as  "  plastic  inflammation."  The  lymphatics  endeavor 
to  absorb  the  fluid,  but  become  occluded  by  coagulation,  and  the  area  they 
drain  becomes  swollen,  hard,  and  "brawny."  Lymph  can  be  seen  in  the 
anterior  chamber  of  the  eye  in  cases  of  plastic  iritis.  The  slighter  the  in- 
flammation, the  less  all)uminous  is  the  fluid;  the  more  intense  the  inflamma- 
tion, the  more  albuminous  is  the  fluid.  The  focus  of  an  inflammation  usually 
feels  brawny  because  of  coagulation  of  a  highly  albuminous  exudate;  the 
periphery  of  an  inflammation  is  soft  and  edematous  because  of  the  presence 
there  of  thin  and  non-coagulable  exudate.  Inflammatory  lymph  contains 
proteids  and  other  substances.  "  Of  these  the  more  imy)ortant  are  ferments, 
the  results  of  proteolysis  (notably  fibrin  and  its  precursors  and  peptones), 
and  in  many  ca.ses  mucin,  together  with  bactericidal  substances,  and,  where 
bacteria  are  present,  the  products  of  their  growth."  *  The  amount  of  the 
*Adami,  in  Allbutt's  "System  of  Medicine." 


Migration  and  Diapedesis 


6i 


exudation  varies  with  the  violence  of  the  irritation,  the  nature  of  the  irritant, 
the  general  condition  of  the  organism,  and  the  state  of  the  tissues  which  are 
involved.  In  dense  tissue  (bone,  periosteum,  etc.)  the  exudation  is  scanty. 
In  loose  tissues  (subcutaneous  tissue)  it  is  profuse.  Profuse  exudation  may 
take  place  into  a  joint,  the  pleural  sac,  the  peritoneal  cavity,  or  the  peri- 
cardium. 

Does  the  plasma  leave  the  vessels  as  a  simple  filtrate?  Some  maintain 
that  it  does.  Heidenhain  and  others  claim  that  it  does  not,  and  believe  that 
the  endothehal  cells  play  an  active  part  in  the  process.  Heidenhain  likens 
exudation  to  secretion,  because  some  materials  from  the  plasma  pass  out 
and  others  do  not.  Adami  is  inclined  to  agree  with  Heidenhain,  that  the 
epithelium  plays  ''not  a  passive,  but  an  active  role."  It  is  a  question  if  open 
spaces  do  or  do  not  exist  between  the  endothelial  cells,  but  the  existence  of 
such  spaces  has  not  been  proved. 

Migration  and  Diapedesis. — Even  early  in  an  inflammation  some  few 
white  corpuscles  pass  through  the  vessel- walls ;  but  when  the  inflammation 
is  well  established,  large  numbers,  and  when  it  is  severe  vast  hordes,  pass  into 


Fig.  27. — Stages  of  the  migration  of  a  single  white  blood-corpuscle  through  the  wall 
of  a  vein  (Caton). 


the  perivascular  tissues.  This  process  is  known  as  "migration"  (Fig.  27). 
The  leukocytes  throw  out  protoplasmic  arms,  insert  themselves  between  the 
cells  of  the  walls  of  the  vessel,  and  pull  themselves  through  by  their  power  of 
ameboid  movement  (Fig.  28).  Most  observers  claim  that  they  do  not  pass 
through  existing  open  doors,  but  form  openings  which  close  after  them.  This 
is  readily  accomplished,  because  the  vessel-wall  is  itself  damaged,  weakened, 
and  convoluted.  Others  claim  that  stomata  exist  between  the  endothelial 
cells,  the  vessel-wall  being  porous  like  a  filter.  The  escape  of  leukocytes 
takes  place  chiefly  from  the  venules,  though  some  migrate  through  the  capilla- 
ries and  even  the  arterioles  (Fig.  27). 

The  leukocytes  are  influenced  to  move  toward  the  damaged  tissue  by  the 
attractive  force  known  as  positive  "chemiotaxis,"  a  force  which  draws  them 
toward  invading  bacteria,  to  regions  of  irritation,  and  to  areas  of  tissue  death. 
Leukocytes  may  move  from  very  virulent  organisms,  influenced  by  what  is 
known  as  negative  "  chemiotaxis."     The  migration  of  a  leukocyte  requires 


62 


Inflammation 


2S. — Ameboid  movements  of  a  leukocyte  (Warner). 


but  a  short  time.  Fig.  27  shows  the  migration  of  a  white  blood-cell  through  a 
vein-wall,  the  process  requiring  one  hour  and  fifty  minutes.  In  very  acute 
inflammations  red  corpuscles  pass  into  the  tissues.  Red  corpuscles  are  not 
capable  of  ameboid  movements,  and  they  escape  through  damaged  areas  in 

the  capiflary  walls,  the  pro- 
cess being  a  passive  one  on 
the  part  of  the  corpuscles. 
The  escape  of  corpuscles  by 
a  passive  process  is  known 
as  "diapedesis,"  in  contra- 
distinction to  the  escape  of 
leukocytes  by  active  ame- 
boid movements,  a  process 
known  as  "migration."  The 
white  corpuscles  usually 
greatly  increase  in  number 
in  the  blood  of  a  person  who 
has  an  acute  inflammation 
(leukocytosis),  and  the  blood-making  organs,  such  as  the  spleen  and  lymph- 
atic glands,  are  often  enlarged. 

Blood  Plaques. — Blood  plates  or  blood  plaques  may  be  discovered  in 
freshly  drawn  blood,  but,  unless  they  are  present  in  unusual  numbers,  they 
will  rarely  be  seen  in  specimens  prepared  in  the  usual  way.  The  third  cor- 
puscles can  be  seen  by  a  high  power  microscope  in  the  moving  blood  of  the 
web  of  a  frog's  foot.  In  blood  outside  of  the  body  they  are  destroyed  as  soon 
as  coagulation  begins,  and  in  order  to  see  them  coagulation  must  be  pre- 
vented. Some  observers  maintain  that  the  third  corpuscles  are  the  real 
fibrin-formers.  The  blood  plaques,  or  third  corpuscles,  are  found  to  be  present 
in  increased  numbers  in  inflammation.  In  health  their  usual  proportion  to 
red  cells  is  as  i  to  20.  They  are  especially  numerous  at  the  height  of  fever 
processes  and  during  convalescence  from  an  extensive  abscess. 

Changes  in  the  Perivascular  Tissues. — The  liquor  sanguinis 
which  exudes  during  an  acute  inflammation  coagulates  unless  prevented  by 
virulent  bacteria.  It  has  often  been  asserted  that  exudation  is  Nature's 
method  of  supplying  nutriment  to  the  cells  of  the  damaged  region.  Adami 
points  out  the  apparently  contradictory  observation  that  the  amount  of  exu- 
date is  in  direct  proportion  to  the  rapidity  of  cell-destruction,  but  nevertheless 
concludes  that  exudation  stands  in  close  relation  with  cell-proliferation.* 
From  whatever  cause,  tissue-cells  multiply,  and  this  process  is  known  as 
"  cell-proliferation." 

When  a  ti.ssue  is  injured  it  inflames,  and,  as  Adami  points  out,  the  reaction 
is  an  attempt  to  repair  injury. 

Irritation  may  lead  to  degeneration  and  death  of  cells;  it  may  lead  to 
growth  and  multiplication.  In  many  cases  both  processes  are  active  in  the 
acute  stage,  the  cells  at  the  focus  of  the  inflammation  undergoing  degeneration 
and  destruction,  and  thf)se  at  the  boundary  undergoing  growth  and  prolifera- 
tion.f 

*  Adami,  in  AUbutt's  ".System  of  Medicine." 
f  AUbutt's  "System  of  Medicine." 


Inflammation  in  Non-vascular  Tissue  63 

If  tissue-cells  have  been  seriously  damaged,  they  perish,  and  new  cells  are 
required  to  replace  them.  The  inflammatory  process  has  led  to  exudation 
of  plasma  and  migration  of  leukocytes  into  the  perivascular  tissues.  The 
connective-tissue  cells  multiply  and  produce  young  cells,  which  are  known 
as  "fibroblasts,"  and  which  eat  up  many  leukocytes.  The  migrated  leuko- 
cytes in  part  surround  the  inflamed  region  and  retard  diffusion  of  the  process. 
Many  enter  the  diseased  area  and  attack  bacteria.  Some  undergo  degen- 
erative changes  and  liberate  fibrin  ferment  which  makes  the  exudate  clot. 
Some  move  out  of  the  inflamed  area,  each  one  carrying  within  it  tissue  debris, 
and  many  are  eaten  up  by  the  fibroblasts.  There  is  no  real  proof  that  leuko- 
cytes proliferate  and  help  directly  to  form  new  tissue.  This  mass  of  young 
cells,  taking  origin  from  the  fixed  cells,  has  been  called  embryonic  tissue, 
because  of  a  fancied  resemblance  to  the  cells  of  the  embryo.  It  has  also  been 
called  indifferent  tissue,  because  of  the  belief  that  it  could  be  converted  in- 
differently into  various  tissue  according  to  circumstances.  It  is  also  spoken 
of  as  inflammatory  new  formation. 

An  exudation  may  be  absorbed  by  the  lymphatics.  It  may  be  converted 
into  pus  if  infected  with  pyogenic  bacteria,  or  be  replaced  by  cells  from  the 
proliferation  of  fixed  tissue-cells,  the  cellular  mass  being  subsequently  vascu- 
larized bv  the  extension  into  it  of  capillary  loops  derived  from  adjacent  capil- 
laries. When  embryonic  tissue  is  filled  with  blood-vessels, — that  is  to  say, 
when  it  is  vascularized, — it  is  called  granulation  tissue.  Granulation  tissue 
is  finally  converted  into  fibrous  tissue.  The  above  complicated  processes, 
vascular  and  perivascular,  are  not  accidents  nor  haphazard  freaks,  but  are 
Nature's  efforts  to  bring  about  a  cure. 

Dilatation  is  due  to  the  direct  effect  of  the  irritant  upon  the  muscle  or  its 
nerve-elements.  Retardation  and  stasis  are  due  to  paralysis  of  the  vessel- 
wall,  which  paralysis  causes  resistance  to  the  passage  of  the  blood-stream 
and  adhesion  of  the  leukocytes  to  the  vessel-wall.  The  blood-liquor  exudes 
and  the  leukocytes  migrate.  Often  these  efforts  of  Nature  succeed.  Accel- 
eration of  the  circulation  may  succeed  in  washing  away  an  irritant  from  the 
vessel-wall.  By  bringing  quantities  of  blood  to  the  part  it  secures  copious 
exudation  of  plasma.  The  exudation  may  wash  away  and  remove  irritants 
from  the  tissues,  and  the  germicidal  blood-liquor  may  destroy  bacteria  in  the 
damaged  area.  The  migration  of  corpuscles  may  prove  of  great  service. 
The  leukocytes  surround  an  area  of  infection  and  tend  to  limit  its  spread. 
Leukocytes  have  phagocytic  properties,  and  energetically  attack  and  often 
destroy  bacteria,  and  they  furnish  antitoxins  which  antagonize  and  may 
neutralize  the  poisons  produced  by  micro-organisms.  Leukocytes  aid  in 
separating  dead  tissue  from  li\-ing,  and  remove  tissue  debris  from  the  area  of 
inflammation.  The  multiplication  of  the  fi.xed  connective-tissue  cells  leads  to 
the  formation  of  fibroblasts,  and  fibroblasts  are  converted  into  fibrous  tissue, 
which  effects  permanent  repair  (these  changes  will  be  alluded  to  again  in  the 
section  on  Repair). 

Nature  may  fail  in  her  efforts.  For  instance,  an  enormous  exudate  in- 
creases stasis  and  may  cause  such  tension  that  gangrene  results. 

Inflammation  in   Non=vascular  Tissue.— A  type  of  non-vascular 

tissue  is  the  cornea,  and  the  cornea  can  inflame.     The  healthy  cornea  contains 
no  blood-vessels.     It  is  formed  of  manv  lavers  of  fibers,  each  laver  running 


64  Inflammation 

parallel  with  the  corneal  surface  and  forming  angles  with  the  fibers  of  the 
adjacent  layers.  Between  the  layers  are  communicating  lymph-spaces  con- 
taining connective-tissue  cells  known  as  corneal  corpuscles.  It  obtains  its 
nourishment  in  part  from  the  vessels  of  the  conjunctiva,  but  chiefly  from  the 
vessels  of  the  ciliary  body  and  sclera.  When  the  cornea  inflames,  the  epi- 
scleral, conjunctival,  and  ciliary  vessels  usually  dilate  and  pour  out  exudate, 
and  the  fluid  exudate  and  the  leukocytes  enter  into  the  corneal  Ivmph-spaces. 
The  exudate  coagulates  and  cell-multiplication  ensues  as  in  any  other  in- 
flammation. In  mild  inflammations  the  vessels  about  the  cornea  may  not 
dilate.  Leukocytes,  from  the  lymph-spaces,  reach  the  seat  of  injury  in  small 
numbers,  and  the  fixed  cells  multiply.  Nancrede  points  out  that  in  trivial 
inflammation  which  injures  but  does  not  destroy  the  epithelium  leukocytes 
may  not  go  to  the  seat  of  inflammation,  the  only  change  being  enlargement 
and  multiplication  of  corneal  corpuscles.  If  new  formation  takes  place,  a 
permanent  opacity  mars  the  cornea  as  a  consequence. 

Cartilage  has  no  blood-vessels;  neither  has  it  spaces,  hke  the  cornea,  for 
a  free  circulation  of  lymph.  Inflammation  can  occur  in  cartilage,  but  it  is 
always  slow  in  evolution  and  prolonged.  Cartilage  is  nourished  by  a  flow 
of  plasma  between  the  cells,  but  there  is  no  direct  connection  with  blood- 
vessels. The  plasma  is  furnished  by  the  vessels  at  the  margin  of  the  peri- 
chondrium. When  inflammation  occurs,  the  cartilage  cells  enlarge  and  their 
nuclei  proliferate,  the  intercellular  substance  softens  and  cartilage  cells  may 
be  cast  off.  After  a  long  time  vessels  may  invade  the  inflamed  cartilage  and 
fibrous  tissue  form  from  the  perichondrium,  but  in  some  cases  a  loss  of  sub- 
stance is  not  repaired. 

Inflammation  of  Mucous  Membrane.— It  may  be  catarrhal,  suppura- 
tive, croupous,  or  diphtheritic.  In  a  catarrhal  inflammation  the  increased 
blood-supply  causes  an  excessive  flow  of  mucus.  The  submucous  tissues 
present  the  ordinary  changes  of  inflammation  and  quantities  of  epithelial 
cells  are  cast  off  from  the  surface.  Fibrous  tissue  may  form  in  the  submucous 
tissue  and  thus  cause  permanent  thickening  (strictures,  etc.). 

Suppurative  inflammation  is  usually  preceded  by  catarrhal  inflammation. 
In  this  condition  the  discharge  is  mucopurulent  and  ulcers  are  apt  to  form. 
A  trivial  loss  of  substance  permits  of  regeneration,  but  a  considerable  loss  is 
repaired  by  fibrous  tissue  which  by  its  bulk  and  by  contracting  may  interfere 
greatly  with  the  functional  usefulness  of  an  organ  or  a  canal. 

A  croupous  inflammation  is  one  in  which  quantities  of  epithelial  cells  are 
ca.st  off  the  surface  and  there  occurs  upon  the  surface  the  formation  of  a  highly 
fibrinous  exudate  (false  membrane). 

In  diphtheritic  inflammation  the  mucous  membrane  is  destroyed  and  the 
false  membrane  invades  the  submucous  tissue.  Diphtheritic  inflammation 
is  due  to  a  specific  bacillus. 

Classification  of  Inflammations. — The  various  forms  of  inflamma- 
tions are — (i)  Simple  or  common,  that  which  is  due  to  any  ordinary  trau- 
matic, chemical,  or  thermal  cau.se,  and  not  to  bacteria,  such  as  traumatic 
periostitis  or  sun  dermatitis.  It  does  not  tend  particularly  to  spread.  As  a 
rule,  the  cause  of  a  simple  inflammation  is  momentary  in  action;  (2)  infec- 
tive or  speciflc,  that  which  is  due  to  micro-organisms,  as  the  streptococcus  of 
erysipelas.     An  unsuccessful  attempt  has  been  made  to  charge  all  inflamma- 


Terminations   of  Inflammation  65 

tions  to  bacteria.  It  is  true  that  bacteria  can  generally  be  found  in  inflam- 
matory areas,  but  that  they  are  the  only  causes  of  inflammation  is  accepted 
by  few.  Infective  inflammations  often  tend  to  spread  widely;  (3)  traumatic, 
which  is  due  to  a  blow  or  an  injury ;  (4)  idiopathic,  which  is  without  an  ascer- 
tainable cause.  There  is  certainly  a  cause,  even  if  it  cannot  be  pointed  out, 
and  the  term  "idiopathic"  means  that  we  do  not  know  the  cause;  (5)  acute, 
which  is  rapid  in  course  and  violent  in  action;  (6)  chronic,  which  follows  a 
'prolonged  course;  (7)  subacute,  which  is  intermediate  in  violence  and  dura- 
tion between  acute  and  chronic;  (8)  sthenic,  characterized  by  high  action. 
Occurs  in  strong  young  subjects;  (9)  asthenic  or  adynamic,  occurring  in  the 
old,  the  debihtated,  and  the  broken-down.  In  such  an  inflammation  there 
is  no  certain  hmitation  of  the  inflammation  by  leukocytes,  and  there  is  an 
indisposition  on  the  part  of  the  tissue-cells  to  form  fibroblasts;  (10)  paren- 
chymitous,  affecting  the  "parenchyma,"  or  active  cells  of  an  organ;  (11) 
interstitial,  affecting  the  connective-tissue  stroma  of  an  organ;  (12)  serous, 
characterized  by  profuse  non-coagulating  exudation  (as  in  pleuritis)  or  by 
marked  inflammatory  edema;  (13)  plastic,  adhesive,  or  fibrinous,  character- 
ized by  an  exudation  which  glues  together  adjacent  surfaces,  as  in  peritonitis; 
(14)  purulent,  phlegmonous,  or  suppurative,  when  pyogenic  cocci  are  present 
and  multiply;  (15)  hemorrhagic,  when  the  exudate  contains  many  red  blood- 
cells,  as  in  strangulated  hernia  and  in  the  pustules  of  black  smallpox;  (16) 
croupous,  when  an  inflammation  produces  upon  the  surface  of  a  tissue  a 
fibrinous  exudate  which  cannot  be  organized  into  tissue,  and  which  is  due  to 
the  action  of  micro-organisms.  An  exudate  of  this  character  was  called  bv 
the  older  surgeons  "aplastic  lymph."  It  occurs  most  usually  on  mucous 
membrane;  (17)  diphtheritic,  which  differs  from  croupous  in  the  fact  that 
the  false  membrane  is  in  the  tissue  rather  than  upon  it;  (iS)  gangrenous,  an 
inflammation  resulting  in  death  of  the  part,  the  gangrene  being  due  to  the 
tension  of  the  exudate  or  the  violence  of  the  poison;  (19)  healthy,  when  the 
tendency  is  to  repair;  (20)  unhealthy,  when  the  tendency  is  to  destruction; 
(21)  latent,  an  inflammation  which  for  some  time  does  not  announce  itself  by 
any  obvious  symptoms,  as  the  inflammation  of  Peyer's  patches  in  tvphoid 
fever;  (22)  contagious,  when  its  own  secretions  can  propagate  it;  (23)  dry, 
without  exudation;  (24)  hypostatic,  a.v'ismg  in  a  region  of  passive  congestion 
(as  a  bed-sore);  (25)  malignant,  due  to  a  malignant  growth;  (26)  catarrhal, 
affecting  a  mucous  membrane;  (27)  neuropathic,  due  to  impairment  of  the 
trophic  functions  of  the  nervous  system,  as  in  perforating  ulcer;  and  (28) 
sympathetic  or  reflex,  due  to  disease  or  injury  of  a  distant  part,  as  when  orchitis 
follows  mumps. 

Extension  of  Inflammation.— Inflammation  extends  by  continuity 
of  structure,  by  contiguity  of  structure,  by  the  blood,  and  by  the  lymphatics. 
Extension  by  continuity  is  seen  in  phlebitis.  Extension  by  contiguity  is 
seen  when  a  cutaneous  inflammation  advances  and  attacks  deeper  struc- 
tures. Extension  by  the  blood  is  seen  in  the  formation  of  the  smallpox 
exanthem.  Extension  by  the  lymphatics  is  witnessed  in  a  bubo  following 
chancroid. 

Terminations  of  Inflammation.— Inflammation  may  be  followed 
by  a  return  of  the  tissues  to  health,  and  this  return  may  take  place  by  deUtes- 
cence,  by  resolution,  or  by  new  growth.  By  delitescence  is  meant  abrupt 
5 


66  Inflammation 

termination  at  an  early  stage,  as  when  a  quinsy  is  aborted  by  the  administra- 
tion of  quinin  and  morphin,  and  the  production  of  a  sweat;  resolution  means 
the  gradual  disappearance  of  the  symptoms  when  inflammation  has  passed 
through  its  regular  stages;  and  new  growth  means  that  an  inflammation  has, 
lasted  a  considerable  time,  with  ample  blood-supply,  and  without  suppuration 
and  has  gone  on  to  the  formation  of  fibroblasts,  granulation  tissue,  and  fibrous 
tissue.  Inflammation  may  be  followed  by  death  of  the  inflamed  part,  or 
necrosis.  Death  of  the  part  may  be  due  to  suppuration,  ulceration,  or  gan- 
grene. 

The  causes  of  inflammation  are — predisposing,  or  those  residing  in 
the  tissues,  and  rendering  them  liable  to  inflame;  and  exciting,  or  those  which 
directly  awake  the  process  into  activity.  The  first  may  be  thought  of  as 
furnishing  inflammable  material;  the  second  ma}'  be  regarded  as  sparks  of 
fire. 

Predisposing  causes  are  those  which  impair  the  general  vigor,  injure  the 
blood,  weaken  the  tissues,  or  lower  nutritive  activities.  Among  these  causes 
are  shock,  hemorrhage,  nervous  irritation,  gout,  rheumatism,  diabetes, 
Bright's  disease,  alcoholism,  and  syphilis.  Plethora  renders  a  person  liable 
to  sthenic  inflammations  (those  characterized  by  high  action).  Tissue 
debility  renders  one  prone  to  adynamic  or  asthenic  inflammations. 

Exciting  Causes. — The  exciting  causes  of  inflammation  are — traumatic, 
as  blows  and  mechanical  irritation;  chemical,  as  the  stings  of  insects,  ivy 
poison,  etc.;  thermal,  heat  and  cold;  and  specific,  the  micro-organisms,  caus- 
ing, for  instance,  tuberculous  peritonitis  or  erysipelas. 

Some  writers  insist  that  every  inflammation  is  due  to  the  action  of  micro- 
organisms, but  this  statement  lacks  proof.  They  maintain  that  inflammation 
is  a  destructive  microbic  process  which  cannot  bring  about  repair,  and  that 
repair  only  begins  when  inflammation  ends.  As  Adami  points  out,  the  advo- 
cates of  this  view  argue  that  swelhng,  pain,  and  discoloration  point  to  the 
existence  of  inflammation;  that  repair  can  take  place  when  these  phenomena 
are  absent,  hence  inflammation  is  not  present  when  repair  begins.  As  a  matter 
of  fact,  swelling,  discoloration,  and  pain  are  phenomena  often  but  not  inva- 
riably associated  with  inflammation;  and  in  inflammation  one  or  all  of 
these  phenomena  may  be  absent.  Because  these  signs  are  not  discovered  is 
no  proof  that  inflammation  does  not  exist.  We  believe  that  inflammation  is 
not  always  due  to  microbes  and  is  not  always  a  destructive  process,  but  may 
be  from  the  start  conservative  and  reparative.  It  is  the  reaction  of  the 
tissue  to  injury  and  is  the  first  step  on  the  road  to  repair.* 

Symptoms  of  Acute  Inflammation. — Inflammation,  if  at  all  severe, 
announces  its  presence  by  symptoms  which  are  both  local  and  constitutional. 
The  local  symptoms  are  heat,  pain,  discoloration,  sweUing,  and  disordered 
function;  the  chief  constitutional  symptom  is  fever. 

Local  Symptoms  of  Inflammation. — The  most  prominent  local  .symp- 
toms were  known  centuries  ago  to  the  famous  Roman,  Celsus,  who  stated  them 
as  "rubor,  calor  cum  lumore  el  dolore^^ — redness  and  heat  with  swelling  and 
pain.  As  set  forth  to-day,  the  local  symptoms  are — (i)  heat;  (2)  pain;  (3) 
discoloration;    (4)  swelling;  and  (5)  disordered  function. 

Heat  is  due  t(j  the  passage  of  an  increased  quantity  of  blood  through  the 

*See  Aflami's  masterly  article  in  Allbutl's  "System  of  Medicine." 


Local  Symptoms  of  Inflammation  67 

damaged  area  and  to  the  arrival  at  the  surface  of  the  body  of  warm  blood 
from  internal  parts.  Although  an  inflamed  part  may  be,  and  usually  is, 
warmer  than  the  surrounding  pjarts,  its  temperature  is  never  greater  than  the 
temperature  of  the  blood.  This  increase  of  heat  is  especially  noticeable  when 
we  contrast  the  feeling  of  an  arm  affected  with  erysipelas  with  the  sound  arm; 
the. diseased  arm  feels  much  warmer,  but  still  its  temperature  is  not  above  the 
general  body-temperature.  An  extremity  in  health,  as  is  well  known,  shows 
on  the  surface  a  temperature  below  that  of  the  blood;  in  an  inflamed  state  the 
temperature  may  nearly  equal  that  of  the  blood.  Heat  is  always  present  in 
inflammation  of  a  superficial  part.  The  surgeon  examines  for  heat  by  placing 
his  hand  upon  the  suspected  area  and  then  placing  it  upon  a  corresponding 
portion  of  the  opposite  side  of  the  patient,  in  order  to  note  the  contrast.  If 
great  accuracy  is  desired,  a  surface  thermometer  is  used. 

Pain  is  a  constant  and  conspicuous  symptom.  It  is  due  to  stretching 
of  or  pressure  upon  nerves  from  exudate ;  to  irritation  of  nerves ;  or  to  inflam- 
mation of  the  nerves  themselves,  producing  cellular  changes.  Pain  is  asso- 
ciated with  tenderness  (pain  on  pressure),  it  is  aggravated  by  motion  and  by 
a  dependent  position  of  the  part,  and  it  varies  in  degree  and  in  character.  In 
serous  membranes  it  is  acute  and  lancinating,  like  dagger-thrusts;  in  connec- 
tive tissue  it  is  acute  and  throbbing;  in  large  organs  it  is  dull  and  heavy;  in 
the  bone  it  is  gnawing  or  boring;  in  the  skin  and  mucous  membrane  it  is 
itching,  burning,  smarting,  or  stinging;  in  the  urethra  it  is  scalding;  in  the 
testicle  it  is  sickening  or  nauseating;  in  the  teeth  it  is  throbbing;  and  in  in- 
flammation under  tense  fascia  it  is  pulsatile.  Pain  in  inflammation  after 
presenting  itself  in  one  form  may  change  in  character.  If  a  pain  becomes 
markedly  throbbing,  suppuration  may  be  anticipated.  Pain  does  not  always 
occur  at  the  seat  of  trouble,  but  may  be  felt  at  some  distant  point.  This  is 
known  as  a  "sympathetic"  pain,  and  means  that  a  nervous  communication 
exists  between  the  inflamed  part  and  a  distant  area,  a  nerve-trunk  referring 
pain  to  its  peripheral  distribution.  Tenderness,  however,  is  detected  at  the 
seat  of  trouble. 

Pain  oj  hepatitis  is  often  felt  in  the  right  shoulder.  Pain  at  the  point  of 
the  shoulder  or  in  the  shoulder-blade  is  felt  also  in  gall-stones  and  in  cancer 
of  the  liver.  The  pain  arises  in  filaments  of  the  pneumogastric  from  the 
hepatic  plexus,  which  filaments  reach  the  spinal  accessory,  pain  being  ex- 
pressed in  the  branches  of  the  spinal  accessory  which  supply  the  trapezius 
and  communicate  with  the  third  and  fourth  cervical  nerves.* 

Pain  oj  coxalgia  is  often  felt  on  the  inside  of  the  knee,  because  the  obturator 
nerve,  which  sends  a  branch  to  the  ligamentum  teres,  also  sends  a  branch  to 
the  interior  and  to  the  inner  side  of  the  knee-joint. 

Inflammation  oj  an  eye  with  increased  tension  causes  brow-ache.  In- 
flammation oj  the  neck  oj  the  bladder  causes  pain  in  the  head  of  the  penis. 
Inflammation  oj  a  testicle  cause  pain  in  the  groin.  Renal  calculus  and  pyelitis 
cause  pain  in  and  retraction  of  the  testicle,  and  pain  in  the  loin,  groin,  or  thigh. 

If  the  covering  of  an  organ  is  involved,  pain  becomes  more  violent;  for 
instance,  hepatitis  becomes  much  more  painful  when  the  perihepatic  structures 
are  attacked.  Inflammation  without  pain  is  known  as  ''latent"  (as  the  in- 
flammation of  Peyer's  patches  in  t}q3hoid).     The  sudden  disappearance    of 

*Embleton's  view  in  Hilton  on  "  Rest  and  Pain,"  a  book  every  student  should  read. 


6S  Inflammation 

inflammatory  pain,  when  not  due  to  the  administration  of  opiates,  suggests 
the  possibility  of  gangrene,  because  analgesia  exists  in  gangrene.  The 
characteristics  of  inflammatory  pain  are  that  it  comes  on  gradually,  has  a  fixed 
seat,  is  continuous,  is  attended  by  other  inflammatory  symptoms,  and  is 
increased  by  motion,  by  pressure,  and  by  a  dependent  position  of  the  part. 
If  there  be  no  tenderness  in  a  part,  the  source  of  the  pain  is  not  local  inflam- 
mation; but  tenderness  may  exist  when  there  is  no  local  inflammation,  as  in 
pain  referred  from  a  distant  part.  Pain  of  inflammation  does  not  correspond 
to  an  exact  nervous  distribution.  If  pain  corresponds  exactly  to  the  area  of 
a  nerve's  distribution,  the  cause  of  it  is  acting  on  the  nerve-trunk  or  on  its 
roots.  If  the  cutaneous  surface  is  involved,  the  lightest  touch  causes  pain. 
If  touching  the  skin  produces  no  pain,  but  deep  pressure  does  produce  it, 
the  deeper  structures  are  the  source.  Pain  in  muscle  and  ligament  is  devel- 
oped by  motion;  in  muscle,  by  contraction,  but  not  by  passive  movements 
with  the  muscle  relaxed;  in  ligament  pain  is  developed  by  active  or  passive 
movements  which  stretch  the  ligament.  If,  for  example,  a  man  with  a  stiff 
neck  has  pain  on  the  right  side  of  the  back  of  his  neck  on  voluntarily  turning 
his  face  toward  the  left  shoulder,  but  is  without  pain  when  his  face  is  turned 
by  the  surgeon,  who,  conversely,  induces  pain  by  turning  the  patient's  face  far 
to  the  right,  this  condition  indicates  the  trouble  to  be  muscular.  If,  however, 
no  pain  arises  on  turning  the  face  to  the  right,  but  it  is  manifest  on  turning  the 
face  actively  or  passively  to  the  left,  the  pain  is  in  those  ligaments  which  stretch 
when  the  face  is  turned  to  the  left.*  In  inflammation  of  the  synovial  mem- 
brane gentle  passive  motion  in  any  direction  causes  pain. 

The  pain  of  colic  differs  from  that  of  inflammation.  It  is  sudden  in  onset, 
intermits,  recurs  in  paro.xysms,  and  is  relieved  by  pressure.  The  pain  of 
inflammation  is  gradual  in  onset,  is  continuous,  and  is  made  worse  by  pressure. 
The  pain  of  neuralgia  is  often  preceded  by  cutaneous  anesthesia  of  the  skin 
of  the  part,  is  very  paroxysmal,  comes  on  suddenly,  darts  through  recognized 
nerve-areas,  the  attack  lasts  some  hours,  and  is  apt  to  recur  at  a  certain  hour. 
It  presents  no  general  tenderness,  as  does  inflammation,  but  we  may  find 
several  points  which  are  acutely  sensitive  to  pressure  (Valleix's  points  doti- 
loiireiix).  The  tender  spots  of  Valleix  are  met  with  in  inveterate  neuralgia, 
and  occur  at  points  where  nerves  "  pass  from  a  deeper  to  a  more  superficial 
level,  and  particularly  where  they  emerge  from  bony  canals  or  pierce  fibrous 
fasciae. "t 

Pain  is  often  of  great  value  by  calling  attention  to  parts  diseased;  but  it 
may  be  a  terrible  evil,  racking  the  organism  and  even  causing  death.  If  pain 
continues  long,  it  becomes  in  itself  formidable:  it  prevents  sleep,  it  destroys 
appetite,  and  it  deteriorates  the  mind,  and  one  of  the  surgeon's  highest  duties 
is  to  relieve  it.  The  physiognomy  or  expression  oj  pliysical  pain  presents  the 
following  characteristics:  Heavy  fulness  about  the  eyes,  and  dropping  of  the 
angles  of  the  mouth,  added  to  appearances  due  to  anemia, widespread  tremor, 
etc.  The  absence  of  the  physiognomy  of  pain  in  a  person  who  complains  of 
great  agony  is  a  strong  indication  that  the  j)atient  exaggerates  the  gra\'ity  of 
his  sufferings  or  deliberately  deceives. 

Discoloration  arises  from  determination  of  blood  lo   tlic  part;  hence  the 

*"  Surgical  Diagnosis,"  by  A.  Pearce  (ioiild. 

fAnstie,  "Neuralgia  and  Diseases  which  Resemble  It." 


Swelling  or  Tumefaction  69 

more  vascular  the  tissue,  the  greater  the  discoloration.  A  non-vascular  tissue 
presents  no  discoloration,  though  we  usually  find  discoloration  adjacent  in  the 
zone  of  blood-vessels  which  furnish  the  tissue  with  nutriment.  Discoloration 
is  most  intense  at  the  focus  or  center  of  inflammatory  action.  Discoloration 
varies  in  tint  and  in  character  according  to  the  tissue  implicated  and  the  nature 
of  the  inflammation.  It  may  be  circumscribed  or  diffuse.  Arborescent 
redness  means  a  distribution  in  dendritic  lines.  Linear  discoloration  signifies 
redness  running  in  straight  lines,  as  in  phlebitis.  Punctiform  discoloration 
occurs  in  points,  and  is  due  to  vascular  rupture.  Maculiform  redness  re- 
sembles an  ecchymosis  or  blotch.     Dusky  discoloration  points  to  suppuration. 

Inflammation  of  the  throat  and  skin  produces  scarlet  discoloration;  in- 
flammation of  the  sclerotic  coat  of  the  eye  and  of  the  fibrous  coat  of  muscle 
produces  lilac  or  bluish  discoloration;  inflammation  of  the  iris  produces  brick- 
dust,  grayish,  or  brown  discoloration;  erysipelas  causes  a  yellowish-red  dis- 
coloration; secondary  syphilis  causes  a  copper-hued  discoloration;  and  ton- 
sillitis causes  a  livid  discoloration.  A  tuberculous  ulcer  is  of  a  purple  color 
on  t?ie  edge.  Gangrene  is  shown  by  a  black  discoloration.  A  scorbutic  ulcer 
is  surrounded  by  an  area  of  violet  color. 

Redness  as  a  sign  of  inflammation  must  be  permanent  and  joined  with 
other  symptoms.  Redness  due  to  inflammation  disappears  on  pressure,  but 
returns  as  soon  as  the  pressure  is  removed.  If  redness  is  due  to  staining  of 
the  surface  by  dye,  pigmentation,  or  extravasation  of  blood,  pressure  will  not 
blanch  the  spot.  If  on  taking  off  pressure  the  redness  of  inflammation  rapidly 
returns,  the  circulation  is  active;  if,  on  the  contrary,  it  very  slowly  reappears, 
the  circulation  is  very  sluggish  and  gangrene  is  threatened.  Subcutaneous 
hemorrhage  gives  rise  to  a  purple-red  color  which  does  not  fade  when  sub- 
jected to  pressure.  Stains  of  the  surface  by  dyes  fail  to  disappear  on  pressure, 
are  distributed  over  a  considerable  surface,  show  a  hue  which  is  uniform 
throughout,  are  obviously  superficial,  are  not  associated  with  other  signs  of 
inflammation,  and  can  be  washed  away. 

A.  Pearce  Gould,  in  his  excellent  little  work  upon  "  Surgical  Diagnosis," 
tells  us  that  the  color  of  a  hyperemic  surface  may  furnish  important  informa- 
tion. Lividity  may  mean  failure  of  the  heart  and  lungs,  or  simply  venous 
congestion  in  the  part.  In  lividity  from  obstruction  of  the  lungs  or  heart  the 
color  slowly  returns  after  pressure  has  driven  it  out.  In  lividity  due  to  local 
congestion  the  color  quickly  returns  when  pressure  is  released  and  the  dilated 
veins  are  often  distinctly  visible.  Of  course,  in  a  local  trouble,  when  the 
circulation  becomes  impaired  to  such  a  degree  that  gangrene  is  threatened, 
the  lividity  fades  very  slowly  on  pressure  and  reappears  very  slowly  on  the 
release  of  pressure. 

Swelling  or  tumejaclion  arises  in  small  part  from  vascular  distention,  but 
chiefly  from  effusion  and  cell-multiplication.  The  more  loose  cellular  mate- 
rial a  part  contains,  the  more  it  swells;  hence  the  eyelids,  scrotum,  vulva, 
tonsils,  glottis,  and  conjunctivae  swell  very  largely  when  inflamed.  A  swelling 
is  soft  or  edematous  when  due  to  uncoagulable  eft"usion ;  is  brawny  and  doughy 
when  due  to  coagulated  effusion;  is  hard  and  elastic  when  produced  by  pro- 
liferating cells.  Swelling  may  do  good  by  unloading  the  vessels  and  acting 
like  a  blister  or  local  bleeding,  or  it  may  do  great  harm  by  pres.^^ing  upon  the 
vessels  and  cutting  off  the  blood-supply.     Swelling  of  the  conjunctiva,  or 


70 


Inflammation 


chemosis,  may  cause  sloughing  of  the  cornea,  and  swelhng  of  the  prepuce 
mav  cause  gangrene.  A  swelhng  may  do  harm  by  obstructing  a  natural 
passage,  as  in  edema  of  the  glottis,  when  the  larynx  becomes  blocked;  or  by 
compression  of  a  normal  channel,  as  in  the  swelling  of  the  perineum,  when 
the  urethra  is  compressed.  A  swollen  area  may  be  covered  with  blisters  or 
blebs.     This  condition  is  noted  particularly  in  burns  and  fractures. 

Disordered  junction  is  always  present  in  inflammation.  It  may  be  mani- 
fested bv  increased  tenderness  or  sensibility,  a  slight  touch,  it  may  be,  pro- 
ducing torturing  pain.  Parts  almost  or  entirely  destitute  of  feeling  when 
healthv  (as  tendons,  ligaments,  and  bones)  become  highly  sensitive  when 
inflamed.  It  may  be  manifested  by  increased  irritability.  In  dysentery  the 
colon  constantly  contracts  and  expels  its  contents;  the  stomach  does  likewise 
in  gastritis;  and  the  bladder  acts  similarly  in  cystitis.  Spasmodic  twitching 
of  the  evelids  occurs  in  conjunctivitis,  and  twitching  of  the  muscles  in  fracture 
and  after  amputation. 

Impairment  of  Special  Function. — In  inflammation  of  the  eye,  when  an 
attempt  is  made  to  look  at  objects,  the  lids  close  spasmodically,  and  even  a 
little  light  causes  great  pain  and  lachrymation  (photophobia).  In  inflamma- 
tion of  the  ear  noises  cause  great  suffering,  and  even  when  in  a  quiet  room  the 
patient  has  subjective  buzzing  and  roaring  sounds  in  his  ears  (tinnitus  aurium). 
In  corvza  the  sense  of  smell,  in  glossitis  the  sense  of  taste,  in  dermatitis  the 
sense  of  touch,  and  in  laryngitis  the  voice  may  be  lost.  In  inflammation  of 
the  brain  the  mind  is  affected;  in  arthritis  the  joints  can  scarcely  be  moved; 
and  in  myositis  it  is  difficult  and  painful  to  employ  the  muscles. 

Derangement  of  Secretions. — In  dermatitis  the  sweat  is  not  thrown  off;  in 
hepatitis  bile  is  not  properly  secreted;  and  in  nephritis  urea  is  not  satisfac- 
torily removed.  The  secretions  may  undergo  important  changes  of  compo- 
sition. The  sputum  in  pneumonia  is  rusty,  and  dysentery  causes  a  discharge 
of  bloody  mucus  (Gross). 

Derangement  of  Absorbents. — In  the  height  of  an  inflammation  the  absor- 
bents are  blocked  and  clogged  by  coagulated  fibrin,  and  they  cannot  perform 
their  offices. 

Constitutional  symptoms  of  acute  inflammation  may  be  absent,  and 
often  are  in  moderate  or  limited  inflammations;  but  in  severe,  extensive,  or 
infective  inflammations  the  symptom  group  known  as  fever  is  certain  to  exist. 
This  is  known  as  symptomatic,  sympathetic,  or  inflammatory  fever,  and  it 
arises  in  non-septic  cases  from  the  absorption  of  aseptic  pyrogenous  exudate 
and  in  microbic  inflammations  from  absorption  of  pyrogenous  toxic  products 
of  bacterial  action.  In  young  and  robust  individuals  an  acute  non-microbic 
inflammation  causes  a  fever  characterized  by  full,  strong  pulse,  flushed  face, 
coated  tongue,  dry  skin,  nausea,  constipation,  and  possibly  acute  delirium  (the 
sthenic  type  of  the  older  authors).  In  broken-down  and  exhausted  indi- 
viduals an  ordinary  inflammation,  and  in  any  individuals  a  bacterial  inflam- 
mation, may  cause  a  fever  with  typhoid  symptoms  (the  typhoid,  asthenic,  or 
adynamic  type).  Fibrin  ferment  is  obtained  from  the  white  corpuscles;  it  is 
liberated  as  the  corpuscles  break  up  in  the  exudate,  and  acting  on  the  liquor 
sanguinis  cause  the  union  of  calcium  and  fibrinogen  and  the  formation  of 
fibrin.  The  absorption  of  fibrin  ferment  many  believe  causes  aseptic  fever 
(page  105).     Inflammatory  blood  contains  an  increased  amount  of  albumin 


Treatment  of  Acute  Inflammation  71 

and  salts.  If  a  person  with  inflammatory  fever  is  bled,  the  blood  coagulates 
rapidly,  the  clot  sinks,  and  there  is  found  on  the  surface  a  cup-shaped  coat, 
made  up  of  liquor  sanguinis  and  white  cells,  known  as  the  "  buffy  coat";  but 
this  is  not  a  sign  of  inflammation,  and  occurs  normally  in  the  blood  of  the 
horse.  The  buffy  coat  forms  when  blood  contains  a  great  number  of  leuko- 
cytes, because  these  leukocytes  sink  more  slowly  than  do  the  red  corpuscles. 
Cupping  occurs  because  the  white  corpuscles  sink  more  slowly  by  the  side 
of  the  tube  than  far  from  the  sides. 

Leukocytosis. — In  man}-  inflammatory  and  infectious  diseases  leukocy- 
tosis is  noted.  It  probably  measures  an  attempt  on  the  part  of  the  organism 
to  protect  itself  from  noxious  materials.  Leukocytosis  is  usually  much  more 
marked  if  pus  exists  than  if  the  exudation  is  serous  or  fibrinous. 

"  The  degree  of  leukocytosis  may  be  considered  a  general  index  to  the  in- 
tensity of  the  infection  and  to  the  strength  of  the  individual's  resisting  powers 
in  reacting  against  it.  It  follows,  therefore,  that  intense  infections  occurring 
in  individuals  whose  resisting  powers  are  strong,  produce  a  decided  increase; 
but  the  presence  of  an  infection  of  like  intensity  in  one  whose  resisting  powers 
are  greatly  crippled  fails  to  cause  leukocytosis,  for  in  such  an  instance  the  organ- 
ism is  so  overpowered  by  the  effects  of  the  morbid  process  that  it  is  incapable 
of  reacting."     ("  Clinical  Hematology,"  by  J.  C.  DaCosta,  Jr.). 

Chronic  Inflammation. — This  condition  progresses  slowly  and  does  not 
produce  symptom.s  of  severity  either  in  the  part  or  the  body  at  large. 

Causes. — Blood  diseases,  as  rheumatism  and  gout;  infective  diseases,  as 
tuberculosis  and  syphilis;  retained  pus  in  an  ill-drained  abscess;  blockage 
of  the  duct  of  a  gland ;  the  retention  of  a  foreign  body  in  a  part ;  the  flow  of  an 
irritant  secretion  (as  saliva  from  a  fistula) ;  repeated  identical  traumatisms 
of  an  occupation,  etc.  W.  Watson  Cheyne  tells  us  chronic  inflammation  is 
not  due  to  the  ordinary  pyogenic  organisms  (see  Cheyne's  article  in  Treves's 
"System  of  Surgery"). 

Tissue-changes. — These  changes  are  practically  the  same  as  in  acute 
inflammation,  but  take  place  far  less  rapidly.  It  is  maintained  by  Cheyne 
and  others  that  typical  granulation  tissue  does  not  form,  the  tissues  of  the  part 
being  replaced  by  fibrous  tissue.  The  amount  of  fibrous  tissue  produced  is 
relatively  very  great.  This  tissue  may  cause  permanent  thickening,  or  may 
contract  and  thus  diminish  the  size  of  a  part.  Contraction  is  very  consider- 
able in  cirrhosis  of  the  liver  and  in  interstitial  nephritis. 

Symptoms. — Pain  varying  in  intensity  and  character;  tenderness;  great 
swelling,  which  in  some  cases  is  followed  by  shrinking,  and  is  usually  indurated 
or  brawny.  As  a  matter  of  fact,  great  swelling  is  the  most  usual  symptom. 
Sometimes  there  is  a  trivial  amount  of  heat.  There  is  rarely  discoloration 
unless  the  skin  is  itself  inflamed,  but  usually  the  surface  veins  are  dis- 
tinctly and  sometimes  they  are  greatly  distended.  There  are  no  constitutional 
symptoms  attributable  purely  to  the  inflammation.  If  there  are  such  symp- 
toms, they  are  due  to  the  disease  which  induced  the  inflammation  or  to  inter- 
ference with  the  function  of  an  organ  because  of  the  fibrous  mass.  (For 
treatment  of  chronic  inflammation  see  articles  upon  special  regions  and 
particular  structures.) 

Treatment  of  Acute  Inflammation. — The  first  rule  in  treating  an 
inflammation  must  be  to  remove  the  exciting  cause.     If  this  cause  is  a  splinter 


72  Inflammation 

in  the  part,  take  out  the  sphnter;  if  it  is  a  foreign  body  in  the  eye,  remove  the 
foreign  bodv,  if  urine  is  extravasated,  open  and  drain;  take  off  pressure  from 
a  corn;  pull  out  an  ingrown  nail;  and  remove  microbes  from  an  infected  area 
by  exposing,  irrigating,  and  applying  antiseptics.  The  rule,  remove  the  cause, 
applies  to  a  chronic  as  well  as  to  an  acute  inflammation.  If  the  cause  of  an 
inflammation  was  momentary  in  action  (as  a  blow),  we  cannot  remove  it,  for 
it  has  already  ceased  to  exist.  After  removing  the  cause,  endeavor  to  bring 
about  a  cure  by  local  and  constitutional  treatment. 

Local  Treatment  of  Inflammation. — It  must  be  remembered  that  the 
division  of  inflammation  into  stages  is  natural,  and  not  artificial,  and  that  a 
remedy  which  does  good  in  one  stage  may  do  harm  in  another. ~  Certain  agents 
are  suited  to  all  stages  of  an  inflammation,  namely,  rest  and  elevation. 

Rest. — Physiological  rest  is  of  infinite  importance,  and  is  always  indicated 
in  acute  inflammation.  In  the  exercise  of  function  blood  is  taken  to  a  part 
and  an  existing  inflammation  is  aggravated.  Further,  as  Billroth  has  pointed 
out,  rest  prevents  the  dissemination  of  infection,  because  motion  exposes 
fresh  surfaces  to  inoculation  and  breaks  down  protective  barriers  of  leuko- 
cytes. Its  principles  were  first  thoroughly  studied  by  Hilton.*  The  means 
of  securing  rest  differ  with  the  structure  or  the  part  diseased.  When  rest  is 
used,  do  not  employ  it  too  long.  Rest  in  bed  diminishes  the  amount  of  blood 
sent  to  an  inflamed  part  and  lessens  the  force  of  the  circulation;  hence  it 
antagonizes  stasis.  It  has  been  shown  that  the  heart  beats  at  least  fifteen 
times  per  minute  less  when  the  patient  is  recumbent  than  when  he  is  erect. 
The  saving  of  strength  and  the  benefit  to  the  local  condition  are  thus  seen  to 
be  enormous.  In  fact,  the  heart  saves  at  least  twenty-one  thousand  beats  a 
day.     In  every  severe  inflammation  insist  on  the  patient  going  to  bed. 

In  cerebral  concussion  rest  must  be  secured  by  quiet,  by  darkness,  by  the 
avoidance  of  stimulants  and  meat,  by  the  apphcation  of  ice  to  the  head,  and 
by  the  use  of  purgatives  to  prevent  reflex  disturbance  and  the  circulation  of 
poisons  in  the  blood.  In  inflamed  joints  rest  must  be  obtained  by  proper 
position,  associated  in  many  cases  with  the  adjustment  of  sphnts  or  plaster 
of  Paris,  or  the  employment  of  extension. 

In  pleuritis  partial  rest  can  be  secured  by  strapping  the  affected  side  with 
adhesive  plaster  or  by  using  a  bandage  or  a  binder  to  hmit  respiratory  move- 
ments. In  fractures  Nature  procures  rest  by  her  splints — the  cal/ns — and 
the  surgeon  procures  rest  by  his  splints — firm  dressings,  or  extension.  In 
cancer  of  the  rectum  and  intractable  rectitis,  a  colostomy  secures  rest  for  the 
inflamed  and  damaged  bowel.  In  enteritis  opium  gives  rest  to  the  bowel  by 
stopping  peristalsis.  In  cystitis  rest  is  obtained  by  the  administration  of  opium 
and  belladonna,  which  paralyze  the  muscular  fibers  of  the  bladder.  The  use 
of  the  catheter  gives  rest  to  the  bladder  by  removing  urine.  A  cystotomy 
allows  complete  rest  by  permitting  the  bladder  to  suspend  its  function  as  a 
reservoir  of  urine.  In  cystitis  from  vesical  calculus  rest  is  obtained  by  cutting 
or  crushing  the  stone.  In  inflamed  mucous  membrane  rest  from  the  contact 
of  irritants  is  secured  by  touching  the  membrane  with  silver  nitrate,  which 
forms  a  protective  coat  of  coagulated  all)umin.  Opening  an  abscess  gives 
its  walls  rest  from  tension.  In  inflammations  of  the  eye  light  must  be  excluded 
to  obtain  complete  rest,  but  tolerably  satisfactory  rest  is  given  in  some  cases 
*  "  Lectures  upon  Rest  and  Pain." 


Leeching  73 

by  the  use  of  glasses  of  a  peacock-blue  tint.  In  aneurysm  the  operation  of 
ligation  cuts  off  the  blood-current  and  gives  rest  to  the  sac.  In  hernia  the 
operation  gives  rest  from  pressure.  Instances  of  the  value  of  rest  could 
indefinitely  be  multiplied. 

Relaxation  is  in  reality  a  form  of  rest,  and  consists  in  placing  the  part  in  an 
easy  position.  In  synovitis  of  the  knee  semiflexion  of  the  knee-joint  lessens 
the  pain.     In  muscular  inflammations  relaxation  relieves  the  pain. 

Elevation. — Elevation  partly  restores  circulatory  equilibrium.  A  felon 
is  less  painful  when  the  hand  is  held  up  in  a  sling  than  when  it  is  dependent. 
A  congestive  headache  is  worse  during  recumbency.  A  gouty  inflammation 
in  the  great  toe  is  more  painful  with  the  foot  lowered  than  when  it  is  raised. 
A  toothache  becomes  worse  on  lying  down. 

Certain  agents  are  suited  to  the  stage  of  vascular  engorgement,  increased 
arterial  tension,  and  beginning  effusion.  These  agents  are — (i)  local  bleed- 
ing or  depletion;  (2)   cutting  off  the  blood-supply;  and  (3)  cold. 

Local  Bleeding. — Local  bleeding,  or  depletion,  is  the  abstraction  of  blood 
from  the  inflamed  area.  This  abstraction  relieves  circulatory  retardation 
and  causes  the  blood  to  move  rapidly  onward;  the  corpuscles  clinging  to  the 
vessel-walls  are  washed  away,  the  capillaries  shrink  to  their  natural  size,  and 
the  exudate  is  absorbed.  In  other  words,  local  blood-letting  increases  the 
rate  of  the  circulation,  though  not  its  force. 

The  methods  of  bleeding  locally  are — {a)  puncture;  {b)  scarification;  (f) 
leeching;  and  {d)  cupping. 

Puncture  is  recommended  in  inflammation,  not  only  because  it  abstracts 
blood  locally,  but  also  because  it  gives  an  exit  to  effusion  under  fibrous  mem- 
branes. It  is  very  useful  in  relieving  tension — for  instance,  in  epididymitis. 
It  is  performed  with  a  tenotome  and  with  aseptic  precautions.  If  numerous 
punctures  are  made,  the  procedure  is  termed  "multiple  puncture."  This  is 
very  useful  when  apphed  to  the  inflamed  area  around  a  leg-ulcer.  The  late 
Prof.  Joseph  Pancoast  was  very  fond  of  employing  multiple  punctures,  desig- 
nating the  operation  "  the  antiphlogistic  touch  of  the  therapeutic  knife." 

Scarification  or  Incision. — By  means  of  scarification  we  bleed  locally, 
evacuate  exudate,  and  relieve  tension.  One  cut  or  many  cuts  may  be  made, 
and  these  cuts  may  be  deep  or  may  not  go  entirely  through  the  skin,  according 
to  circumstances.  Multiple  incisions  are  useful  when  applied  to  inflamed 
ulcers,  ulcers  in  danger  of  gangrene,  and  to  almost  any  condition  of  great  ten- 
sion. Scarification  is  of  notable  value  when  edema  of  the  glottis  exists.  Free 
incision  is  of  great  benefit  in  periostitis  and  in  threatened  gangrene.  In  osteo- 
myelitis the  medullary  canal  must  be  promptly  opened. 

Leeching. — Leeches  must  not  be  applied  to  a  region  plentifully  endowed 
with  loose  cellular  tissue,  as  great  swelling  and  discoloration  are  sure  to  ensue. 
These  regions  are  the  prepuce,  labia  majora,  scrotum,  and  eyelids.  Leeches 
should  never  be  applied  to  the  face  (because  of  the  scar),  near  specific  sores 
or  inflammations,  nor  over  a  superficial  artery,  vein,  or  nerve.  A  leech  is  best 
applied  at  the  periphery  of  an  inflammation  and  between  an  inflammation 
and  the  heart.  To  leech  at  the  inflammatory  focus  only  aggravates  the  trouble. 
Before  applying  leeches,  wash  the  part  and  shave  it  if  hairy.  Place  the  leech 
.  in  a  test-tube  or  an  inverted  wine  glass,  inserting  the  tail  or  thick  end  first, 
and  invert  the  tube  so  that  the  leech's  head  will  come  in  contact  with  the  pre- 


74 


Inflammation 


pared  skin.  The  leech  is  restrained  in  the  tube  until  it  "takes  hold"  and 
begins  to  feed,  when  the  tube  is  removed.  If  the  leeches  will  not  bite,  smear 
the  part  with  milk  or  a  httle  blood.  Never  pull  off  a  leech;  let  it  drop  off. 
It  will  usually  drop  off  when  full,  but  if  it  refuses  to  do  so,  sprinkle  it  with 
salt.  After  removing  a  leech,  employ  warm  fomentations  if  continued  bleed- 
ing is  desired.  Sometimes  the  bleeding  persists,  but  this  may  be  arrested  by 
styptic  cotton  and  pressure.  In  some  rare  cases  the  bleeding  continues  in 
spite  of  pressure.  This  is  due  to  the  fact  that  the  tissue  contains  a  consider- 
able quantity  of  a  material  secreted  from  the  throat  of  the  leech,  which  mate- 
rial prevents  coagulation  of  blood.  In  such  a  case  excise  the  bite  and  the  area 
of  tissue  adjacent  to  it,  and  suture  the  wound.  Leeching  leaves  permanent 
triangular  scars.  The  Swedish  leech,  which  is  preferred  to  the  American, 
draws  from  two  to  four  drams  of  blood.  After  a  leech  has  been  removed,  if 
we  desire  to  use  it  again,  place  it  in  salt  water.  This  causes  it  to  vomit  the 
blood  which  it  has  taken  up.  Leeching  has  both  a  constitutional  and  a  local 
effect.  It  is  at  the  present  time  used  comparatively  rarely,  but  it  is  employed 
by  some  practitioners  over  the  spermatic  cord  in  epididymitis,  on  the  temple 
in  ocular  inflammation,  and  over  the  right  iliac  region  to  relieve  the  pain  in 
mild  cases  of  appendicitis. 


Fig.  29. — Scarificator. 


Fig.  30. — Hturteloup's  artificial  leech. 


Cupping. — Dry  cups  deviate  blood  from  a  deeply  placed  inflamed  area  to 
the  surface.     Wet  cups  actually  remove  blood. 

Dry  Cups. — Dry  cups  are  apphed  without  first  incising  the  skin.  One 
or  more  may  be  applied.  A  special  instrument  is  sold  in  the  shops  for  the 
performance  of  dry  cupping.  It  consists  of  a  glass  bell,  with  a  globular  and 
hollow  top  of  rubber.  The  rubber  bulb  is  emptied  of  air  by  squeezing,  the 
glass  bulb,  the  edges  of  which  have  been  greased,  is  pushed  upon  the  skin,  and 
the  compression  is  relaxed  upon  the  rubber  bulb.  A  partial  vacuum  is 
created,  and  an  area  of  skin  and  subcutaneous  tissue  full  of  blood  rises  into 
the  glass  bell. 

Cupping  can  be  easily  performed  by  means  of  a  tumbler.  The  edge  of  the 
glass  is  greased;  a  bit  of  blotting-paper  wet  with  alcohol  is  placed  in  the  bottom 
of  the  tumbler  and  lighted.  After  a  brief  period  the  glass  is  inverted  and 
placed  upon  the  skin,  which  has  been  dampened  with  warm  water.  As  the 
air  in  the  glass  cools,  the  tis.sues  rise  into  the  partial  vacuum. 

Wet  Cups. — Wet  cuj)S  draw  blood,  and  the  skin  should  be  cleansed  before 
they  are  applied.     In  wet  cupping  apply  a  cup  for  a  moment,  remove  it,  incise 


Cold  in  Treatment  of    Inflammation  75 

or  puncture  the  skin,  and  replace  the  cup  to  draw  the  requisite  amount  of 
blood.  Incisions  may  be  made  by  an  ordinary  scalpel,  a  lancet,  or  a  scarifi- 
cator, a  cup  being  then  applied.  An  excellent  scarificator  is  shown  in  Fig. 
29.  In  this  instrument  concealed  blades  are  thrown  out  by  touching  a  spring. 
Baron  Heurteloup  devised  an  instrument  (Fig.  30)  in  which  the  incision  is 
made  by  a  scarificator.  The  blood  is  drawn  out  by  a  pump,  the  tube  being 
placed  upon  the  cut  area  and  the  withdrawal  of  the  piston  creating  a  vacuum. 
This  instrument  is  known  as  the  "artificial  leech."  After  scarification  and 
the  application  of  the  cup,  the  partial  vacuum  draws  blood  into  the  cup;  when 
the  surface  ceases  to  bleed,  the  cup  is  removed,  and  if  further  bleeding  is 
thought  desirable,  the  clots  are  wiped  away  and  the  cup  is  again  applied,  and 
after  its  removal  warm  fomentations  are  used  (Cheyne  and  Burghard).  Wet 
cupping  is  of  value  in  pleuritis,  pericarditis,  and  nephritis. 

Cutting  off  the  Blood-supply. — Onderdonk,  of  New  York,  in  1813 
recommended  ligation  of  the  main  artery  of  a  Hmb  for  the  cure  of  inflamma- 
tion in  important  structures  supplied  by  the  vessel.  The  procedure  was 
warmly  advocated  by  Campbell,  of  Georgia,  for  the  treatment  of  gunshot 
wounds  of  joints.  This  plan  of  treatment  is  now  not  to  be  considered  for  a 
moment;  antisepsis  furnishes  us  with  a  safer  and  more  certain  plan.  Van- 
zetti,  of  Padua,  advocates  digital  pressure  to  cut  off  the  blood-supply  to  an 
inflamed  part. 

Cold. — Cold  is  a  very  powerful  and  useful  agent  if  used  judiciously  and 
applied  at  the  proper  time.  It  is  valuable  because  of  its  reflex  eft'ect  upon  the 
vessels  of  the  inflamed  area  rather  than  because  of  direct  action  upon  the  cells 
of  a  part.  It  should  be  used  early  in  the  case,  before  stasis  occurs.  It  is  not 
to  be  used  in  the  later  stages  of  inflammation,  for  it  will  then  only  aggravate 
the  existing  state;  in  fact,  when  there  is  considerable  exudation  cold  does  no 
good. 

Cold  acts  by  constricting  the  vessels  of  a  hyperemic  area,  thus  lessening 
the  amount  of  blood  sent  to  the  part,  and  preventing  the  evolution  of  the  pro- 
cess into  the  stage  of  stasis  and  exudation.  Further,  it  prevents  the  migra- 
tion of  leukocytes,  retards  cell-proliferation,  relieves  pain  and  tension,  and 
lowers  temperature.  If  cold  is  too  intense,  if  it  is  kept  too  long  applied,  if  it 
is  used  late  in  an  inflammation,  if  it  is  used  upon  an  old  or  feeble  patient,  or 
if  it  is  employed  when  there  is  much  exudation  or  a  condition  of  tissue  strangu- 
lation, it  does  actual  harm.  It  lessens  the  nutritive  activity  of  cells,  constricts 
the  lymph-spaces  and  channels,  increases  existing  stasis,  and  hence  lowers  the 
vitality  of  the  tissues.  If  the  parts  are  constricted,  as  in  strangulated  hernia, 
or  if  they  are  compressed  by  a  large  exudate,  or  fed  by  diseased  blood-vessels, 
cold  may  cause  gangrene.  Nancrede,  in  his  "Principles  of  Surgery,"  points 
out  that  in  an  inflammation  stasis  soon  arises  at  the  focus  of  the  inflammation, 
and  there  is  an  area  of  stasis  surrounded  by  a  zone  of  hyperemia.  Cold 
benefits  the  hyperemic  zone  but  aggravates  the  stasis.  Nancrede  cautions  us 
as  follows:  "Judgment  is  therefore  requisite  to  decide  whether  the  evil  at 
the  focus  will  not  outweigh  the  good  exerted  at  the  periphery."  *  Nancrede 
further  points  out  that  cold  must  not  be  used  intermittently;  but  if  employed 
at  all,  must  be  continuously  applied.  If  cold  is  applied  intermittently,  there 
will  be  a  reaction  whenever  it  is  removed,  and  this  reaction  causes  increased 

*  "  Principles  of  Surgery." 


76  Inflammation 

hyperemia.  Hence,  cold  must  be  "  continued  in  action  to  prevent  reaction." 
If  during  the  employment  of  cold  the  skin  becomes  purple  and  congested  and 
the  circulation  feeble,  at  once  discontinue  the  use  of  it,  as  its  continuance  will 
be  dangerous. 

Cold  may  be  used  as  wet  cold  or  as  dry  cold. 

Wet  Cold. — Wet  cold  is  easily  applied,  but  it  is  much  more  depressing  than 
dry  cold,  is  likely  to  produce  discomfort,  macerates  the  skin,  and  may  lead 
to  the  formation  of  excoriations,  etc.  A  part  can  be  subjected  to  wet  cold  by 
the  appUcation  of  evaporating  fluids  or  the  use  of  a  siphon.  When  wet  cold 
is  used  inspect  the  part  at  frequent  intervals,  and  discontinue  the  treatment 
if  evidences  of  stasis  become  positive.  Evaporating  fluids  are  extensively 
employed.  If  such  a  fluid  is  used,  never  cover  the  part  with  a  thick  dressing. 
If  this  should  be  done,  the  fluid  wiU  not  evaporate  with  sufficient  rapidity  to 
produce  cold.  A  piece  of  thin  muslin  or  flannel  should  be  moistened  with  the 
fluid  and  laid  upon  the  part,  and  be  kept  constantly  moist  by  the  application 
from  time  to  time  of  smaU  quantities  of  the  liquid.  Lead-water  and  laudanum 
is  used  extensively,  and  probably  owes  its  chief  value  to  the  fact  that  it  pro- 
duces cold  on  evaporation.  Lead-water  and  laudanum  is  composed  of  Sj  of 
laudanum,  .5j  of  liquor  plumbi  subacetatis,  and  i  pint  of  water.  Liquor 
plumbi  subacetatis  dilutus  may  be  used  without  laudanum.  It  is  thought 
that  the  addition  of  laudanum  tends  to  aflay  pain.  A  solution  of  ammonium 
chlorid  may  be  used  in  the  strength  of  5j  of  the  drug  to  2  quarts  of  water.  If 
ammonium  chlorid  is  used  for  more  than  a  short  period  of  time,  it  is  prone  to 
cause  the  formadon  of  bhsters  which  are  irritable  and  painful.  Cheyne  and 
Burghard  use  the  following  formula:  h  ounce  of  ammonium  chlorid,  i  ounce 
of  alcohol,  and  7  ounces  of  water.  Plain  spring-water,  iced  water,  or  a  mixture 
of  alcohol  and  water  may  be  used.  The  siphon  is  occasionally  used.  If 
there  is  a  wound,  the  fluid  must  be  aseptic  or  antiseptic.  In  conjunctivitis, 
cold  is  applied  to  the  eye  by  means  of  linen  or  muslin  soaked  in  iced  water  laid 
upon  the  closed  Hds,  and  frequently  changed. 

To  apply  wet  cold  by  means  of  a  siphon,  the  part  is  covered  with  one  layer 
of  wet  linen  or  muslin  and  is  laid  upon  a  rubber  sheet  folded  like  a  trough  and 
emptying  into  a  bucket.  A  vessel  filled  with  cold  water  is  placed  upon  a 
higher  level  than  the  bed.  A  wet  lamp-wick  is  now  taken,  one  end  is  inserted 
into  the  water  of  the  vessel,  and  the  other  end  is  laid  upon  the  part.  Capillary 
action  and  gravity  combine  to  keep  the  part  moist.  A  rubber  tube  may  be 
used  instead  of  a  wick.  If  a  tube  is  employed,  tie  it  in  a  knot  or  clamp  it  so 
that  the  fluid  is  delivered  drop  by  drop  (Fig.  31).  Ordinary  water  or  iced 
water  can  be  used.  If  the  water  be  too  warm,  it  can  be  reduced  to  about  45°  F. 
by  adding  i  part  of  alcohol  to  every  4  parts  of  water.  A  mixture  of  5  parts 
of  nitrate  of  potassium,  5  parts  of  chlorid  of  ammonium,  and  16  parts  of  water 
produces  great  cold. 

Dry  cold  is  more  manageable  and  more  generally  useful  than  wet  cold. 
It  is  applied  by  means  of  a  rubber  bag  or  a  bladder  filled  with  ground  or  finely 
cracked  ice,  several  folds  of  flannel  being  first  laid  over  the  part.  The  flannel 
collects  the  moisture  from  the  "sweating"  bag  and  thus  prevents  maceration 
of  the  skin.  Further,  it  saves  the  tissue  from  being  subjected  to  too  much 
direct  cold  and  enables  us  to  obtain  the  beneficial  reflex  effect.  The  ice-bag 
of  India-rubber  is  widely  used.     We  can  venture  to  apply  by  means  of  the 


Heat  in  Treatment  of  Inflammation 


71 


ice-bag  a  greater  degree  of  cold  than  it  is  proper  to  apply  by  the  use  of  fluids, 
as  dry  cold  is  not  so  likely  to  induce  gangrene  as  is  moist  cold.  If  there 
is  much  tenderness,  the  weight  of  an  ice-bag  causes  pain,  and  it  is  best  to 
suspend  it  from  a  frame,  so  that  it  lightly  touches  the  part.  The  frame  is  the 
same  as  is  used  to  keep  the  bedclothes  from  a  fractured  leg,  and  is  made  from 
barrel  hoops.  During  the  time  an  ice-bag  is  being  used  the  part  must  be 
inspected  at  brief  intervals  to  see  that  the  circulation  is  not  unduly  depressed. 
The  ice-bag  is  frequently  used  in  joint-inflammation,  in  intracerebral  inflam- 
mation, in  the  early  stage  of  appendicitis,  in  epididymitis,  and  in  acute  myelitis. 
If  a  joint  is  sprained,  the  immediate  application  of  an  ice-bag  is  of  great  ser- 
vice. A  part  can  be  encircled  with  a  rubber  tube  through  which  iced  water 
is  made  to  flow  (Fig.  32).     Even  when  this  apparatus  is  used  the  part  should 


Fig.  31. — Siphon  (Esmarch). 


first  be  wrapped  in  flannel.  Leiter's  tubes,  which  are  tubes  of  lead  made  to 
fit  various  regions  and  which  carry  a  stream  of  cold  water,  can  also  be  used. 
A  piece  of  flannel  must  be  placed  between  the  tube  and  the  skin.  The  tem- 
perature of  these  tubes  can  be  lowered  to  any  desired  degree  by  lowering  the 
temperature  of  the  circulating  fluid.  Cheyne  and  Burghard  caution  us  to 
use  a  fluid  at  a  temperature  not  under  50°  or  60°  F.,  to  inspect  the  part  every 
three  or  four  hours,  and  not  to  employ  the  tubes  longer  than  twenty-four 
hours.* 

Heat  is  emploved  bv  some  early  in  an  inflammation.     It  is  rarely  bene- 
ficial at  this  stage,  except  when  applied  by  a  hot-air  apparatus  for  the  treat- 

*"  Manual  of  Surgical  Treatment,"  by  W.  Watson  Cheyne  and  F.  F.  Burghard. 


78 


Inflammation 


Fig.  32. — The  Esmaich  cooling  coil 


ment  of  an  injured  joint.     It  is  true  that  a  degree  of  heat  which  does  not 
actually  destroy  the  tissues  will   contract  the  vessels  as  does   cold ;    but  this 

degree  of  heat  will  not  be 
kJn*r\  borne  by  the  patient,   and 

will  not  be  tolerated  unless 
but  a  limited  portion  of  a 
superficial  part  is  involved. 
Certain  agents  are  suit- 
ed to  the  stage  of  fully 
developed  inflammation, 
when  there  is  a  great  deal 
of  swelling  due  to  effusion 
and  cell-proliferation.  The 
indication  in  this  stage  is  to 
abate  swelling  by  promot- 
ing absorption.  This  is  ac- 
complished by  (i)  compres- 
sion; (2)  the  local  use  of 
astringents  and  sorbefaci- 
ents;  (3)  the  douche;  (4) 
massage;  and  (5)  heat. 
Compression. — Compression  is  especially  useful  in  fully  developed  or  in 
chronic  inflammation,  but  it  will  do  good  also  in  the  first  stage.  Compression 
is  of  great  usefulness;  it  supports  the  vessels  and  causes  them  to  drink  up 
effusion,  and  it  strongly  rouses  the  absorbents.  This  agent  is  valuable  in 
most  external  inflammations  with  marked  swelling  and  is  particularly  bene- 
ficial in  chronic  inflammation.  In  erysipelas  of  an  extremity  the  part  should 
be  elevated  and  the  extremity  bandaged  from  the  periphery  to  the  body.  In 
ulcers,  especially  those  with  hard  and  blue  edges,  the  use  of  Martin's  elastic 
bandage  or  of  straps  of  adhesive  plaster  gives  decided  relief.  In  chronic 
inflammation  of  a  joint  elastic  compression  is  of  great  value.  In  epididymitis, 
after  the  acute  stage,  the  testicle  may  be  strapped  with  adhesive  plaster.  In 
lymphadenitis  compression  by  a  weight  or  by  a  bandage  is  very  generally 
employed.  In  fractures  compression  not  only  antagonizes  spasm,  but  often 
combats  the  swelling  and  pain  of  inflammation.  Compression  must  be 
judicious:  it  must  never  be  forcible,  and  it  must  not  be  applied  to  a  limb 
without  including  the  distal  portion  of  the  extremity  (never,  for  instance, 
strongly  compress  the  elbow  without  including  the  hand,  nor  the  palm  without 
bandaging  the  fingers).  Injudicious  compression  causes  severe  pain  and 
great  edema,  and  may  produce  gangrene. 

Astringents  and  Sorbefacients. — Astringents  may  have  direct  value  in 
inflammation  of  the  skin,  but  it  is  not  likely  that  they  have  any  effect  on  deep- 
seated  inflammation.  When  used  in  evaporating  lotions  in  an  earlier  stage 
of  inflammation  the  cold  does  good  rather  than  the  drug.  Lead-water  and 
laudanum  is  extensively  employed  and  it  is  thought  to  .somewhat  allay  in- 
flammatory pain.  The  mixture  certainly  gives  comfort  in  cutaneous  ery- 
sipelas. It  is  very  doubtful  if  lead-water  is  of  any  service  at  any  stage  of  a 
deep-.seated  inflammation  or  in  any  fully  developed  inflammation.  If  used 
after  the  first  stage  it  must  not  be  applied  as  an  evaporating  lotion,  because 


The  Douche  79 

cold  will  do  harm.  Pieces  of  lint  are  soaked  in  the  fluid  and  placed  upon  the 
part,  and  a  bandage  is  applied.  The  wet  lint  which  has  been  placed  upon 
the  part  is  covered  with  oiled  silk  or  a  rubber  dam  before  the  bandage  is 
apphed.  If  used  in  the  latter  manner,  the  body-heat  is  retained  in  the  part. 
If  greater  heat  is  required,  a  hot-water  bag  can  be  placed  outside  of  the 
bandage.  Lead-water  is  not  used  in  treating  wounds  and  hot  lead-water 
should  not  be  applied  to  a  cutaneous  inflammation. 

Tincture  of  iodin  is  astringent,  sorbefacient,  counterirritant,  and  anti- 
septic. It  must  not  be  used  pure.  For  application  to  adults  it  should  be 
diluted  with  an  equal  amount  of  alcohol,  and  for  children  with  3  parts  of 
alcohol.  In  using  iodin,  paint  it  upon  the  part  with  a  camel's-hair  brush  and 
fan  it  dry,  applying  one  or  more  coats.  The  repeated  application  of  iodin 
to  the  skin  is  of  great  benefit  in  inflammation  of  the  glands,  muscles,  tendons, 
joints,  and  periosteum.  Iodin  is  apt,  after  a  time,  to  vesicate,  and  must  not 
be  used  in  full  strength,  because  it  is  irritant.  It  is  of  special  value  in  chronic 
inflammation.     In  deep-seated  inflammation  it  acts  as  a  counterirritant. 

Nitrate  of  silver  is  a  non-irritating  astringent  of  considerable  value  in 
inflammation  of  mucous  membranes.  It  forms  a  protective  coat  of  coagu- 
lated albumin,  and  is  much  used  in  treating  the  throat,  mouth,  and  genital 
organs.  In  urethral  inflammation  a  proteid  compound  of  silver  known  as 
protargol  may  be  used. 

Ichthyol  is  a  drug  of  decided  efficienc}-  in  reducing  inflammatory  swelling. 
It  is  usually  employed  in  ointments,  the  strength  being  from  25  to  50  per  cent. 
It  is  best  exhibited  with  lanolin.  When  rubbed  in  over  inflamed  glands, 
joints,  and  lymphatic  enlargements,  it  is  of  great  value.  In  children  a  25  per 
cent.,  and  in  adults  a  50  per  cent.,  ointment  should  be  rubbed  in  thoroughly 
twice  a  day.  In  inflammatory  skin-disease,  synovitis,  thecitis,  frost-bite, 
bubo,  chUblain,  and  in  many  other  conditions,  acute  or  chronic,  the  use  of 
ichthyol  is  indicated.  The  odor  of  ichthyol  is  highly  disagreeable,  and  when 
ordered  for  a  refined  person  it  had  better  be  deodorized.  For  this  purpose 
Hare  uses  oil  of  citronella,  "Lxx  to  5j  of  ointment. 

Mercurials. — Blue  ointment,  pure  or  diluted  to  various  strengths,  is  ex- 
tremely valuable.  It  is  spread  upon  lint  and  kept  applied  over  areas  of  fully 
developed  inflammation.  It  is  especially  useful  in  acutely  or  chronically 
inflamed  joints,  glands,  tendons,  etc.  Blue  ointment  is  strongly  irritant,  and 
will  soon  blister  or  excoriate  a  tender  skin.  It  is  very  beneficial  in  periostitis, 
and  is  employed  largely  in  chronic  inflammations. 

The  Douche. — The  douche  consists  of  a  stream  of  water  falling  upon  a 
part  from  a  height.  The  water  may  be  poured  from  a  receptacle  or  may  run 
through  a  tube,  and  may  be  either  hot  or  cold.  Alternating  hot  and  cold 
streams  are  very  popular  in  inflammations  of  joints  and  tendons,  especially  in 
chronic  inflammation.  This  mode  of  application  is  known  as  the  "  Scotch 
douche."  It  restores  the  tone  of  the  blood-vessels  and  plasma-channels  and 
promotes  the  absorption  of  inflammatory  exudate.  If  the  part  is  very  tender, 
the  water  should  be  squeezed  upon  it  from  sponges.  In  a  sprain  of  the  knee- 
joint,  after  a  time,  when  thickening  has  occurred,  pour  upon  the  part  daily, 
from  a  height,  first  a  pitcherful  of  very  hot  water,  then  a  pitcherful  of  very  cold 
water;  then  use  friction  with  a  hand  greased  with  cosmolin.  Hot  vaginal 
douches  are  generally  employed  in  pelvic  inflammations. 


8o  Inflammation 

Massage, — Massage  is  a  procedure  not  frequently  enough  employed. 
It  is  very  useful  in  some  acute  inflammations,  though  in  these  it  must  be 
gentle.  It  is  of  great  service  in  the  treatment  of  sprains  of  joints  and  fractures. 
It  is  influential  for  good  in  chronic  inflammations  at  the  period  when  rest  is 
abandoned.  It  acts  by  promoting  the  movements  of  tissue-fluids  (blood, 
lymph,  and  areolar  fluid),  stimulating  the  absorbents,  strengthening  local 
nervous  control,  and  thus  improving  nutrition.  Passive  motion  in  joints 
acts  as  massage. 

Heat. — Heat  may  be  used  continuously  or  intermittently,  and  may  be 
either  moist  or  dry.  A  considerable  degree  of  heat  will  act  like  cold  and 
contract  the  vessels.  The  degree  necessary  to  cause  vascular  contraction 
would  not  destroy  the  tissue,  but  would  produce  discomfort,  which  discomfort 
would  become  unbearable  during  the  continuance  of  the  application.  There- 
fore, heat  is  rarely  used  in  the  earliest  stage  of  an  acute  inflammation.  It  is 
hard  to  state  exactly  when  heat  should  be  substituted  for  cold.  Certainly 
after  a  day  or  two  it  is  preferable.  The  sensations  of  the  patient  may  be  of 
use  in  determining  this  point,  and  if  heat  gives  comfort  it  may  be  used.  Mod- 
erate heat  should  be  used  when  inflammation  is  not  very  superficial.  In  a 
cutaneous  inflammation  heat  usually  does  harm,  because  it  increases  the 
congestion  of  an  inflamed  superficial  part.  In  deep-seated  inflammations 
heat  to  the  surface  acts  as  a  revulsive  or  counterirritant.  Thus  a  poultice  to 
the  chest  may  do  good  in  the  first  stage  of  pneumonia,  and  cauterization  of 
the  skin  near  a  joint  may  benefit  an  acute  synovitis.  The  use  of  heat  for 
purposes  of  counterirritation  will  be  discussed  under  the  head  of  Counter- 
irritants.  A  moderate  degree  of  heat  applied  over  a  fully  developed  and  not 
too  superficial  inflamed  area  dilates  the  vessels,  especially  the  veins.  Thus 
circulation  is  re-established  in  an  area  filled  with  stagnant  blood  or  blood 
which  is  scarcely  moving,  fluid  exudate  is  absorbed,  tension  is  lessened,  the 
lymph-spaces  and  vessels  distend,  and  lymphatic  absorption  becomes  active. 
The  application  of  heat  increases  the  ameboid  activity  of  the  leukocytes, 
phagocytes  gather  in  great  numbers  and  surround  an  area  of  infection,  and 
those  which  have  taken  up  bacteria  or  tissue  debris  hurry  away.*  Heat 
notably  lessens  the  pain  of  inflammation.  It  is  often  used  purely  to  relieve 
pain. 

The  forms  oj  heat  are — (i)  fomentations;  (2)  poultices;  (3)  water-bath; 
and  (4)  dry  heat. 

Fomentation  is  the  application  to  the  skin  of  a  piece  of  flannel  containing 
a  hot  liquid.  A  basin  is  warmed  and  over  the  top  of  the  basin  a  towel  is  placed. 
A  piece  of  flannel  folded  in  two  or  three  thicknesses  is  laid  upon  the  towel  and 
boiling  water  is  poured  upon  it.  By  twisting  the  towel  the  water  is  squeezed 
out.  Great  care  must  be  taken  to  squeeze  the  water  out  of  the  flannel,  other- 
wise the  skin  may  be  scalded.  The  hot  flannel  is  laid  upon  the  skin  over  the 
disordered  part.  A  rubber  dam  larger  than  the  flannel  is  placed  over  it,  a 
mass  of  cotton  is  laid  upon  the  rubber  dam,  and  a  bandage  is  applied.  The 
fomentation  must  be  changed  within  an  hour  unless  a  hot-water  bag  has  been 
placed  outside  the  bandage,  in  which  case  it  need  not  be  changed  for  two 
hours  or  more.  The  flannel  which  is  dipped  into  the  hot  liquid  is  known  as  a 
"stupe."  The  turpentine  stupe  is  made  by  wringing  out  the  flannel  as  above 
*Nancrede,  in  "Principles  of  Surgery." 


Poultice  or  Cataplasm  8 1 

and  then  putting  upon  it  from  lo  to  20  drops  of  turpentine.  Instead  of  foment- 
ing the  part,  steam  may  be  thrown  upon  it.  Fomentations  are  used  chietiy 
for  their  reflex  influence  over  deep  congestions  or  inflammations.  The  liquid 
of  a  fomentation  may,  if  desired,  contain  corrosive  sublimate,  carbolic  acid, 
or  other  agents.  A  fomentation  containing  an  antiseptic  is  known  as  an 
antiseptic  fomentation.  An  antiseptic  fomentation,  or,  as  it  is  often  called, 
an  antiseptic  poultice,  is  made  and  applied  as  follows:  Gauze  is  used  instead 
of  flannel,  and  is  laid  upon  the  towel  over  the  basin  as  previously  described. 
A  verv  warm  solution  of  corrosive  sublimate  (i  :  1000)  is  poured  upon  the 
gauze,  the  material  is  partly  wrung  out,  placed  upon  the  part,  covered  with  a 
rubber  dam,  and  upon  it  a  hot-water  bag  is  placed.  Fomentations  are  very 
useful  in  relieving  pain  in  any  stage  of  an  inflammation  and  act  also  as  counter- 
irritants.  Fomentations  are  used  in  preference  to  ordinary  poultices  if  there 
is  any  probabihty  of  a  surgical  operation  becoming  necessary,  because  skin  to 
which  a  poultice  has  been  applied  cannot  be  satisfactorily  sterilized.  The 
antiseptic  fomentation  is  of  great  service  in  removing  sloughs  from  foul  wounds 
and  ulcers.  It  is  the  only  form  of  poultice  which  is  admissible  when  the  skin 
is  broken. 

Poultice  or  Cataplasm. — A  poultice  is  a  soft  mass  applied  to  a  part  to  bring 
heat  and  moisture  to  bear  upon  it.  Poultices  can  be  made  of  ground  flaxseed, 
of  slippery-elm  bark,  of  arrowroot,  starch,  bread  and  milk,  potatoes,  turnips, 
etc.  To  make  a  flaxseed  poultice,  scald  a  spoon  and  a  tin  basin,  put  the  flax- 
seed into  the  dry  hot  basin,  and  pour  upon  it  boiling  water  in  sufficient  quan- 
tity to  form  a  thick  paste.  The  proper  consistence  is  found  when  the  mass 
would  stick  if  it  were  thrown  against  a  wall.  It  is  now  spread  to  the  thickness 
of  a  quarter  of  an  inch  upon  a  piece  of  warm  muslin,  a  free  edge  being  left  all 
around,  the  edges  of  the  muslin  are  turned  in,  and  the  flaxseed  is  covered 
with  a  bit  of  gauze  to  prevent  adhesion  to  the  skin.  The  poultice  should  be 
placed  upon  the  part  and  be  covered  outside  with  oiled  silk,  a  rubber  dam,  or 
waxed  paper.  A  mass  of  cotton  is  applied  outside  of  the  rubber  and  the  poul- 
tice is  held  in  place  by  a  bandage  or  binder.  It  can  be  kept  very  warm  for  a 
considerable  period  by  placing  upon  it  a  bag  filled  with  hot  water.  If  a  hot- 
water  bag  is  not  employed,  a  poultice  should  be  changed  every  two  hours. 
Spongiopilin,  when  moistened  with  hot  water,  is  a  good  substitute  poultice. 
Lint  soaked  with  hot  water  and  covered  with  some  impermeable  material  does 
very  well.  The  fermented  poultice,  which  was  once  popular  for  gangrenous 
ulcers,  was  made  by  sprinkling  yeast  upon  an  ordinary  cataplasm.  The 
charcoal  poultice  is  made  by  stirring  charcoal  into  the  usual  poultice- mass. 
A  poultice  containing  opium  is  known  as  a  "sedative"  poultice.  About  gr.  ij 
of  opium  to  the  ounce  of  poultice-mass  may  relieve  pain.  Flaxseed  is  a  vege- 
table material,  adheres  to  the  skin,  enters  the  mouths  of  glands  and  follicles, 
undergoes  decay,  and  can  be  removed  only  with  great  difficulty.  The  prepa- 
ration of  an  antiseptic  poultice  or  fomentation  is  described  above.  Poultices 
must  not  be  kept  on  the  part  too  long,  as  they  will  cause  vesication,  especially 
in  adynamic  conditions.  If  a  poultice  is  causing  vesication,  remove  it  and 
do  not  replace  it.  or  replace  it  after  sprinkling  the  part  and  the  poultice  with 
powdered  oxid  of  zinc.  If  suppuration  exists  or  is  seriously  threatened,  do 
not  waste  time  by  using  poultices,  but  incise  at  once.  Incision  may  pre- 
vent suppuration  bv  relieving  tension,  affording  drainage,  and  permitting  the 
6 


82  Inflaniination 

local  use  of  antiseptics.  If  pus  exists,  it  cannot  be  evacuated  too  soon.  To 
use  poultices  and  delay  incision  is  often  productive  of  irreparable  harm. 
After  incision  of  a  purulent  focus  it  is  common  practice  to  apply  an  antiseptic 
fomentation  in  order  to  draw  quantities  of  leukocytes  to  the  part  and  thus 
limit  the  spread  of  infection  and  stimulate  granulation. 

Hot-water  Bath. — The  continuous  hot  bath  is  now  rarely  employed  exf^ept 
in  burns  and  cases  of  phagedena,  when  it  often  proves  curative.  In  these 
cases  an  antiseptic  agent  may  be  dissohed  in  the  water.  Continuous  immer- 
sion in  a  warm  bath  is  regarded  favorably  by  some  surgeons  for  the  treatment 
of  sloughing  wounds  and  large  purulent  areas.  The  immersion  of  a  part 
from  time  to  time  in  water  as  hot  as  can  be  tolerated  is  useful  in  fully  developed 
and  in  chronic  inflammation.  Such  immersion  benetits  an  inflamed  joint, 
lessening  the  pain,  sweUing,  and  stiffness. 

Dry  heat  is  applied  by  a  metallic  object  dipped  in  hot  water  and  laid  upon 
the  part;  by  Leiter's  tubes,  through  which  hot  water  flows;  by  the  hot-water 
bag  or  by  the  hot-air  apparatus.  Some  surgeons  use  the  hot-water  bag  in 
cases  of  mild  appendicitis,  in  order  to  favor  the  formation  of  adhesions.  The 
hot-water  bag  is  often  soothing  and  beneficial  when  laid  upon  an  inflamed 
joint,  or  on  the  perineum  or  the  hypogastric  region  in  cystitis.  A  bag  of  hot 
sand,  a  hot  brick,  or  a  bottle  or  can  of  hot  water  may  be  used  instead  of  the 
bag.  The  hot-air  apparatus  is  of  very  great  service  in  the  treatment  of  in- 
flamed joints  {vide  dry  hot-air  apparatus). 

Treatment  when  Suppuration  is  Threatened. — When  suppuration  is  threat- 
ened, ordinary  hot  fomentations  or  antiseptic  fomentations  must  be  used, 
and  the  part  must  be  kept  at  rest.  As  previously  explained,  the  flaxseed 
poultice  is  inadmissible.  When  suppuration  is  threatened,  the  use  of  heat 
causes  the  collection  of  multitudes  of  leukocytes,  which  tend  to  limit  the  area 
of  infection  and  destroy  bacteria.  Even  when  suppuration  is  not  prevented, 
heat  aids  in  the  rapid  breaking  down  of  the  diseased  tissue  at  the  focus  of 
the  inflammation  and  causes  hordes  of  leukocytes  to  gather  and  encompass 
the  suppurating  tissue,  and  these  leukocytes  prevent  the  spread  of  the  in- 
fection. 

In  most  cases,  when  suppuration  is  obviously  inevitable  or  seriously 
threatened,  a  free  incision  will  be  of  greatest  benefit. 

Irritants  and  Counterirritants  in  Inflammation. — Irritants  attract 
an  increased  supply  of  blood  to  the  part  whereon  they  are  applied,  and  are 
used  for  their  local  effects.  Counterirritants  are  used  to  affect  by  reflex 
influence  some  distant  part.  In  chronic  inflammation  irritants  may  do  good 
by  promoting  the  blood-supply,  thus  favoring  the  removal  of  exudates  (lini- 
ment for  rheumatism  and  synovitis,  and  nitrate  of  silver  for  ulcers).  Counter- 
irritants  are  powerful  pain-reHevers  when  used  over  an  inflamed  structure; 
they  bring  blood  to  the  surface  and  are  thought  by  many  writers  to  cause 
anemia  of  internal  ]jarts,  the  site  and  area  of  anemia  depending  on  the  site, 
the  area,  and  the  duration  of  the  surface  irritation.  Some  recent  studies  .seem 
to  indicate  that  counterirritation  produces  hyperemia  of  the  superficial  part, 
compensatory  anemia  of  .surrounding  regions,  and  anemic  edema  of  the  sub- 
cutaneous tissue  and  muscles  (W.  Wccksberg,  "Zeit.  f.  klin.  Med.,"  Bd. 
xxxvii,  H.  3  u.  4).  Nancrede  dissents  from  the  statement  that  counterirritants 
cause  anemia  of  internal  j)arts;  and  he  maintains  that  they  irritate  deejier  ])arts 


Irritants  and   Counterirritants  83 

and  cause  more  external  blood  to  be  taken  to  them.  He  claims  that  a  blister 
applied  to  the  chest  produces  a  hyperemic  area  in  the  pleura,  and  refers  to 
Furneaux  Jordan's  opinion  that  direct  irritation  to  the  surface  over  a  joint 
adds  to  synovial  hyperemia,  and  that  consequently  in  joint-inflammation 
counterirritants  should  be  applied  above  and  below  a  joint,  but  not  directly 
over  it.  As  a  matter  of  fact,  we  know  chnically  that  powerful  counterirritation 
directly  over  an  inflamed  superficial  joint  is  occasionally  followed  by  an  aggra- 
\-ation  of  the  trouble,  and  that  in  pericarditis  blistering  directly  over  the  peri- 
cardium may,  as  pointed  out  by  Brunton,  make  the  condition  worse.  Coun- 
terirritants not  only  relieve  pain  in  the  earlier  stages  of  inflammation,  but  they 
also  promote  absorption  of  exudate  in  the  later  stages,  and  are  particularly 
valuable  in  chronic  inflammations.  Great  benefit  is  obtained  by  blistering 
old  thickened  ulcers,  and  by  painting  the  chest  with  iodin  to  relieve  pleuritic 
effusion.  Frictions,  besides  their  pressure  effects,  act  as  counterirritants. 
Frictions  may  relieve  skin  pain,  and  are  associated  with  the  application  of 
stimulating  liniments  in  the  treatment  of  stiff  joints.  A  mustard  plaster  is  a 
valuable  counterirritant  in  an  acute  deeply  seated  inflammation.  Tincture 
of  iodin  is  extensively  used  in  chronic  inflammation. 

There  is  no  more  efficient  method  of  relieving  pleural  effusion  than  by 
the  application  of  a  succession  of  blisters.  Blisters  are  also  used  in  the  treat- 
ment of  inflamed  joints,  pericarditis,  pneumonic  consolidation  of  the  lung, 
acute  and  chronic  rheumatism,  etc.;  and  are  applied  back  of  the  ears  or  at  the 
nape  of  the  neck  in  congestive  coma  or  meningitis.  A  blister  can  be  produced 
in  a  few  minutes  by  soaking  a  bit  of  lint  in  chloroform,  and  after  applying  it 
to  the  surface,  covering  it  with  oiled  silk  or  with  a  watch-glass.  Equal  parts 
of  lard  and  ammonia  will  blister  in  five  minutes.  It  is  easier  to  blister  with 
cantharidal  collodion  or  blistering  paper.  Before  applying  a  blister,  shave 
the  part  if  it  be  hairy,  then  grease  the  plaster  with  olive  oil  and  apply  it. 
Blistering  plaster  is  left  in  place  six  hours  in  the  case  of  an  adult,  but  only  two 
hours  in  the  case  of  an  old  person  or  a  child;  the  plaster  is  then  remo\'ed,  and 
if  a  blister  has  not  formed,  the  part  must  be  poulticed  for  a  few  hours.  When 
a  blister  is  obtained,  open  it  with  a  needle  which  has  been  dipped  in  boiling 
water.  If  the  surgeon  wishes  the  blister  to  heal,  it  should  be  covered  with  a 
piece  of  lint  smeared  with  cosmolin  or  with  zinc  ointment.  If  it  is  to  be  kept 
open  for  a  time,  cut  away  the  stratum  corneum  and  dress  with  cosmolin,  each 
ounce  of  which  contains  six  drops  of  nitric  acid. 

Pustulation  can  be  eft'ected  with  tartar-emetic  ointment  or  with  \'ienna 
paste.  Tartar-emetic  ointment  was  formerly  used  on  the  scalp  in  meningitis. 
Vienna  paste  consists  of  5  parts  of  caustic  potash  and  6  parts  of  lime  made  into 
a  paste  with  alcohol.  It  is  applied  for  five  minutes,  and  is  then  washed  off 
with  vinegar. 

The  hot  iron  is  the  most  powerful  of  counterirritants.  It  is  chiefly  used 
in  chronic  inflammation  of  joints,  bone,  and  the  spinal  cord.  The  application 
is,  of  course,  very  painful,  and  it  is  best  to  give  an  anesthetic  before  using  the 
cautery.  A  flat  cautery  iron  may  be  used,  or  the  round  iron.  The  latter  is 
known  as  the  button  or  Corrigan's  cautery.  The  iron  is  used  at  a  white  heat. 
One  area  or  several  may  be  seared.  The  cautery  is  drawn  lightly  two  or 
three  times  over  each  spot  we  wish  to  burn.  The  object  is  to  destroy  only  the 
superficial  layers  of  the  skin.     After  the  cauterization  is  completed,  lint  wet 


84  Inflammation 

with  iced  water  is  applied  for  several  hours  to  allay  pain,  and  then  hot  anti- 
septic fomentations  are  used  until  the  slough  separates. 

If  we  wish  to  prevent  healing  after  separation  of  the  slough,  dress  the  sore 
with  cosmolin,  each  ounce  of  which  contains  6  drops  of  nitric  acid.  It  is  not 
wise  to  cauterize  deeply  directly  over  a  superficial  joint. 

Constitutional  Treatment  of  Inflammation. — Certain  remedies  are 
used  in  inflammation  for  their  general  or  constitutional  effects;  these  remedies 
are — (i)  general  bleeding;  (2)  arterial  sedatives;  (3)  cathartics;  (4)  diaphor- 
etics; (5)  diuretics;  (6)  anodynes;  (7)  antipyretics;  (8)  emetics;  (9)  mercury 
and  iodids;  (10)  stimulants;  and  (11)  tonics. 

General  Bleeding,  Venesection,  or  Phlebotomy. — Venesection  is  suited 
to  the  early  stages  of  an  acute  inflammation  in  a  young  and  robust  subject. 
The  indication  for  its  employment  is  increased  arterial  tension,  as  shown  by  a 
strong,  full,  rapid,  and  incompressible  pulse  in  a  vigorous  young  patient. 
General  blood-letting  diminishes  blood-pressure  and  increases  the  speed  of 
the  blood-current,  thus  amends  stasis,  absorbs  exudate,  and  washes  adherent 
corpuscles  from  the  vessel-wall;  furthermore,  it  reduces  the  whole  amount 
of  body  blood  and  thus  forces  a  greater  rapidity  of  circulation,  decreases  the 
amount  of  fibrin  and  albumin,  lowers  the  temperature,  arrests  cell-prolifera- 
tion, and  stops  effusion. 

This  procedure  was  in  former  days  so  highly  esteemed  that  it  settled  into 
a  routine  formula  to  be  applied  to  every  condition  from  yellow  fever  to  dislo- 
cation. The  terrible  mortality  of  the  cholera  epidemics  from  1830  to  1835 
led  practitioners  to  question  the  belief  that  bleeding  was  a  general  panacea, 
and  from  this  doubt  there  was  born  in  the  next  generation  violent  opposition 
to  blood-letting  in  any  disease.  Like  most  reactions,  opposition  has  gone  too 
far,  the  pendulum  of  condemnation  has  swung  beyond  the  line  of  truth  and 
sense,  and  thus  is  universally  neglected  or  broadly  condemned  a  powerful  and 
valuable  resource.  Many  physicians  of  long  experience  have  never  seen  a 
person  bled;  its  performance  is  not  demonstrated  in  most  schools,  and  but 
few  patients  and  families  will  permit  it  to  be  done.  But  when  properly  used 
it  is  occasionally  beneficial.  It  is  applicable,  however,  only  to  the  young, 
.strong,  and  robust,  and  not  to  the  old,  weak,  or  feeble.  It  is  used  for  violent 
acute  inflammations  of  important  organs  or  tissues,  and  not  for  low  inflam- 
mations or  for  slight  affections  of  unimportant  parts.  It  is  used  in  the  early, 
but  not  in  the  late,  stages  of  an  inflammation.  It  is  used  when  the  pulse  is 
frequent,  full,  hard,  and  incompressible,  but  not  when  it  is  slow,  small,  soft, 
compressible,  and  irregular.  It  is  used  when  the  face  is  flushed,  but  not  when 
it  is  pallid.  It  is  not  used  in  fat  persons,  drunkards,  very  nervous  people,  or 
the  sufferers  from  adynamic,  septic,  or  epidemic  diseases.  It  is  of  value  in 
some  few  cases  of  congestion  of  the  lungs,  pneumonitis,  pleuritis,  meningitis, 
prostatitis,  cystitis,  and  other  acute  inflammatory  conditions.  It  is  particularly 
valuable  when  uremia  exists  or  when  there  is  distention  of  the  right  side  of 
the  heart.     The  method  of  bleeding  is  described  on  page  331. 

After  bleeding,  the  patient  should  be  put  on  arterial  sedatives,  diuretics, 
diaphoretics,  anodynes,  and,  if  necessary,  purgatives.  A  favorite  mixture  of 
Prof.  S.  D.  Gross  was  the  antimonial  and  saline,  gr.  xl  of  Epsom  salt,  gr.  yV 
of  tartar  emetic,  2  drops  of  tincture  of  aconite,  and  .^j  of  sweet  spirits  of  niter, 
in  enough  ginger  syrup  and  water  to  make  5ss;  given  every  four  hours. 


Cathartics  85 

Arterial  Sedatives. — Drugs  of  this  character  are  of  great  use  before  stasis 
is  pronounced;  but  if  used  after  stasis  is  established  they  will  increase  it.  If 
stasis  existe  it  may  be  relieved  by  blood-letting,  local  or  general,  and  then 
arterial  sedatives  can  be  given.  Either  local  bleeding  or  venesection  abolishes 
stasis  and  lowers  tension,  and  arterial  sedatives  maintain  the  effect  and  hold 
the  ground  which  is  gained.  The  arterial  sedatives  employed  are  aconite, 
veratrum  viride,  gelsemium,  and  tartar  emetic.  These  sedatives  lessen  the 
force  and  the  frequency  of  the  heart-beats,  and  thus  slow  and  soften  the  pulse, 
and  are  suited  to  a  robust  person  with  an  acute  inflammation,  but  are  not 
suited  to  a  weak  individual  in  an  adynamic  state. 

Aconite  is  given  in  small  doses,  never  in  large  amounts.  One  drop  of 
the  tincture  in  a  little  water  is  given  ever}'  half  hour  until  its  effect  is  manifest 
on  the  pulse,  when  it  may  be  given  every  two  or  three  hours.  Large  doses 
of  aconite  produce  pronounced  depression,  and  are  dangerous.  Aconite 
lowers  the  temperature,  slows  the  pulse,  and  produces  diaphoresis. 

Veratrum  viride  is  a  powerful  agent  to  slow  the  pulse  and  to  lower  blood- 
pressure;  it  produces  moisture  of  the  skin,  and  often  nausea.  It  is  given  in 
I -drop  doses  of  the  tincture  every  half  hour  until  its  physiological  effects  are 
manifested,  when  the  period  between  doses  is  extended  to  two  or  three  hours. 
Ten  drops  of  laudanum  given  a  quarter  of  an  hour  before  each  dose  of  vera- 
trum viride  will  prevent  nausea. 

Gelsemium  is  an  arterial  sedative  highly  approved  by  Bartholow.  It  is 
given  in  doses  of  5  to  10  drops  of  the  tincture  every  three  or  four  hours. 

Tartar  emetic  lowers  arterial  tension  and  lessens  the  pulse-rate.  This 
drug  is  not  generally  employed;  if  it  is  used  with  the  greatest  care  it  is  no 
better  than  some  other  agents,  and  if  it  is  not  so  used  it  will  cause  dangerous 
depression.  The  dose  is  from  gr.  ^V  to  gr.  jq-  in  water  every  three  hours 
until  the  physiological  effects  are  manifest. 

Cathartics, — Purgation  is  of  great  value  in  inflammation.  By  it  putrid 
material  is  removed  from  the  intestine,  fluid  containing  poisonous  elements 
is  drawn  from  the  blood,  and  the  liability  to  infection  of  the  tissues  is  lessened. 
The  administration  of  purgatives  is,  of  course,  not  to  be  a  routine  procedure 
in  inflammatory  states.  The  bowels  may  be  acting  so  freely  that  no  cathartic 
is  required.  Treatment  in  an  inflammation  should  be  inaugurated,  if 
constipation  exists,  by  giving  a  cathartic.  The  tongue  affords  important 
indications  as  to  the  necessity  for  purgation.  Castor  oil  can  be  given  in  cap- 
sules, or  the  juice  of  half  a  lemon  is  squeezed  into  a  tumbler,  i  ounce  of  oil 
poured  in,  and  the  rest  of  the  lemon  is  squeezed  on  top,  thus  making  a  not 
unpalatable  mixture.  Aloin,  podophyllum,  the  salines,  and  calomel  in  5- 
or  lo-grain  doses,  followed  by  a  saline,  have  their  advocates.  In  peritonitis 
the  salines  are  of  unquestionable  value,  a  teaspoonful  of  Epsom  salt  and  a 
teaspoonful  of  Rochelle  salt  being  given  hourly  until  a  movement  occurs.  In 
the  course  of  inflammation,  from  time  to  time,  if  there  be  constipation,  a 
coated  tongue,  and  foulness  of  the  breath,  there  should  be  ordered  gr.  j  of 
calomel  with  gr.  xxiv  of  bicarbonate  of  sodium,  made  into  twelve  powders, 
one  being  given  every  hour;  if  the  bowels  are  not  moved  by  the  time  the 
powders  are  all  taken,  a  saline  should  be  given.  If  a  violent  purgative  eft'ect 
is  desired,  as  in  meningitis,  croton  oil  or  elaterium  may  be  ordered.  If  con- 
stipation is  persistent,  give  fluid  extract  of  cascara  sagrada  daily  (20  to  40 


86  Inflammation 

drops),  or  a  pill  at  night  containing  gr.  \  of  extract  of  belladonna,  gr.  I  of 
extract  of  nux  vomica,  gr.  yV  of  aloin,  gr.  j  of  extract  of  physostigma,  and  gtt. 
J  of  oil  of  cajuput.  Enemas  or  clysters  may  be  used  in  some  cases.  A  very 
useful  enema  is  composed  of  f5j  of  oil  of  turpentine,  fSiss  of  olive  oil,  f^ss 
of  mucilage  of  acacia,  in  fox  of  water  Soapsuds  and  vinegar  in  equal  parts 
make  a  serviceable  clyster.  A  combination  of  oil  of  turpentine,  castor  oil, 
the  volk  of  an  egg,  and  water  can  be  used.  Asafetida,  gr.  xxx  to  the  yolk 
of  one  egg,  makes  a  good  enema  to  amend  flatulence. 

Diaphoretics. — These  agents  are  very  useful.  A  profuse  sweat  removes 
much  toxic  material  from  the  blood  and  in  the  beginning  of  an  acute  inflam- 
mation, such  as  tonsilhtis,  may  abort  the  disease.  Dover's  powder  is  commonly 
used,  but  pilocarpin  is  preferred  by  some.  Camphor  in  doses  of  from  5  to 
10  grains  is  diaphoretic,  and  so  are  antimony  and  ipecac.  Acetate  and 
citrate  of  ammonium,  opium,  alcohol,  hot  drinks,  heat  to  the  surface  (baths, 
hot  bricks,  hot-water  bags),  serpentaria,  and  guaiac  are  diaphoretic  agents. 

Diuretics. — Diuretics  are  useful  in  fevers  when  the  urine  is  scanty  and 
high-colored,  and  are  valuable  aids  in  removing  serous  effusions  and  other 
exudates.  Among  the  diuretics  may  be  mentioned  calomel  in  repeated  large 
doses,  cocain,  alcohol,  digitalis,  the  nitrites,  squill,  turpentine,  copaiba,  and 
cantharides.  The  liquor  potasste  and  the  acetate  of  potassium  are  the  best 
agents  to  increase  the  solids  in  the  urine.  The  liquor  potassii  citratis  in 
doses  of  foj  to  f5iv  is  efficient.  Large  draughts  of  water  wash  out  the  kidneys. 
If  the  heart  is  weak,  citrate  of  caffein  is  a  good  .stimulant  diuretic,  and  hot 
coffee  is  very  serviceable  in  promoting  the  secretion  of  urine.  The  injection 
of  hot  salt  solution  into  the  rectum  and  under  the  skin  favors  diuresis,  and 
the  intravenous  infusion  of  salt  solution  is  a  \ery  powerful  diuretic.  The 
application  of  heat  to  the  loins  promotes  the  secretion  of  urine.  Sodio- 
theobromin  salicylate  (diuretin)  is  an  uncertain  but  often  Aaluable  diuretic, 
in  doses  of  gr.  x  every  two  or  three  hours. 

Anodynes  and  Hypnotics. — Drugs  may  be  required  to  allay  ])ain  or 
procure  sleep.  Dover's  powder,  besides  being  diaphoretic,  is  anodyne. 
Opium  acts  well  after  lileeding  or  purgation.  If  it  causes  nausea,  it  should  be 
preceded  one  hour  by  the  administration  of  gr.  xxx  of  bromid  of  potassium. 
Opium  is  used  by  the  mouth,  l)y  the  rectum,  or  hypodermatically.  It  is  used 
when  there  is  pain,  but  its  use  is  not  to  be  long  persisted  in  if  it  can  be  avoided. 
It  is  given  in  doses  measured  purely  by  the  necessities  of  the  case.  If  opium 
disagrees,  try  the  combination  of  morphin  with  atropin.  After  an  operation 
antipyrin  or  phenacetin  will  often  quiet  pain  and  secure  sleep.  When  a  person 
feels  "so  tired  he  can't  sleep,"  alcohol  in  the  form  of  whiskey  or  brandy  must 
be  given.  Sleeplessness  not  due  to  pain  is  met  by  chloral,  trional,  the  bromids, 
or  sulphonal.  Chloral  is  dangerous  in  conditions  of  weak  heart  or  exhaustion. 
Bromids  must  be  given  in  large  doses  to  be  efficient.  Sul])honal  must  be  given 
about  four  or  five  hours  before  sleep  is  expected,  in  doses  of  from  gr.  x  to  gr.  xx 
in  hot  milk  or  hot  mint  water.  Trional  is  safe  and  \cry  satisfactory.  It  is 
given  in  floscs  of  gr.  xv  to  gr.  xxv  in  hot  water. 

Antipyretics. ^ — Arterial  sedatives,  diaphoretics,  and  ])urgati\cs  lower 
temperature,  and  have  previously  been  alluded  to  (page  85).  There  are  two 
great  classes  of  febrifuges — those  which  les.sen  heat-production  and  those 
which  increase  heat-ehmination.     In  the  first  group  we  find  quinin,  salicylic 


Mercury  and  the  lodids  87 

acid  and  the  sahcylates,  kairin,  alcohol,  antimony,  aconite,  digitalis,  cupping, 
and  bleeding.  In  the  second  group  we  find  alcohol,  nitrous  ether,  antipyrin, 
acetanilid,  phenacetin,  opium,  ipecac,  cold  to  the  surface,  and  cold  drinks. 
In  surgical  inflammations  it  is  rarely  necessary  to  employ  heroic  means  to 
lower  temperature.  The  use  of  such  an  agent  as  antipyrin  is  contraindicated 
in  the  weak  and  adynamic,  and  it  is  never  to  be  thought  of  as  a  means  of  lower- 
ing temperature  unless  the  latter  goes  above  103°  F.  Quinin,  in  doses  of 
gr.  x.x  to  gr.  XXX  given  at  4  p.  m.,  may  prevent  an  evening  rise;  salol  or  salicin 
can  be  given  during  the  day.  Inunctions  of  30  minims  of  guaiacol  lower  the 
temperature  in  tuberculous  conditions  and  in  septic  fevers.  These  inunctions 
are  made  upon  the  abdomen,  and  often  produce  surprising  results.  Dujardin- 
Beaumetz  maintained  that  fever  is  a  condition  in  which  the  animal  organism 
is  endeavoring  to  oxidize  and  render  inert  certain  poisonous  material,  and 
that  antipyretic  drugs  lessen  oxidation  and  actually  make  the  patient  worse. 
This  view  is  in  accordance  with  the  experience  of  a  number  of  surgeons.  It 
is  a  suggestive  fact  that  bacteria  are  said  to  multiply  more  rapidly  when  kept 
at  about  the  normal  body-temperature  than  when  kept  at  fever  heat  (102°  F., 
or  more).  The  mere  discomfort  of  fever  may  be  much  mitigated  by  anti- 
pyretic drugs,  but  the  fever  process  is  not  benefited  b}-  them. 

Emetics. — Emetics  may  do  good  when  the  patient  suffers  from  a  parched, 
coated  tongue,  a  dry  and  hot  skin,  nausea,  and  gastric  oppression,  but  it  is 
very  rarely  in  these  days  that  we  employ  them.  There  can  be  used  5j  of  alum 
in  molasses,  gr.  xx  of  sulphate  of  zinc,  or  a  tablespoonful  of  mustard  and  a 
teaspoonful  of  salt  given  in  warm  water  and  followed  by  large  draughts  of 
warm  water.  Ipecac  in  a  dose  of  gr.  xx  can  be  employed.  The  emetic  dose 
of  tartar  emetic  is  gr.  ij,  but  it  is  too  depressant  a  drug  to  trifle  with.  The 
sulphuret  of  antunony  in  doses  of  from  i  to  5  grains  is  safe.  Apomorphin 
hypodermatically,  in  a  dose  of  from  gr.  y^^  to  gr.  |,  will  act  in  five  minutes. 
Emetics  are  valuable  in  inflammatory  conditions  of  the  air-passages,  Init  their 
use  is  contraindicated  in  diseases  of  the  heart,  brain,  and  bowels,  in  hernia, 
in  dislocations,  in  fractures,  and  in  aneurysms. 

Mercury  and  the  lodids. — Mercury  is  an  alterative — that  is,  an  agent 
which  favorably  affects  body  nutrition  without  causing  any  recognizable 
change  in  the  fluids  or  the  solids  of  the  bod}-.  Mercury  lessens  blood  plas- 
ticity, hinders  the  exudation  of  liquor  sanguinis — thus  furnishing  less  food  to 
the  cells  in  the  perivascular  tissues — and  retards  cell-proliferation.  Further, 
by  a  stimulant  action  on  the  absorbents  it  promotes  the  breaking  up  of  an 
existing  inflammatory  exudation,  and  hence  limits  damage  from  excess  of 
new  formation.  The  time  at  which  mercury  is  best  given  is  when  violent 
.symptoms  have  abated,  the  guides  being  a  reduced  temperature  and  a  moist 
skin.  Mercury  is  often  given  in  conjunction  with  the  local  use  of  sorbefacienis 
(ichthyol,  or  mercurial  ointment).  When  possible,  the  administration  of 
mercury  is  associated  with  compression  of  the  inflamed  part.  It  is  sometimes 
given  until  the  gums  are  .slightly  touched,  but  it  is  not  given  to  the  point 
of  salivation.  When  the  breath  becomes  offensive  and  the  gums  tender  on 
snapping  the  teeth,  or  when  griping  and  diarrhea  begin,  the  dose  should  be 
reduced,  or  the  drug  should  be  stopped  (.see  Ptyalism).  In  iritis  mercury  is 
used  to  get  rid  of  the  plastic  effusion  which  is  causing  pupillar\-  fixation  and 
opacity.     In  keratitis  the  gums  should  be  touched  s/iglitly.     In  orchitis,  after 


S8  Inflammation 

the  subsidence  of  the  acute  symptoms,  mercury  should  be  employed.  In 
pericarditis,  meningitis,  and  in  many  chronic  and  lingering,  and  in  all 
syphilitic  inflammations,  this  drug  can  be  used. 

Some  persons  will  be  salivated  with  very  minute  doses  of  mercury,  either 
because  of  idiosyncrasy  or  previous  saturation.  Others  can  take  enormous 
doses  without  any  appreciable  constitutional  effect.  The  action  of  mercurials 
can  be  favored  by  a  combination  with  ipecac  or  with  tartar  emetic. 

In  giving  mercury,  if  a  prompt  effect  is  desired,  give  gr.  iij  of  calomel  every 
three  hours  until  a  metallic  taste  is  noted  in  the  mouth.  If  the  case  is  not  so 
urgent,  gray  powder  is  a  good  combination.  Children  are  given  calomel  and 
sugar  or  mercury  and  chalk.  If  it  is  desired  to  give  the  drug  for  some  time, 
corrosive  sublimate  is  a  suitable  form,  and  small  doses  will  actually  increase 
the  number  of  red  blood-corpuscles.  Corrosive  sublimate  is  to  be  given  alone 
or  combined  only  with  iodid  of  potassium.  The  green  iodid  of  mercury  is  a 
drug  suitable  for  prolonged  administration.  In  the  prolonged  use  of  mercury 
it  will  often  be  necessary  to  give  at  the  same  time  a  little  opium  to  prevent 
diarrhea  and  griping.  A  rapid  effect  can  be  obtained  by  rubbing  daily  with 
a  gloved  hand  5j  of  the  oleate  of  mercury  or  5ss  of  the  ointment  into  the 
groins,  the  axilla,  or  the  inside  of  the  thighs.  Suppositories  of  mercurial 
ointment  induce  rapid  ptyahsm.  Hypodermatic  injections  of  corrosive  sub- 
limate or  gray  oil  may  be  used,  and  must  be  thrown  deeply  into  the  muscles 
of  the  buttock  or  back.  Old  people,  those  who  are  exhausted,  anemic,  and 
broken  down,  and  the  tuberculous  bear  mercury  badly.  If  it  be  given  to  them 
at  all,  it  must  only  be  in  small  amounts  and  for  a  brief  time. 

Alkaline  iodids  are  useful  in  removing  the  products  of  inflammation;  they 
can  be  given  for  a  long  time,  and  admirably  supplement  mercurials.  Iodid 
of  potassium  can  be  prescribed  in  combination  with  corrosive  sublimate  as 
follows : 

R  .       Hydrarg.  chlor.  corros., gr-  ij  ; 

Potass,  iodidi, .^^  ^t  9J  5 

Syr.  sarsaparillae  comp., q.  s.  ad  f^viij.  —  M. 

Sig. — f^ij,  in  water,  after  meals. 

Iodid  of  potassium,  well  diluted,  is  given  on  a  full  stomach;  it  is  never 
given  concentrated  or  before  meals.  A  convenient  mode  of  administration 
is  to  procure  a  concentrated  solution  of  the  iodid  of  potassium,  remembering 
that  every  drop  equals  about  gr.  j  of  the  drug,  and  give  as  many  drops  as  may 
be  desired  in  half  a  glass  of  water  after  meals.  If  the  medicine  disagrees,  add 
to  each  dose,  after  it  is  put  in  water,  5j  of  the  aromatic  spirit  of  ammonia. 
Extract  of  licorice  is  a  good  vehicle  for  the  iodid.  If  the  mixture  in  water 
disagrees,  the  drug  should  be  given  in  milk.  Capsules  are  satisfactory,  but 
a  drink  of  water  should  be  taken  just  before  and  again  just  after  taking  a 
capsule,  to  protect  the  stomach  from  the  concentrated  drug.  Iodid  of  sodium 
may  agree  when  iodid  of  potassium  does  not.  When  the  iodids  disagree  they 
produce  iodism.  The  first  indications  of  iodism  are  a  bad  taste  in  the  mouth, 
running  of  the  eyes  and  nose,  and  sneezing,  followed  by  a  feeling  of  exhaustion, 
absolute  loss  of  appetite,  nausea,  tremor,  and  skin  eruptions  (acne,  hemor- 
rhages, blebs,  hydroa,  etc.).  If  iodism  occurs,  stop  the  drug  and  give  the 
patient  Fowler's  solution  in  increasing  doses,  laxatives,  diuretic  waters,  and 
also  nutritious  food,  and  stimulants  if  depression  is  great.  Sometimes  bella- 
donna does  good  in  obstinate  cutaneous  disorders  induced  by  the  iodids. 


Antiphlogistic    Regimen  89 

Remedies  Directed  against  Special  Morbid  States. — If  inflammation 
is  associated  with  rheumatism,  gout,  scurvy,  syphihs,  tuberculosis,  or  any 
other  constitutional  disease  or  predisposition,  appropriate  treatment  should  be 
instituted  to  control  the  disease  or  combat  the  predisposition,  and  at  the  same 
time  the  area  of  inflammation  must  be  locally  treated.  Syphilis  is  treated  by 
the  internal  use  of  mercury  and  fti  some  cases  the  iodids  are  also  given ;  scurvy, 
by  vegetable  juices  and  potash  salts;  rheumatism,  by  the  alkalies  or  salicylates; 
gout,  by  colchicum  or  piperazin;  tuberculosis,  by  the  fats,  tonics,  and  an 
open-air  life. 

Alcohol. — The  use  of  alcoholic  stimulants  is  called  for  by  conditions  rather 
than  by  diseases,  being  indicated  by  the  state  of  the  patient  rather  than  by 
the  name  of  the  malady.  For  a  brief  acute  inflammation  in  a  robust  young 
person  alcohol  is  not  needed;  but  all  who  are  weak  or  exhausted,  be  they 
young  or  old,  all  who  are  aged,  those  who  are  accustomed  to  alcoholic  bever- 
ages, those  who  have  high  temperatures  or  failure  of  circulation,  and  those 
who  labor  under  septic  inflammations  or  adynamic  processes  require  alcohol, 
and  it  should  be  given  with  a  free  hand.  In  an  acute  malady,  a  feeble,  com- 
pressible, rapid,  or  irregular  pulse,  and  great  weakness  of  the  first  sound  of  the 
heart  are  indications  that  alcohol  is  required.  Low,  muttering  delirium  is  a 
strong  indication  for  stimulation.  There  is  no  dose  of  alcohol  for  these  states; 
it  is  given  for  its  effect.  Two  ounces  of  brandy  or  whiskey  may  be  needed 
in  a  day,  or  perhaps  twenty  ounces.  If  the  breath  of  the  patient  smells 
strongly  of  the  alcohol,  he  is  getting  too  much.  If  delirium  increases  after 
each  dose,  alcohol  is  doing  harm.  Alcohol  is  contraindicated  in  acute  menin- 
gitis. In  acute  illness  use  whiskey,  brandy,  champagne,  or  alcohol  and 
water.  During  convalescence  there  may  be  used  a  little  port,  claret,  or 
sherry  wine,  or  malt  liquor.  These  agents  will  promote  appetite,  digestion, 
and  sleep. 

Strychnin  is  a  very  valuable  stimulant.  It  can  be  given  in  doses  of  gr.  -^-^ 
to  gr.  -^-Q  three  times  a  day. 

Tonics. — The  use  of  tonics  is  indicated  during  convalescence  from  acute 
and  throughout  the  course  of  chronic  inflammations.  There  may  be  used 
iron,  quinin,  and  strychnin  in  the  form  of  eli.xir;  iron  alone,  as  in  the  tincture 
of  the  chlorid;  quinin  in  tonic  doses  (gr.  vj  to  gr.  viij  daily) ;  or  Fowler's  solu- 
tion of  arsenic.     An  excellent  pill  consists  of — 

R  .       Acid,  arseiios. , gr.  j  ; 

Strychnini,  .         gr.  ss  ; 

Quinini, gr.  xlviij  ; 

P^erri  redact., gr.  vj. — M. 

Ft.  in  pil.  No.  xxiv. 

Sig. — One  after  each  meal. 

Bitter  tonics  before  meals  improve  the  appetite.  One  of  the  best  of  tonics  is 
tincture  of  nux  vomica  in  gradually  increasing  doses. 

Antiphlogistic  Regimen. — This  term  comprises  the  necessarv  directions 
relating  to  diet,  ventilation,  cleanliness,  etc. 

Z>/e/.— When,  in  the  early  stages  of  an  acute  inflammation,  the  patient 
cannot  eat,  there  must  be  administered  a  cathartic  before  food  is  given. 
Nausea  is  combated  with  calomel  and  soda,  drop-doses  of  a  6  per  cent,  solu- 
tion of  cocain,  iced  champagne,  iced  brandy,  chloroform-water,  hot  water, 
cracked  ice,  or  the  application  of  counterirritation  to  the  epigastric  region. 


go  Inflammation 

When  the  process  is  depressive  from  the  start,  and  in  any  case  after  the  earliest 
stage,  feeding  is  of  vital  moment.  The  great  tissue-waste  calls  for  large 
quantities  of  nutritive  material,  but  the  impaired  digestion  demands  that  the 
food  shall  be  easily  assimilable;  hence  it  is  taken  in  liquid  form,  small  quan- 
tities being  frequently  given.  Milk  contains  all  the  elements  required  by  the 
body,  and  is  the  food  of  foods.  If  it  disagrees,  it  should  be  boiled  and  mixed 
with  lime-water,  or  to  each  dose  an  equal  amount  of  \'ichy  or  soda-water  may 
be  added.  Peptonized  milk  is  a  valuable  agent.  One  part  of  milk,  2  parts 
of  cream,  and  2  parts  of  lime-water  make  a  nutritious  and  digestible  mixture. 
Milk  punch  is  largely  used.  Whey  may  be  used  when  plain  milk  cannot  be 
taken.  Eggs  are  highly  nutritious,  but  are  apt  to  disturb  the  stomach;  they 
ma}-  be  given  as  egg-nog,  or  simply  soft-boiled,  or  the  yolk  can  be  beaten  up 
in  a  cup  of  tea.  When  considerable  nausea  exists,  the  yolk  of  an  egg  may 
be  added  to  oj  of  lemon-juice  and  oij  of  sugar,  the  glass  being  filled  with  car- 
bonated water.  Beef  tea  is  certainly  a  stimulant,  but  its  food  powers  are 
questionable.  It  is  prepared  by  cutting  up  one  pound  of  lean  beef,  adding 
to  it  a  quart  of  water,  and  then  simmering,  but  not  boiling,  down  to  a  pint, 
finally  filtering  and  skimming  the  liquid.  The  dose  is  a  wineglassful  seasoned 
to  taste.  Meat-juice,  obtained  by  squeezing  partly  cooked  meat  with  a  lemon 
squeezer,  is  extremely  nutritious.  Liquid-beef  peptonoids  are  both  agreeable 
and  nutritious;  they  are  given  in  doses  of  oss  to  5j.  Clam- juice  is  palatable 
and  digestible.  \\'hen  nothing  else  will  stay  on  the  stomach  koumiss  will 
often  be  retained.  This  fermented  milk  is  nutritious,  stimulant,  and  very 
useful.  Coffee  is  a  valuable  stimulant  in  febrile  conditions.  If  the  stomach 
retains  no  food,  the  patient  must  be  fed  entirely  !:>}•  the  rectum.  If  the  stomach 
rejects  most  of  the  food  swallowed,  mouth  feeding  must  be  supplemented  by 
nutritive  rectal  enemata.  When  the  sufferer  feels  able  to  eat  a  little,  any  good 
soup,  strained  and  skimmed,  should  be  ordered.  As  the  patient  gets  better 
he  may  be  fed  on  sweetbreads,  chops,  o\-sters,  etc.,  until  he  gradually 
reaches  ordinary  diet. 

The  temperature  should  be  taken  at  regular  intervals,  and  the  condition  of 
the  gastro-intestinal  tract  should  be  observed.  The  urine  must  be  examined 
at  intervals,  and  the  daily  amount  passed  must  be  known.  If  insufficient 
urine  is  being  passed,  increase  the  amount  of  fluid,  particularly  of  water,  given 
by  the  mouth.  If  the  urine  is  scanty  and  the  patient  is  nauseated  by  drinking 
water,  give  enemata  of  hot  saline  fluid  or  employ  hypodermoclysis.  The 
pulse  and  heart  must  l)e  frequentl}-  observed,  and  cardiac  weakness  must  be 
combated  by  suitable  stimulants. 

Ventilation  and  Cleanliness. — The  ventilation  of  the  ajjartment  is  of  the 
greatest  importance.  Every  day  the  windows  should  Ijc  opened  widely  for  a 
time,  the  patient,  of  course,  being  protected.  When  the  windows  are  oy)en 
the  air  of  a  rof)m  can  be  fjuickly  changed  by  swinging  the  door  to  and  fro.  A 
constant  access  of  fresh  air  must  be  secured,  and  the  temperature  kept  as  near 
as  possible  to  68°  F.  The  sick  man  must  be  cleaned  and  be  sponged  off  with 
alcohol  anrl  water  every  day  if  high  fever  exists.  It  is  important  that  the  bed- 
clothing  be  clean  and  that  the  sheet  be  unwrinkled,  as  otherwise  bed-sores 
may  form. 

Treatment  of  Chronic  Inflammation. — The  subject  of  chronic  inflam- 
mation has  been  referred  to  prexiously.     The  local  treatment  comprises  rest,. 


Treatment  of  Chronic  Inflammation  91 

relaxation,  elevation,  counterirritation,  massage,  passive  movements,  the 
douche,  the  appHcation  of  sorbefacients,  the  use  of  compression,  and  incision. 
The  patient  must  be  placed  under  proper  hygienic  and  climatic  conditions; 
the  diet  must  be  judiciously  regulated;  drugs  are  given  symptomatically  or 
to  combat  some  constitutional  tendency  or  disease  (see  articles  upon  special 
regions  and  diseases). 


92  Repair 


IV.  REPAIR. 

When  a  tissue  is  damaged,  it  reacts  to  the  injury  and  Nature  attempts  to 
effect  repair.  It  is  held  by  many  that  inflammation  is  a  destructive  process 
and  repair  is  a  constructive  process;  that  repair  is  constantly  effected  in  an 
aseptic  wound  without  many  of  the  evidences  of  inflammation;  that  repair 
does  not  proceed  from  inflammation,  but  is  retarded  or  prevented  if  inflam- 
mation occurs.  As  before  stated,  we  agree  with  Adami,  that  inflammation 
is  reaction  to  injury  and  the  effort  of  Nature  to  repair  the  injury.  As 
Adami  points  out,  the  attempt  to  repair  may  fail,  the  reaction  to  injury  being 
excessive  or  not  powerful  enough;  but  even  should  the  attempt  fail,  the 
conservative  intention  exists.  "What  is  the  development  of  cicatricial  tissue 
but  an  attempt  at  repair?  W^hat  other  meaning  can  be  ascribed  to  the 
increased  bactericidal  power  of  the  inflammatory  exudate  as  compared  with 
that  of  ordinary  lymph  and  blood-serum  ?  Why  do  leukocytes  accumulate  in 
a  region  of  injury  ?  Why  do  some  of  them  incorporate  bacteria  and  irritant 
particles,  and  others  bring  about  the  destruction  of  these  without  necessarily 
ingesting  them?  All  these  are  means  whereby  irritants  are  antagonized  or 
removed,  and  reparation  and  return  to  the  normal  sought  after."  * 

Repair  is  favored  by  good  general  health,  asepsis  of  the  wound,  coaptation  of 
wound  edges,  and  rest.  It  is  retarded  or  prevented  by  infection,  gaping  of  the 
wound,  frequent  or  forcible  motion,  and  impairment  of  the  general  health. 

Albuminuria  and  diabetes  particularly  obstruct  repair.  R.  T.  Morris 
points  out  that  sugar  in  the  blood  is  hygroscopic,  removes  water  from  the 
tissues,  and  thus  obstructs  repair;  and  also  that  the  wound  fluids  contain 
sugar  and  are  good  culture-media  ("Med.  News,"  June  29,  1901). 

Healing  by  First  Intention. — A  wound  may  heal  by  "first  inten- 
tion." This  mode  of  healing,  which  is  known  as  "primary  union,"  occurs 
without  suppuration,  and  is  observed  in  the  heahng  of  an  aseptic  wound.  If 
infection  occurs,  primary  union  will  not  take  place.  The  phrase  "by  first 
intention"  comes  down  to  us  from  the  past.  It  was  properly  thought  that 
Nature  intends  to  repair  a  wound,  and  first  intention  signifies  the  first  or 
most  desirable  way  to  be  wished  for.  In  a  small  aseptic  incision,  in  which  no 
considerable  vessels  are  cut,  repair  will  take  place  very  rapidly  after  the  edges 
have  been  approximated  and  the  wound  dressed.  In  fact,  the  wound  edges 
may  be  firmly  held  together  in  twenty-four  hours.  In  such  a  wound  a  smaU 
amount  of  blood  flows  from  the  capillaries  between  the  edges  of  the  wound, 
and  this  blood  clots.  A  trivial  amount  of  exudation  and  some  few  migrated 
corpuscles  pass  into  the  clot  and  into  the  tissues.  The  fixed  connective-tissue 
cells  and  the  endothelial  ceUs  of  the  vessels  multiply,  and  form  epithelioid 
cells,  known  as  fibroblasts.  The  fibroblasts  eat  up  many  of  the  leukocytes 
and  multiply,  so  that  the  new  cells  from  one  side  of  the  wound  finally  interlace 
with  the  new  cells  from  the  other  side.  Nearby  capillaries  become  irregular 
in  outline;  at  certain  points  bulging  occurs,  and  at  these  points  new  capillaries 
develop,  extend  into  the  mass  of  fibroblasts,  and  join  new  capillaries  of  the 
opposite  side.  The  reparative  material  is  now  said  to  be  organized;  it  has 
""'Adami,  in  Allbutt's  "System  of  Medicine." 


Healing  by  First  Intention  93 

become  granulation  tissue.  The  fibroblasts  become  spindle-shaped  and 
develop  into  interlacing  fibers  (Fig.  31).  The  tissue  is  now  fibrous  tissue; 
it  contracts  strongly,  and  finally  most  of  the  capillaries  are  obliterated  by 
pressure.  In  such  a  slight  wound  the  reaction  to  injury  is  chiefly  noted  in  the 
cells  of  the  part,  and  the  vessels  and  leukocytes  play  but  a  small  part  in  repair. 
The  exudation  is  so  scanty  that  there  is  practically  no  swelling  unless  some 
arises  from  venous  obstruction.  The  vessels  are  so  slightly  affected  that  there 
is  no  redness.  The  final  step  in  healing  is  contraction  of  the  fibrous  tissue  and 
the  covering  of  the  surface  with  epithelium,  which  springs  from  the  epithelial 
cells  upon  the  edges.  This  final  process  is  called  "cicatrization,"  and  con- 
.-^ists  in  the  formation  from  fibroblasts  of  new 

fibrous  tissue  and  the  contraction  of  the  new  ^         '     *"      "<----  ^ 

tissue.     The     "immediate     union"     of     some         "^^ 

writers    never   occurs.     This    term    means   the  ^  y 

union  of  microscopical  parts  to  their  counter-  ^ 

parts    without    any    effort    at    repair.     A    first  "''- 

union  is  effected  always  by  clotted  blood  and         _^-;"T'    _  ^,"0'^- 

coagulated  exudate,  next  by  proliferating  cells,  "■^'      ^.-/■'     ^  y       ^ 

and  finally  by  fibrous  tissue.  A  wound  healing  p.^  ,^,  _cei)s  developing  into 
bv  first  intention  exhibits  no  evidence  of  inflam-  fibers  (Bennett), 

mation.     There  is  some  slight  tenderness,  but 

no  actual  pain.  A  certain  amount  of  swelling  arises  because  of  exudation 
of  fluid  from  the  blood,  and  the  coagulation  of  this  fluid  makes  the  wound 
edges  hard.  \'enous  obstruction  leads  in  some  cases  to  a  considerable  fluid 
.'^welling.  A  wound  may  heal  by  first  intention  even  if  some  bacteria  are 
present,  if  the  part  has  a  good  blood-supply  and  the  patient  is  in  good  health. 
Active  leukocvtes  and  germicidal  blood-serum  may  prevent  infection.  In 
a  more  extensive  incised  wound  many  vessels  are  cut.  After  oozing  ceases 
the  vessels  are  closed  by  clots  continuous  with  the  clot  between  the  sides  of 
the  wound.  An  exudation  of  plasma  from  the  blood-vessels  and  of  lymph 
from  the  Ivmph-spaces  takes  place.  Leukocytes  in  great  numbers  invade 
the  wound  edges  and  the  exudate,  and  the  exudate  clots.  Thus,  an  infection 
may  be  surrounded  and  limited.  This  mass  of  blood-clot,  plasma-clot,  and 
leukocvtes  used  to  be  known  as  "  coagulable  lymph.''  The  leukocytes  actively 
eat  up  the  clot,  and  by  the  end  of  the  third  day  occupy  the  space  formerly 
occupied  bv  the  clot.  The  fixed  connective-tissue  cells  and  endothelial  cells 
multiply  and  grow  into  the  mass  of  leukocytes,  eating  up  many  of  the  leuko- 
cytes, and  finally  join  the  fibroblasts  of  the  other  side  of  the  wound.  Some 
leukocvtes  enter  into  the  lymph-spaces.  Xew  capillaries  form  from  the  capil- 
laries at  the  wound  margins.  By  the  end  of  the  first  week  the  fibroblasts 
begin  to  assume  various  outlines,  sending  out  poles  or  branches  or  becoming 
spindle-shaped.  These  spindle-shaped  cells  become  fibers,  and  the  fibers  of 
the  new  tissue  interlace  and  strongly  contract.  Thus  the  edges  are  pulled 
firmlv  together.  Finally  new  epithelium  derived  from  epithelium  at  the  edges 
forms  and  grows  over  the  wound  (Figs.  34-36),  and  exhibits  the  stages  of 
repair  in  heahng  by  first  intention.  In  order  to  obtain  primary  union  the 
surgeon  must  cleanse  the  wound  and  must  be  thoroughly  aseptic;  bleeding 
must  be  carefully  arrested;  the  parts  are  accurately  coaptated  by  sutures; 
aseptic  or  antiseptic  dressings  are  applied,  and  special  care  is  taken  to  secure 
rest.     In  a  large  wound  special  methods  to  secure  drainage  are  required.     In 


94 


Repair 


a  small  wound  drainage  is  obtained  between  the  stitches.  The  use  of  irritant 
germicides  in  a  wound  greatly  increases  the  amount  of  discharge  and  renders 
drainage  necessary  in  even  a  comparatively  small  wound  for  the  first  twenty- 


^  --  .1 


Fig-  36. 
Figs.  34-36. — Healing  by  first  intention  (after  Pick)  :    a.  Skin  ;    A,  fibroblasts;    c,  d,  e,  capillaries. 
Fig.  34,  Clot  iti  the  vessels  continuous  with  clot  between  the  edges  of  the  wound.    Fig.  35,  Migration 
of  leukocytes  into  the  perivascular  tissues  and  into  the  clot  between  the  edges  of  the  wound.    Fig.  36, 
Formation  of  new  capillaries. 


four  hours.  During  the  first  twenty-four  hours  after  a  large  wound  l)egins  to 
heal  by  first  intention  the  discharge  of  bloody  serum  is  most  plentiful,  but  after 
this  period  it  l^ecomes  very  scanty  and  soon  ceases  entirely,  and  can  be  much 


Healing  b\-  Second  Intention  95 

diminished  in  quantity  in  the  first  day  by  the  application  of  pressure.  Warren 
says  that  after  a  hip-joint  amputation  over  a  pint  of  bloody  serum  flows  out 
during  the  first  twenty-four  hours.  In  an  aseptic  wound,  as  a  rule,  one-half 
of  the  stitches  are  removed  on  the  fifth  or  sixth  day  and  the  remainder  on  the 
eighth  day,  but  for  two  weeks  more  the  wound  should  be  rested  and  supported, 
as  the  new  tissue  is  not  ^ery  resistant  to  infection.  Aseptic  fever  always  arises 
when  much  exudation  is  given  out  and  not  quickly  and  perfectly  drained. 
Aseptic  fever  is  due  to  the  ab.sorption  of  aseptic  pyrogenous  material  (page 
105).  If  an  incised  wound  becomes  infected,  the  pyogenic  organisms  destroy 
the  bond  of  union  which  is  forming  between  the  wound  edges  by  liquefying 
the  intercellular  substance.  As  a  consequence,  the  wound  edges  are  widely 
separated  by  pus. 

What  used  to  be  known  as  "healing  by  blood-clot"  is  healing  by  fir.st  in- 
tention. If  there  is  a  considerable  gap  between  the  edges  of  an  aseptic  wound, 
and  the  gap  is  filled  with  a  blood-clot,  healing  goes  on  in  the  same  manner  as 
when  the  gap  is  narrow,  although  more  corpuscles,  more  exudate,  and  more 
fibroblasts  are  required  to  effect  repair. 

Healing  by  Second  Intention. — Heahng  of  a  wound  in  which  there 
is  a  large  cavity  in  the  tissue  or  in  which  the  edges  have  gaped  apart  is  known 
as  healing  by  granulation,  or  healing  by  "second  intention."  It  is  elTected 
in  the  same  manner  as  healing  by  "first  intention,"  the  processes  in  the  two 
cases  being  practically  identical.  As  a  matter  of  fact,  in  healing  by  granu- 
lation there  is  usually  wound  infection.  As  a  result  of  infection  intercellular 
substance  is  peptonized,  many  reparative  cells  are  cast  off,  and  repair  can  be 
effected  only  after  the  formation  of  enormous  numbers  of  fibroblasts  and  the 
expenditure  of  considerable  time.  It  requires  much  longer  for  an  infected 
wound  to  heal  than  for  an  incised  wound  to  be  repaired,  and  an  infected  wound 
can  heal  only  by  granulation.  A  short  time  after  the  infliction  of  a  wound  the 
oozing  ceases  because  thrombi  form  in  the  vessels  and  some  clot  gathers  in 
tissue-gaps  and  interstices.  Exudation  begins  and  leukocytes  migrate  into 
the  exudate  and  into  the  walls  of  the  wound.  In  an  hour  or  two  the  surface 
of  the  wound  becomes  distinctly  glazed  or  glistening,  because  of  the  formation 
and  coagulation  of  fibrin.  The  exudation  is  at  first  thin  and  red,  and  it  be- 
comes so  profuse  as  to  wash  away  the  discolored  fibrin  coat.  In  a  few  days 
the  discharge  usually  becomes  purulent.  The  connective-tissue  cells,  espe- 
cially the  endothelial  cells  of  the  vessels,  proliferate  and  form  fibroblasts,  and 
the  fibroblasts  multiply  to  close  the  wound.  From  adjacent  capillaries  new 
capillaries  form.  This  formation  takes  place  as  follows:  A  portion  of  a  cap- 
illary thickens  and  a  whip-like  process  comes  off  from  the  thickened  part. 
This  jjrocess  fuses  with  a  second  filament  budded  from  another  or  from  the 
same  capillary,  or  runs  straight  out  as  a  terminal  vessel.  The  filaments  after 
a  time  are  hollowed  out  from  within,  protoplasmic  tubes  are  formed,  and 
endothelial  cells  develop  from  the  protoplasm.  In  some  cases  a  tubular 
prolongation  comes  off  from  a  capillary  directly.  Fig.  37  shows  the  formation 
of  a  capillary.  In  a  wound  healing  by  granulation  these  newly  formed  capil- 
laries run  among  the  fibroblasts,  and  some  of  them  run  perpendicularly  to  the 
surface,  or  a  loop  forms  and  reaches  the  surface.  The  surface  of  a  granu- 
lating wound  is  covered  with  migrated  leukocytes,  and  directly  under  these 
are  fibroblasts  covering  the  new  vascular  strings  or  loops.     Vascular  strings 


96 


Repair 


or  loops  coated  with  fibroblasts  are  called  granulations  (Fig.  39  shows  a 
granulating  surface).  When  the  discharge  becomes  purulent,  many  leuko- 
cytes and  fibroblasts  are  destroyed,  inflammation  increases,  exudation  be- 
comes profuse,  and  cellular  multiplication  widespread  and  rapid  in  order  to 


F'g-  37- — Development  of  a  blood-vessel  in  mesentery  of  an  embryo  (Warren). 


make  up  for  the  cells  lost  by  microbic  action.  Gradually  the  gap  is  filled.  As 
it  is  being  filled  the  older  fibroblasts  in  the  deeper  layers  of  the  edges  and  base 
of  the  wound  are  converted  into  cicatricial,  fibrous,  or  scar  tissue.  (Fig.  38.) 
As  the  granulations  rise  to  a  higher  level  at  the  surface  the  area  of  fibrous  tissue 

becomes  broader  at  the  base 
and  margins,  and  this  young 
fibrous  tissue  contracts.  By 
contracting  it  draws  the  edges 
of  the  wound  nearer  together 
and  thus  lessens  the  area  of 
the  surface  which  must  be  cov- 
ered with  epithelium.  When 
the  granulations  reach  the  level 
of  the  cutaneous  surface  the 
epithelial  cells  at  the  margin  of 
the  wound  proliferate,  and 
young  ei)ithelial  cells,  constitut- 
ing a  bluish  or  opalescent  film, 
comes  only  from  epithelium. 
The  epithelial  covering 


F'g-  3^- — Cicatricial  tissue;   X  670  (Fowler). 


grow    over    the    granulations.      Epithelium 

Granulations  are  never  converted  into  epithelium 

comes  only  from   the  epithelium   at  the  wound    margins,   unless   there  be 

epithelial    remains   in    the   wound;    for    in.stance,    an    undestroyed    papilla. 


Healing  of  Wounds  in   Non-vascular  Tissues  97 

sweat-duct,  or  hair  follicle.  The  process  of  covering  the  surface  with 
epithelium  is  known  as  epidennization.  The  epidermization  of  a  large 
area  always  consumes  considerable  time  and  sometimes  Nature  fails  to 
accomplish  it.  In  such  cases  skin-grafting  is  employed  {q.  v.).  Before, 
during,  and  for  a  time  after  epidermization  the  fibrous  tissue  of  the  walls 
and  base  of  the  wound  contracts.  Thus  the  wound  margins  are  pulled 
and  held  nearer  together,  the  gap  to  be  bridged  is  diminished  in  size,  the 
danger  of  tearing  apart  of  the  epithelial  coat  is  lessened,  many  capillaries  are 
destroyed  by  pressure,  and  the  scar  becomes  firm,  white,  and  puckered. 
Cicatrization  consists  in  the  conversion  of  immature  connective  tissue  into 
mature  fibrous  tissue  and  in  the  con- 
traction of  the  new  fibrous  tissue.  If 
infection  is  severe,  destruction  will  ex- 
ceed repair  and  healing  will  not  occur. 
In  such  a  case  there  is  coagulation 
necrosis  of  granulation  tissue,  and  the 
wound  becomes  covered  with  tissue  re- 
mains (aplastic  lymph).     If  granulations 

rise    above    the    cutaneous   level,   healing      Fig!  sg.-Blood-vess'els  inVranulation  (Gross). 

will  not  take  place,  because  the  epithe- 
lium cannot  then  grow  over  the  raw  surface.  A  wound  in  this  condition  is  said 
to  possess  exuberant  granulations,  or  proud  flesh.  In  some  cases  the  granula- 
tions are  pale  from  insufficient  blood-supply,  and  in  others  edematous  from 
venous  congestion.  Contraction  of  the  fibrous  tissue  may  be  insufficient  because 
there  is  adhesion  to  deep  unyielding  fascia  or  to  periosteum.  Excessive  con- 
traction, so  often  seen  after  burns,  often  produces  terrible  deformity.  The 
scars  or  cicatrices  of  burns  contain  much  elastic  tissue.  Infected  wounds  and 
ulcers  heal  by  second  intention. 

Healing  by  Third   Intention. — This  consists  in  the  union  of  two 

granulating  surfaces,  the  granulations  of  one  side  fusing  with  the  granu- 
lations of  the  other  side.  It  is  seen  in  the  union  of  collapsed  abscess-walls. 
The  surgeon  occasionally  seeks  to  obtain  union  by  third  intention  by  approxi- 
mating two  granulating  surfaces.  If  the  surfaces  are  aseptic,  he  will  often 
succeed.  The  process  follows  what  is  known  as  secondary  suturing.  It  is 
not  unusual  to  pack  a  wound  with  iodoform  gauze  to  control  oozing.  \Mien 
this  is  done  it  is  customary  to  pass  the  sutures,  but  not  to  tie  them.  After  a 
few  days  the  gauze  is  removed  and  the  sutures  are  tied.  This  plan  renders 
healing  much  more  rapid  than  could  be  obtained  by  the  process  of  healing 
by  second  intention. 

Healing  of  Subcutaneous  Wounds. — Blood  fills  the  tissue-gap  and 
the  blood  clots.  Plasma  exudes  and  corpuscles  migrate  into  the  clot  and  the 
tissue  about  it.  The  clot  is  eaten  up  by  the  leukocytes.  The  connective- 
tissue  cells  and  the  endothelial  cells  of  the  adjacent  tissue  proliferate  and  form 
fibroblasts,  and  fibroblasts  multiply  and  replace  the  clot.  The  area  of  fibro- 
blasts is  vascularized  by  the  formation  of  new  capillaries,  and  fibrous  tissue 
forms  and  strongly  contracts. 

Healing  of  Wounds  in  Non=vascular  Tissues.— In  a  trivial  injury 
of  the  cornea  a  few  leukocytes  gather  from  the  lymph-spaces  and  a  few  of  the 
fixed  cells  proliferate.  When  the  cornea  is  distinctly  wounded,  an  increased 
7 


98  Repair 

flow  of  Ivmph  occurs.  The  nerves  are  irritated,  vessels  adjacent  to  the  cornea 
distend,  and  many  leukocytes  invade  the  lymph-spaces.  The  corneal  cor- 
puscles multiply  and  alter  in  shape.  The  product  of  the  process  may  be 
transparent  if  fibrin  is  absorbed  and  leukocytes  pass  away,  for  proliferating 
corneal  corpuscles  form  transparent  tissue.  The  surface  epithelium  is  re- 
placed by  proliferation  of  the  deep  layer  of  corneal  epithelium.  If  the  wound 
has  penetrated  the  posterior  portion,  it  is  filled  by  proHferating  epithelium 
from  the  membrane  of  Descemet.  In  a  severe  injury  of  the  cornea  endothelial 
cells  and  corneal  corpuscles  proliferate,  vessels  grow  in  from  the  corneal  mar- 
gins toward  the  seat  of  inflammation,  fibrous  tissue  forms,  and  permanent 
opacity  results. 

Repair  in  cartilage,  if  it  occurs  at  all,  is  very  slow  and  is  accomplished  in 
the  same  way  as  repair  in  the  cornea.  Any  marked  injury  is  repaired  by  white 
fibrous  tissue,  furnished  by  the  cells  of  the  perichondrium,  and  the  scar  is 
permanent. 

Cell=di vision. — The  multiplication  of  connective-tissue  cells  in  repair 
may  be  by  direct,  but  is  usually  by  indirect,  cell-division.  Direct  cell-division 
consists  in  division  of  the  nucleus  followed  by  division  of  the  entire  cell. 

Indirect  cell-division,  or  karyokinesis,  takes  place  after  remarkable  changes 
in  the  nucleus.  The  membrane  of  the  nucleus  disappears;  the  nuclear  net- 
work becomes  first  close  and  then  more  open;  and  the  cell  becomes  round,  if 
not  so  before.  The  network  of  the  nucleus,  now  consisting  of  one  long  fiber, 
takes  the  shape  of  a  rosette;  next  it  takes  a  star  form — the  aster  stage;  two 
sets  of  V's  next  form — the  equatorial  stage;  an  equatorial  line  appears  and 
widens,  and  each  set  of  V's  retreats  toward  a  pole.  Thus  two  new  nuclei  are 
formed,  each  polar  V  passing  in  inverse  order  through  the  previous  changes  of 
shape,  and  the  protoplasm  of  the  original  cell  collecting  about  each  nucleus 
(Fig.  40).^ 

Repair  of  Nerve. — A  nerve-fiber  consists  of  a  core  known  as  the  axis- 
cylinder,  which  is  the  essential  element  in  function,  .\bout  the  axis-cylinder 
is  an  almost  liquid  material,  known  as  the  medullary  sheath  or  white  substance 
of  Schwann,  or  myelin.  The  myelin  is  surrounded  by  a  firm  sheath  known 
as  the  neurilemma  (sheath  of  Schwann,  primitive  sheath,  neurolemma).  On 
its  inner  surface,  or  between  it  and  the  white  substance  of  Schwann,  are  nuclei 
which  are  supposed  by  some  to  be  peripheral  nerve-cells  (neuroblasts).  The 
neurilemma  is  absent  in  the  brain  and  cord.  The  continuity  of  the  white 
substance  of  Schwann  is  interrupted  at  frequent  intervals,  and  these  breaks  in 
the  myelin  are  called  nodes  of  Ranvier.  Numbers  of  fibers  of  the  kind 
just  described,  bound  into  bundles  by  connective  tissue  and  surrounded  by  a 
fibrous  sheath,  con.stitute  a  nerve.  It  is  known  that  a  nerve  may  be  regen- 
erated and  completely  regain  function  after  division;  that  regeneration  is 
strongly  favored  by  suturing  the  ends  together;  and  that  if  the  ends  of  a  di- 
vided nerve  are  more  than  one  inch  apart,  regeneration  will  rarely  take  place 
unless  they  are  sutured  together.  The  method  by  which  regeneration  is  effected 
has  been  much  flisputed  and  is  still  involved  in  uncertainty.  If  a  nerve  is 
divided,  the  peripheral  segment  at  once  loses  its  function  and  then  undergoes 
degeneration  (Wallerian  degeneration).  The  degeneration  begins  within 
twenty-four  to  forty-eight  hours  and  affects  the  entire  peripheral  segment. 
The  axis-cylinder  perishes,  the  myelin  runs  into  globules  and  is  absorbed, 


Repair  of  Nerve  99 

leaving  an  almost  empty  sheath;  the  nuclei  of  the  inner  surface  of  the  neuri- 
lemma proliferate  for  a  time,  but  cease  to  do  so  before  the  myehn  is  completely 
absorbed.  The  sheath  shrinks  and  looks  empty,  but  here  and  there  are  col- 
lected masses  of  proliferated  nuclei  and  protoplasm.  The  common  view  is 
that  regeneration  takes  place  as  follows:  The  nuclei  again  prohferate  and 
form  a  mass  of  protoplasm  within  the  old  sheath,  which  protoplasm  joins  the 
proximal  segment.  Such  a  protoplasmic  fiber  has  "conduction  and  irrita- 
bility" (Raymond's  "Human  Physiology"),  but  there  is  as  yet  neither  myelin 
nor  axis-cylinder.  "  The  fiber  is  responsive  to  mechanical  stimuli,  but  not 
to  induction  shocks,  which  latter  property  returns  only  after  the  axis-cylinder 
is  developed.  The  medullary  substance  later  appears  and  forms  a  tube; 
and  still  later  the  axis-cylinder  is  formed,  having  its  origin  in  the  central  end 
of  the  nerve"  (Raymond's  "Human  Physiology"). 

Degeneration  takes  place  in  days,  but  regeneration  requires  months.  Re- 
generation takes  place  by  the  multiplication  of  pre-existing  nerve-fibers  and  not 
by  the  transformation  of  connective  tissue  into  nerve  structure.  The  ends  of 
a  divided  nerve,  it  is  true,  are  united  by  connective  tissue  formed  by  the  pro- 
liferation of  fibroblasts,  but  this  connectiv'e  tissue  is  only  a  bridge  to  carrv 
nerve  elements  across  the  gap  between  the  proximal  and  peripheral  segments. 
The  new  axis-cylinder  of  the  peripheral  segment  is  a  prolongation  of  the  old 
axis-cylinder  of  the  proximal  segment,  projected  in  the  following  manner. 
A  fiber,  which  is  at  first  devoid  of  myelin,  is  prolonged  from  a  proximal  axis- 
cylinder;  it  divides  into  many  cylinders,  which  pierce  the  granulation  tissue 
between  the  ends  and  enter  into  the  empty  sheaths  of  Schwann  of  the  distal 
segment  or  insinuate  themselves  between  these  sheaths  (Ranvier,  Reclus, 
Senn).  The  above  is  the  view  entertained  by  those  who  teach  that  the  new 
axis-cylinders  come  entirely  and  only  from  the  prolongation  of  old  axis- 
cylinders  of  the  proximal  segment,  and  that  the  distal  segment  is  passive  in 
the  process  until  "neurotised"  (Vanlair),  and  that  regeneration  is  impossible 
in  the  distal  segment  unless  it  is  in  approximation  with  the  proximal  segment 
or  within  easy  reach  of  the  prolongations  of  the  axis-cylinders  from  above. 
Another  view  is  that  the  axis-cylinders,  myelin,  and  neurilemma  are  formed 
from  cells  which  exist  in  the  distal  segment,  and  that  juvenile  axis-cyhnders 
and  medullary  sheaths  are  formed  in  the  peripheral  portion  and  then  effect  a 
junction  with  like  structures  of  the  central  segment.  The  last-mentioned 
view  is  advocated  by  Mayer  and  Eichhorst,  Tizzoni,  Cattani,  and  others,  and 
Ballance  and  Stewart  have  recently  published  a  most  valuable  monograph 
advocating  it  ("The  Healing  of  Nerves").  The  views  of  Ballance  and 
Stewart  may  be  set  forth  as  follows:  When  a  nerve-trunk  is  divided,  the  periph- 
eral segment  degenerates  whether  it  has  been  sutured  to  the  proximal  segment 
or  not,  and  the  portion  of  the  proximal  segment  near  the  wound  also  degen- 
erates. The  injury  produces  at  once  an  effusion  of  blood,  migration  of  leuko- 
cytes takes  place  into  and  about  the  wound  at  the  proximal  segment,  but 
leukocytic  invasion  of  the  entire  distal  segment  is  noted.  After  three  days 
connective-tissue  cells  begin  to  replace  the  leukocytes,  and  after  two  weeks 
the  excess  of  leukocytes  is  no  longer  observed,  proliferated  connective-tissue 
cells  having  taken  their  place  (page  94,  "  Healing  of  Nerves").  The  proximal 
segment  in  the  neighborhood  of  the  wound  and  the  entire  distal  segment  are 
invaded  by  proliferating  connective-tissue  cells.     The  connective-tissue  cells 


lOO  Repair 

completely  absorb  the  fatty  myelin  and  axis-cylinders.  The  cells  of  the  neuri- 
lemma actively  multiply,  and  connective-tissue  cells  lying  among  chains  of 
neurilemma  cells  become  spindle-shaped  and  "the  degenerated  nerve-trunk 
therefore  becomes  hard,  fibrous,  and  cirrhosed"  (Ballance  and  Stew^art  on  the 
"Healing  of  Nerves,"  page  95). 

In  the  proximal  end  of  a  divided  nerve  an  "  end-bulb  "  is  formed.  This  was 
long  supposed  to  be  due  to  the  prolongation  of  nerve-fibers  from  the  central 
fibers  and  a  turning  backward  because  they  cannot  cross  the  gap.  As  a  matter 
of  fact,  the  ends  of  the  divided  fibers  curl  up ;  on  and  in  this  scaffold-like  arrange- 
ment new  fibers  are  placed,  they  having  been  produced  by  the  neurilemma 
cells  which  have  taken  on  "  neuroblastic  function"  (Ballance  and  Stewart). 
When  a  nerve  has  been  sutured,  the  earliest  signs  of  regeneration  "  occur  at 
the  end  of  three  weeks"  (Ballance  and  Stewart).  Short  lengths  of  new  fibers 
are  laid  down  within  old  neurilemma  sheaths.  The  new  axis-cylinder  "is 
seen  to  consist  in  the  deposition  along  one  side  of  a  spindle-shaped  neurilemma 
cell,  of  a  thin  thread  which  grows  in  length  until  it  projects  beyond  the  limits 
of  the  parent  cell  and  stretches  on  toward  its  next  neighbor  in  the  same  longi- 
tudinal row"  (Ballance  and  Stewart).  The  new  medullary  sheath  is  "laid 
down  by  a  process  of  secretion"  (Ballance  and  Stewart)  along  the  sides  of  the 
neurilemma  cells. 

Ballance  and  Stewart  go  on  to  point  out  that  if  the  central  theory  of  regen- 
eration is  true,  not  a  trace  of  regeneration  could  occur  in  the  distal  segment 
when  the  two  segments  have  not  been  united  by  sutures,  and  yet  such  regen- 
eration does  occur,  although  slowly,  the  new  axis-cyhnders  and  medullary 
sheaths  not  attaining  full  size.  "  Evidently  some  stimulus  afforded  by  the 
conduction  of  impulses  is  necessary  in  order  to  permit  of  their  full  devel- 
opment" (Ballance  and  Stewart).  In  the  notable  study  quoted  at  such  length 
are  some  experiments  on  the  "  conduct  and  fate  of  transplanted  nerve."  When 
the  gap  is  wide  between  the  two  ends,  a  portion  of  fresh  nerve-trunk  may  be 
inserted  to  bridge  it.  The  transplanted  piece  degenerates;  it  is  invaded  by 
leukocytes,  and  proliferating  connective-tissue  cells,  medullary  sheaths,  and 
axis-cylinders  are  destroyed,  but  regeneration  may  subsequently  occur;  "but 
when  it  does  occur,  it  is  not  from  the  activity  of  the  cells  of  the  graft  itself" 
(Ballance  and  Stewart).  Blood-vessels  enter  the  degenerated  graft  at  each 
end  and  they  are  accompanied  by  chains  of  neurilemma  cells,  which  form 
axis-cylinders  and  medullary  sheaths.  The  graft  is  merely  a  scaffold  (Ballance 
and  Stewart). 

The  studies  of  Ballance  and  Stewart  persuade  us  that  regeneration  does 
occur  in  the  distal  part  independently  of  the  proximal  part,  although  full 
development  does  not  take  place  unless  there  is  a  junction  with  the  central 
part.  As  to  the  exact  method  of  regeneration  we  still  feel  somewhat  uncer- 
tain. When  we  remember  that  the  nerve-fibers  of  the  spinal  cord  are  devoid 
of  neurilemma  and  that  the  cord  can  regenerate,  we  must  conclude  that  regen- 
eration can  take  j)lace  in  the  cord  without  the  aid  of  neurilemma  cells,  and 
must  infer  that  the  same  may  Ijc  true  in  a  nerve. 

Repair  of  the  Spinal  Cord  and  Brain. — Can  the  spinal  cord  regen- 
erate ?  Many  observers  have  doubted  it.  But  there  is  no  doubt  of  the  fact 
that  sometimes,  after  the  subsidence  of  an  acute  myelitis  or  the  relief  of  a 
pressure  which  produced  complete  and  prolonged  paralysis,  there  is  a  return 


Repair  of  Muscle 


lOI 


of  functional  power.  It  is  usually  assumed  that  restoration  is  possible  in 
fibers  which  have  not  been  hopelessly  damaged,  but  is  not  possible  in  tho^e 
which  have  been  destroyed;  but,  as  Gowers  says,  there  are  cases  in  which  "  we 
can  scarcely  believe  that  the  axis-cylinders  retain  their  continuity,  although 
conducting  capacity  is  ultimately  restored."  Clinical  evidence  indicates 
strongly  that  the  pyramidal  fibers  may  regenerate.  Mills  says  ("The 
Nervous  System  and  Its  Diseases"):  "Nerve-tracts  in  the  spinal  cord  and 
brain  have  power  to  regenerate,  but  this  is  not  so  great  as  in  the  peripheral 
nerves,  and  yet  even  old  cases  of  compression  of  the  spinal  cord  may  make 
great  improvement  after  a  long  time,  largely  through  the  regeneration  of  the 
columns  of  the  cord."  Mills  affirms  that  although  nerve-cells  sometimes  a]j- 
pear  to  regenerate,  the  destruction  in  these  cases  was  not  complete. 

When  axis-cylinders  have  been  destroyed  in  the  cord  and  yet  some  power 
returns,  we  ask  ourselves  if  this  occurs  because  new  fibers  have  grown  down 
from  above.  Gowers  says  that  such  a  growth  has  been  proved  to  occur  in  the 
lower  animals,  but  has 
not  as  yet  been  demon- 
strated in  man ;  although 
specimens  have  been  de- 
scribed which  strongly 
suggest  such  an  occur- 
rence in  the  human  sub- 
ject. That  the  cord  can 
regenerate  was  recently 
proved.  Dr.  Francis  T. 
Stewart,  of  Philadelphia, 
sutured  a  completely  di- 
vided spinal  cord  and  an 
extraordinary  restoration 

of  function  took  place  (Francis  T.  Stewart  and  Richard  H.  Harte,  in  "Phila. 
Med.  Journal,"  June  7,  1902).  This  case  is  commented  on  at  some  length  in 
the  section  on  Injuries  of  the  Spinal  Cord. 

Many  claim  that  a  brain  injury  cannot  be  followed  by  repair  with  restora- 
tion of  function;  some  think  that  complete  regeneration  can  take  place;  others, 
that  partial  regeneration  may  occur.  Vitzon  and  Tedeschi  even  belie\e  that 
nerve-cells  in  the  brain  can  regenerate.  It  seems  probable  that  extensive 
injuries  are  not  repaired,  but  slighter  ones  may  be,  new  ganghon-cells  and 
neuroglia  being  formed.  Tedeschi  describes  the  process  of  repair  after  a 
wound  of  the  brain  as  follows:  Degeneration  occurs  and  a  limited  focus  of 
necrosis  forms  and  then  the  adjacent  tissue  shows  evidences  of  repair.  Cajiil- 
laries  form  from  the  endothelial  cells,  glia  tissue  from  the  neuroglia,  ganglion- 
cells  present  karyokinetic  changes,  and  some  nerve-fibers  appear  in  the  scar 
(Senn's  ''Principles  of  Surgery"). 

Repair  of  Muscle.— It  has  long  been  taught  that  the  repair  c^f  muscle 
by  muscle  is  impossible,  and,  as  a  matter  of  fact,  it  does  not  take  j^lace  if  the 
ends  of  a  divided  muscle  are  separated  to  the  extent  of  an  inch  or  more.  When 
a  muscle  is  divided  transversely  by  a  considerable  cut,  the  ends  retract  and  a 
wide  space  is  left  between  them.  Blood  flows  into  the  space  between  the  ends 
and  also  between  individual  fibers  of  the  injured  muscle,  and  the  blood  clots. 


Fig.  40. — Forms   assumed 


by   a    nucleus   dividing   (Green,   from 
Flemmiiig). 


I02 


Repair 


Exudation  of  plasma  occurs  and  migration  of  corpuscles  takes  place.  Fibro- 
blasts are  produced  by  proliferation  of  connective-tissue  cells  and  a  mass  of 
fibroblasts  soon  replaces  the  blood-clot.  Granulation  tissue  is  formed  by 
vascularization  of  the  mass  of  fibroblasts,  and  granulation  tissue  is  converted 
into  scar  tissue,  but  not  at  all  into  muscle.  After  slight  injuries  a  trivial 
amount  of  muscular  regeneration  does  occur  by  the  multiplication  of  living 
muscle-cells,  but  not  by  metamorphosis  of  fibroblasts.  Fibroblasts  are  in- 
capable of  a  transformation  into  muscular  tissue.  When  the  ends  of  a  divided 
muscle  are  separated  to  a  slight  degree  or  when  they  have  been  brought  to- 


Fig.  41.— Fracture  one  week  :  blood-          Fig.  42.— Callus  of  fracture  Fig.  43.— Femur  of  a  child 

clot  containing  fragment  of  bone  (War-      (dog)  four  weeks  :  commenc-  fifth    week     after      fracture 

ren).                                                                   ing    ossification   of    external  (Warren). 

callus  (Warren). 


gether  and  sutured,  some  muscular  regeneration  occurs.  After  an  injury  some 
of  the  muscular  fibers  wither,  perish,  and  are  absorbed.  The  process  of  regen- 
eration arises  from  the  remaining  fibers.  The  nuclei  of  the  muscle-fiber 
proliferate  and  so  do  the  nuclei  of  the  perimysium.  The  muscle-cells  are 
called  myoblasts  and  the  nuclei  of  the  perimysium  are  called  sarcoblasts. 
About  the  juvenile  muscle-cells  a  deposit  of  protoplasm  takes  place  (Weber). 
The  embryonal  cells  gradually  become  spindle-shaped  and  muscular  fiber  is 
formed  by  cellular  fusion  or  by  elongation  of  individual  cells. 

The  above  remarks  refer  to  striated  muscle.     Unstriated  muscle  fibers 
are  repaired  solely  by  "indirect  multiplication  of  their  nuclei"  (Senn). 


Repair  of  Blood-vessels  103 

If  a  muscle  has  been  divided,  it  should  be  sutured.  This  process  insures 
more  rapid  repair  and  secures  a  better  functional  result,  and  is  followed  by 
much  muscular  regeneration. 

Repair  of  Tendon. — When  a  tendon  is  divided,  the  ends  retract,  and  the 
sheath,  as  a  rule,  becomes  filled  with  blood-clot.  The  blood-clot  is  rapidly 
removed,  fibroblasts  replacing  it.  This  new  tissue  arises  from  the  sheath, 
and  the  cut  ends  of  the  tendon  do  not  participate  in  the  process.  Granu- 
lation tissue  is  formed;  this  is  converted  into  fibrous  tissue,  and  after  a  time 
the  fibrous  tissue  becomes  true  tendon.  If  no  blood-clot  forms  in  the  sheath, 
the  walls  of  this  structure  collapse  and  adhere,  and  the  separated  tendon-ends 
are  held  together  by  a  flat  fibrous  band  formed  from  the  collapsed  sheath 
(Warren's  "Surgical  Pathology"). 

Repair  of  Bone. — When  a  bone  is  broken,  a  blood-clot  quickly  forms  in 
the  medullary  cavity,  between  the  broken  ends  and  under  and  outside  the  peri- 
osteum. Leukocytes  invade  and  destroy  the  clot.  The  cells  outside  the  peri- 
osteum, the  cells  of  the  periosteum  and  of  the  medullary  tissue,  particularly 
the  endothelial  cells,  proHferate  and  produce  cells  which  are  practically  fibro- 
blasts. The  osteoblasts  in  the  medullary  tissue  and  in  the  deeper  layers 
of  the  periosteum  multiply  and  are  distributed  through  the  mass  of  fibro- 
blasts. The  osteoblasts  may  form  bone  directly  or  may  form  cartilage  first. 
Some  teach  that  fibroblasts  can  be  converted  into  bone;  others  positively 
deny  such  a  conversion.  The  point  is  not  settled,  but  it  is  well  to  remem- 
ber that  in  myositis  ossificans  a  muscle  is  converted  into  bone,  and  hence 
that  it  is  probable  that  fibroblasts  formed  from  periosteum  and  medullary 
tissue  will  be  much  more  prone  to  undergo  such  a  development.  During 
regeneration  the  bone  ends  soften  and  are  partially  absorbed  by  osteoclasts. 
These  cells  are  large  osteoblasts  which  have  lost  the  power  of  bone  produc- 
tion and  furnish  a  secretion  which  dissolves  osseous  matter.  The  excess  of 
callus  is  finally  absorbed  by  osteoclasts.  (For  a  more  extended  description 
see  Repair  of  Fractures.) 

Repair  of  Blood-vessels. — If  an  artery  is  cut  across  and  ligated,  a  clot 
forms  within  its  lumen  and  about  its  divided  end,  and  the  circulation  in  the 
vessel  at  this  point  is  permanently  arrested.  The  proximal  clot,  it  used  to  be 
thought,  always  reaches  the  first  collateral  branch.  This  statement  was  true 
before  the  days  of  asepsis;  it  is  not  always  true  now.  Often  a  clot  stops  far 
short  of  the  branch  above.  Exudation  of  plasma  and  migration  of  corpuscles 
take  place  from  the  vasa  vasorum.  The  clot  becomes  filled  with  leukoc}tes, 
which  gradually  destroy  it,  and  it  plays  no  active  part  in  repair.  Fibroblasts 
form  by  the  multiplication  of  the  cells  of  the  vessel  wall  and  the  clot  is  now 
replaced  by  fibroblasts.  The  fibroblasts  are  converted  into  granulation 
tissue,  granulation  tissue  becomes  fibrous  tissue,  the  fibrous  tissue  contracts, 
and  the  artery  is  converted  into  a  fibrous  cord  (Fig.  133).  Warren  insists 
that  the  muscle-cells  of  the  middle  coat  play  an  active  part  in  repair.  Usually, 
when  a  ligature  is  applied  to  an  artery  in  continuity,  a  deliberate  attempt 
is  made  to  rupture  the  internal  and  middle  coats,  in  order  to  permit  of  contrac- 
tion and  retraction  above  and  below  the  seat  of  hgature,  and  a  turning  inward 
of  the  inner  coat.  Such  a  sequence  of  events  happens  when  an  artery  is  com- 
pletely divided  across  and  not  tied,  and  favors  the  rapid  formation  of  a  clot. 

Ballance  and  Edmunds  ("Ligation  in  Continuity")  maintain  that  repair 


104  Repair 

is  obtained  most  rapidly  when  the  artery  is  tied  with  two  ligatures,  the  vessel 
at  this  point  being  deprived  of  blood,  but  the  internal  and  middle  coats  being 
kept  intact.  Cell-prohferation  forms  a  spindle-shaped  mass  of  new  cells  and 
the  lumen  is  obhterated  at  the  seat  of  ligation  by  fibroblasts  obtained  from 
the  fixed  cells  of  the  wall  of  the  arter}-.  Senn  advocates  the  employment  of 
two  hgatures,  not  placed  side  by  side  as  in  the  method  of  Ballance  and  Ed- 
munds, but  so  applied  as  to  include  "a  bloodless  space  about  half  an  inch  in 
length"  (Senn's  "Principles  of  Surgery"). 

When  a  lateral  ligature  is  applied  to  a  vein  or  when  a  small  wound  in  a 
vein  or  artery  is  sutured,  the  circulation  in  the  vessel  is  not  completely  cut  off, 
a  thrombus  of  small  size  is  formed  on  the  vessel-walls,  the  fixed  cells  of  the 
vessel-wall  proliferate,  and  a  scar  of  fibrous  tissue  effects  repair.  A  com- 
pletely divided  vein  heals  as  does  a  completely  divided  artery  (Fig.  134)- 
The  clot  after  the  aseptic  application  of  a  hgature  to  a  vein  may  be  of  slight 
extent,  but  in  some  cases  the  proximal  clot  reaches  the  first  collateral  branch 
and  in  others  goes  far  above  it. 

Repair  of  Skin. — The  fibrous  structure  is  repaired  by  fibrous  tissue. 
Hair  follicles,  sweat-glands,  and  sebaceous  glands  are  not  reformed.  The 
epithelial  layer  is  regenerated  by  the  proliferation  of  adjacent  epithelial  cells. 
Lymphatic  tissue  can  regenerate  either  from  the  fatty  tissue,  the  divided 
ends  of  the  lymph  ducts  or  both  structures.  The  kidney  and  testicle  can 
undergo  some  regeneration.  The  liver  and  spleen  can  undergo  considerable 
regeneration. 


Aseptic  Fever  105 


V.  SURGICAL  FEVERS. 

The  surgeon  encounters  fever  as  a  result  of  an  inflammation  or  an  aseptic 
wound,  in  consequence  of  infection,  and  in  certain  maladies  of  the  nervous 
system.  It  is  important  to  remember  that,  while  elevated  temperature  is 
generally  taken  as  a  gauge  of  the  intensity  of  fever,  it  is  not  a  certain  index. 
There  may  be  fever  with  subnormal  temperature  (as  in  the  collapse  of  typhoid 
or  pneumonia),  and  there  may  be  elevated  temperature  without  true  fever  (as 
in  certain  diseases  of  the  nervous  system).  It  is  true,  however,  that  elevation 
of  temperature  is  almost  always  noted,  and  is  usually  accepted  as  the  measure 
of  the  height  of  the  fever. 

The  essential  phenomena  oj  fever,  according  to  Maclagan,  are — (i)  wasting 
of  nitrogenous  tissue;  (2)  increased  consumption  of  water;  (3)  increased 
elimination  of  urea;  (4)  increased  rapidity  of  circulation;  and  (5)  preternat- 
ural heat. 

Traumatic  fevers  follow  a  traumatism  and  attend  the  healing  or  in- 
fection of  a  wound.  The  forms  are — (i)  benign  traumatic  fever;  (2)  malig- 
nant traumatic  fever. 

Benign  traumatic  fever  is  divided  into  two  classes — the  aseptic  and  the 
septic.  There  is  but  one  form  of  aseptic  fever,  the  post-operation  rise.  The 
septic  benign  fevers  are  surgical  fever  and  suppurative  fever.  The  malignant 
traumatic  fevers  are  sapremia,  septic  infection,  and  pyemia.  In  this  section 
we  discuss  only  the  benign  fevers. 

Aseptic  fever  often,  but  not  always,  appears  after  a  thoroughly  aseptic 
operation  and  after  a  simple  fracture  or  a  contusion.  It  is  not  preceded  by  a 
chill,  by  chilliness,  or  by  a  feeling  of  illness.  It  may  appear  during  the  evening 
of  the  day  of  operation  or  not  until  the  ne.xt  day,  and  reaches  its  highest  point 
by  the  evening  of  the  second  day  (100°  to  103°  F.).  This  elevation  is  spoken 
of  as  the  "post-operation  rise."  Besides  the  elevated  temperature  there  are 
no  obvious  symptoms ;  the  patient  feels  well,  sleeps  well,  and  often  wants  to  sit 
up ;  there  are  no  rigors  and  there  is  no  delirium.  The  wound  is  free  from  pain 
and  appears  entirely  normal.  Blood  examination  may  show  moderate  leukocy- 
tosis. This  fever  is  due  to  absorption  of  pyrogenous  material  from  the  wound 
area,  the  material  being  obtained  from  clot  or  inflammatory  exudate,  or  from 
both.  Many  observers  believe  that  the  pyrogenous  element  is  fibrin  ferment, 
which  is  absorbed  from  disintegrating  blood-clot  and  coagulating  exudate. 
Warren  thinks  the  fever  is  due  to  fibrin  ferment,  and  "  also  to  other  substances 
slightly  altered  from  their  original  composition  during  life."  Some  have 
asserted  that  the  fever  is  due  to  nervous  shock. 

Schnitzler  and  Ewald  have  recently  studied  aseptic  fever.*  These  ob- 
servers maintain  that  aseptic  fever  can  exist  when  no  fibrin  ferment  is  free  in 
the  blood,  that  fibrin  ferment  can  be  free  in  the  blood  when  there  is  no 
fever,  and,  in  consequence,  that  fibrin  ferment  is  not  the  cause  of  the  eleva- 
tion of  temperature.  They  rule  out  of  consideration  nervous  shock  as 
a   cause,  and   assert   that  a    combination  of   several  factors  is  responsible, 

*  See  Archiv  fiir  klinische  Medicin,  Bd.  liii,  H.  3,  1896;  also  statement  of  their  views 
in  Medical   Record,  Dec.  19,  1896. 


io6  Surgical  Fevers 

nucleins  and  albumoses  which  are  set  free  by  traumatism  being  looked  upon  as 
the  most  active  causative  agents.  The  presence  of  nuclein  in  the  blood  in 
aseptic  fever  is  indicated  by  leukocytosis  and  by  the  increase  of  the  alloxur 
bodies  (including  uric  acid)  in  the  urine.  The  capacity  of  nucleins  and 
albumoses  to  cause  fever  is  greater  in  the  tuberculous  than  in  the  nontuber- 
culous.  The  diagnosis  of  aseptic  traumatic  fever  is  only  made  after  a  care- 
ful examination  has  assured  the  surgeon  there  is  no  obscure  or  hidden  area  of 
infection. 

In  some  cases  aseptic  fever  may  appear  after  an  operation,  and  later  be 
replaced  by  a  septic  fever.  If  the  temperature  remains  high  after  a  few  days, 
if  other  svmptoms  appear,  or  if  after  the  temperature  becomes  normal  it  again 
rises,  the  wound  should  be  examined  at  once,  as  trouble  almost  certainly  exists. 

True  traumatic  or  genuine  surgical  fever  is  seen  as  a  result  of  infected 
wounds  where  there  is  decided  inflammation,  but  no  pus.  The  real  cause  is  the 
presence  of  fermentative  bacteria  in  the  wound  and  the  absorption  of  their  toxic 
products.  The  most  active  and  commonly  present  organisms  are  those  of  putre- 
faction. Surgical  fever  ceases  as  soon  as  free  discharge  occurs,  and  the  appearance 
of  such  a  fever  is  an  indication  for  instant  drainage.  The  condition  is  ushered 
in  two  or  three  days  after  the  operation  by  chilly  sensations  and  general  dis- 
comfort. The  temperature  rises  pretty  sharply,  ascends  with  evening  ex- 
acerbations and  morning  remissions,  and  reaches  its  height  about  the  third 
or  fourth  day,  when  suppuration  sets  in;  the  temperature  begins  to  drop  when 
pus  forms,  if  the  pus  has  free  exit,  and  reaches  normal  at  the  end  of  a  week 
(see  Suppurative  Fever).  The  temperature  may  reach  104°  F.  or  more,  but 
rarely  rises  above  103°  F.  The  patient  has  the  general  phenomena  of  fever: 
thirst,  anorexia,  nausea,  dry  and  coated  tongue,  constipation,  pain  in  the  back 
and  legs,  and  headache.  The  urine  is  scanty  and  high-colored.  Blood 
examination  usually  shows  decided  leukocytosis.  The  wound  is  painful, 
tender,  swollen,  discolored,  and  often  foul,  and  stitch-abscesses  may  form. 
Some  or  all  of  the  stitches  must  be  cut,  and  the  area  should  be  asepticized, 
and  packed  with  iodoform  gauze  or  drained  by  a  tube.  The  fact  that  this 
fever  is  apt  to  cease  when  suppuration  begins  led  the  older  surgeons  to  hope 
for  pus  and  to  endeavor  to  cause  it  to  form.  A  severe  grade  of  surgical  fever, 
such  as  arises  when  there  is  putrefaction  in  a  large  and  ill-drained  wound,  is 
known  as  sapremia  (page  161). 

Suppurative  Fever. — This  fever,  which  is  due  to  the  absorption  of  the 
toxins  of  pyogenic  organisms,  occurs  after  suppuration  has  begun,  is  found 
when  the  pus  has  not  free  exit,  and  is  an  intoxication  rather  than  an  infection. 
It  can  follow  or  be  associated  with  surgical  fever,  or  may  arise  in  cases  in  which 
surgical  fever  has  not  existed.  Suppuration  in  a  wound  is  indicated  by  a  rapid 
rise  of  temperature — possibly  by  a  chill.  The  temperature  rises  to  a  con- 
siderable height,  shows  morning  remissions  and  evening  exacerbations,  and 
as  it  begins  to  fall  toward  morning  sweating  occurs.  The  patient  is 
much  exhausted  and  presents  the  phenomena  of  fever  previously  described. 
The  skin  about  the  wound  becomes  swollen,  dusky  in  color,  and  edematous, 
pain  becomes  pulsatile,  and  much  tenderness  develops.  Blood  examination 
shows  very  marked  leukocytosis.  The  wound  must  at  once  be  drained  and 
asepticized.  In  a  chronic  suppuration,  such  as  occurs  in  the  mixed  infection 
of  a  tuberculous  area,  there  exists  a  fever  with  marked  morning  remissions 


Surgical   Scarlet   Fever  I07 

and  vesperal  exacerbations,  attended  with  drenching  night-sweats,  emaciation, 
diarrhea,  and  exhaustion.  This  is  Is^nown  as  hectic  fever  ;  it  is  really  a  chronic 
suppurative  fever.  The  treatment  of  hectic  fever  consists  in  the  drainage 
and  disinfection,  if  possible,  the  excision  of  the  infected  area,  the  employment 
of  a  nutritious  diet,  stimulants,  tonics,  remedies  for  the  exhausting  sweats, 
and  free  access  of  fresh  air. 

Some  Other  Forms  of  Fever  Seen  by  the  Surgeon. — Fever  of 
Tension. — When  there  is  great  tension  upon  the  stitches  the  spots  where  the 
stitches  perforate  ulcerate  and  some  fevers  arise.  To  relieve  the  fever  of 
tension  cut  one  or  several  stitches.  This  fever  is  in  some  cases  surgical,  and 
in  some  suppurative,  according  as  to  whether  the  infective  organisms  cause 
fermentation  or  suppuration. 

Fever  of  Iodoform  Absorption  (see  page  27). 

Fever  of  Ptyalism,  or  Mercurial  Fever  (see  page  238). 

Fever  of  Morphinism. — Sometimes  a  morphia  habitue  suffers  from 
severe  chills  and  intermittent  fever  of  the  quotidian  or  tertian  type.  The  con- 
dition is  usually  thought  to  be  malarial,  a  view  which  is  strengthened  by  the 
common  association  with  neuralgia;  but  quinin  proves  futile  as  a  remedy 
and  blood-examination  gives  a  negative  result.  If  we  have  reason  to  suspect 
that  the  patient  is  using  morphia,  examine  the  urine  for  the  drug  and  wash 
out  the  stomach  and  examine  the  washing.  The  latter  test  is  of  value  even 
when  morphia  is  used  hypodermatically,  because  that  drug  is  excreted  into  the 
stomach. 

Fever  of  Cocain-poisoning  (see  Local  Anesthesia). 

Hepatic  Fever  (see  section  on  Liver  and  Gall-bladder). 

Hysterical  Fever. — This  reniarkable  condition  is  occasionally,  though 
rarely,  encountered.  Most  of  the  reported  cases  of  great  hyperpyrexia  are 
instances  of  simulation  and  fraud.  It  may  happen  that  elevated  temperature 
is  the  sole  evidence  of  illness,  there  being  no  wasting  or  other  febrile  symp- 
toms. Such  elevated  temperature  may  be  attained  daily  for  months.  As  a 
rule,  hysterical  stigmata  can  be  detected.  Osier  points  out  that  cases  of 
hysterical  fever  "with  spurious  local  manifestations"  are  very  deceptive. 
The  case  may  resemble  meningitis,  peritonitis,  or  some  other  acute  inflam- 
matory condition;  but  the  course  of  the  supposed  malady  is  found  to  be 
atypical  and  the  symptoms  are  observed  to  be  variable  and  often  anomalous. 
There  is  no  leukocytosis;  frequently  there  is  an  apparent  increase  in  red  cells 
because  of  vasomotor  disturbance,  a  fall  in  hemoglobin,  and  an  increased 
proportion  of  lymphocytes  and  eosinophiles  ("  Clinical  Hematology,"  by  J.  C. 
DaCosta,  Jr.). 

An  emotional  fever  sometimes  occurs  after  accidents  or  operations. 
The  patient  may  have  a  chill,  and  then  develop  violent  headache,  photo- 
phobia, and  hysterical  excitement,  with  elevated  temperature. 

Malaria. — It  is  wise  to  examine  the  blood  in  supposed  septic  fevers,  for 
only  by  this  means  can  malaria  be  excluded.  It  is  more  common  to  mistake 
sepsis  for  malaria  than  malaria  for  sepsis.  In  malaria  the  spleen  is  enlarged, 
the  attacks  exhibit  periodicity,  neuralgias  are  common  associates,  and  quinin 
cures  the  condition. 

Surgical  Scarlet  Fever. — It  is  maintained  by  some  writers  (notably 
Victor  Horsley  and  Sir  James  Paget)  that  a  child  is  rendered  especially  sus- 


io8  Surgical  Fevers 

ceptible  to  scarlet  fever  by  the  shock  of  a  surgical  operation.  Scarlet  fever 
which  develops  after  a  wound,  a  burn,  or  an  operation  is  spoken  of  as  surgical 
scarlet  fever.  Warren  quotes  Thomas  Smith  as  having  had  ten  cases  of 
scarlet  fever  in  forty-three  operations  for  lithotomy  in  children.  The  puer- 
peral state  is  supposed  also  to  predispose  to  scarlet  fever.  It  is  not  certain 
whether  the  poison  enters  by  the  wound,  or  whether  shock  and  exhaustion 
predispose  to  ordinary  scarlatina,  or  whether  ordinary  scarlatina  was  incu- 
bating before  the  accident  or  operation.  Some  surgeons  hold  that  an  attack 
of  scarlet  fever  after  an  operation  is  a  mere  coincidence.  Others  maintain, 
and  with  great  show  of  reason,  that  a  red  scarlatiniform  eruption  appearing 
after  an  operation,  rarely  indicates  genuine  scarlet  fever,  but  usually  points 
to  infection,  as  such  eruptions  are  known  occasionally  to  arise  in  septicemia. 
It  rarely  indicates  scarlet  fever,  and  yet  it  sometimes  does.  There  is  such  a 
condition  as  surgical  scarlet  fever,  as  is  proved  by  the  facts  that  victims  of 
the  disease  have  been  known  to  communicate  it,  and  that  it  is  often  fol- 
lowed by  "nephritis  and  usually  by  desquamation"  (Holt's  "Diseases  of 
Infancy  and  Childhood"). 

Hoffa  has  discussed  this  subject  elaborately.  He  concludes  that  four  types 
of  eruption  can  follow  operation:  (i)  a  vasomotor  disturbance  due  to  irrita- 
tion of  sensory  nerves,  and  manifested  by  a  transient  urticaria  or  erythema; 
(2)  a  toxic  erythema  due  to  absorption  of  aseptic  pyrogenous  material  from 
the  injured  area — the  absorption  of  carboHc  acid,  iodoform,  or  corrosive 
sublimate,  or  the  effect  of  ether;  (3)  an  infectious  rash  which  is  sometimes 
found  in  septicemia  or  pyemia,  and  due  to  minute  emboli  composed  of  bac- 
teria, which  emboli  lodge  in  the  capillaries;  (4)  true  scarlet  fever,  with  the 
usual  symptoms  and  comphcations,  the  organisms  having  entered  by  way  of 
the  wound,  and  the  eruption  often  beginning  at  the  wound  edges  (quoted  in 
Warren's  "Surgical  Pathology").  Surgical  scarlatina  is  aberrant.  It  de- 
velops rapidly,  the  period  of  incubation  is  extremely  brief,  the  throat  may  or 
may  not  be  involved.  Holt  tells  us  that  the  rash  is  usually  atypical  and  that 
"the  general  symptoms,  particularly  those  relating  to  the  nervous  system," 
are  "especially  severe"  ("Diseases  of  Infancy  and  Childhood").  The  in- 
fection is  believed  to  be  due  to  a  specific  germ,  but  it  has  not  been  certainly 
identified.  Streptococci  have  been  found  in  the  throat,  skin,  and  the  pus  from 
secondary  otitis  media. 

If  surgical  scarlet  fever  develops  the  wound  should  be  drained  and  asepti- 
cized, and  if  the  situation  admits  of  it,  dressed  with  hot  antiseptic  fomentations. 
Otherwise  the  treatment  is  the  same  as  for  ordinary  scarlatina. 

Urinary  Fever  and  Urethral  Fever  (see  section  on  Diseases  of  Genito- 
urinary (Organs). 

Syphilitic  Fever  (see  page  227). 

Thyroid  Fever  (see  section  on  Thyroid  (iland). 


Suppuration  109 


VI.  SUPPURATION  AND  ABSCESS. 

Suppuration  is  a  process  in  which  tissues  and  inflammatory  exudates  are 
liquefied  by  the  action  of  pyogenic  organisms,  and  it  is  a  common  result  of 
microbic  inflammation.  The  organisms  which  are  responsible  are  referred 
to  on  page  37.  Staphylococci  produce  local  suppuration;  streptococci  cause 
spreading  suppuration.  Pyogenic  bacteria  liquefy  exudate  by  peptonizing 
it.  The  pyogenic  organisms  are  very  irritant,  and  when  deposited  cause 
inflammation;  inflammation  leads  to  exudation,  but  the  exudate  cannot 
coagulate  or  coagulates  but  imperfectly,  because  it  is  peptonized  by  the  fer- 
ment of  the  micro-organisms.  If  an  area  of  embryonic  tissue  is  invaded  by 
the  pvogenic  micro-organisms,  it  is  promptly  peptonized.  The  peptonizing 
action  is  upon  the  fibrinous  elements  of  an  exudate  and  upon  the  intercellular 
substance  of  embryonic  or  granulation  tissue.  Cells  are  separated  from 
intercellular  substance,  and  in  consequence  degenerate  and  die.  Peptonized 
exudate  or  embryonic  tissue  is  called  pus.  In  suppurations  induced  by 
staphvlococci  a  barrier  of  leukocytes  is  first  formed  around  the  region  of  irri- 
tation; this  barrier  is  reinforced  by  fibroblasts,  the  pus  is  imprisoned,  and 
rapid  spreading  and  wide  diffusion  are  prevented.  In  inflammations  induced 
by  streptococci  the  peptonizing  action  of  the  organisms  is  so  great  that  no 
barrier  of  white  blood-cells  or  of  proliferating  connective-tissue  cells  forms  in 
time  to  imprison  the  micro-organisms;  hence  the  suppuration  spreads  rapidly 
and  widely.  Suppuration  can  be  induced  by  the  injection  of  pyogenic  bacteria, 
by  their  entry  through  a  wound,  and  by  rubbing  them  upon  the  skin.  In 
some  rare  instances,  especially  when  the  diet  has  been  putrid,  they  may  enter 
through  the  blood  and  lodge  at  a  point  of  least  resistance.  When  a  medullary 
canal  suppurates  after  a  chill  to  the  surface  or  after  a  blow  that  does  not  cause 
a  wound,  we  know  that  the  organisms  must  have  arrived  by  means  of  the 
blood.  Organisms  which  reach  a  point  of  least  resistance  through  the  blood 
come  from  some  atrium  of  infection  which  may  be  discoverable  or  which  may 
not  be  found.  The  entry  of  pyogenic  bacteria  does  not  necessarily  cause 
suppuration,  as  the  healthy  human  body  can  destroy  a  considerable  number, 
even  if  given  in  one  '' dose" ;  but  a  large  number  in  a  healthy,  or  even  a  small 
number  in  an  unhealthy,  organism  almost  certainly  leads  to  pus-formation. 
The  pus  of  all  acute  abscesses  contains  bacteria  of  suppuration,  but  the  pus 
of  tuberculous  abscesses  does  not,  unless  there  be  a  mixed  infection;  in  other 
words,  pure  tuberculous  pus  is  not  pus  at  all. 

Can  suppuration  be  induced  without  micro-organisms?  It  is  true  that 
the  injection  of  irritants  can  cause  the  formation  of  a  thin  fluid  which  contains 
no  organisms;  but  this  non-bacterial  fluid  is  not  pus.  A  purulent  fluid 
is  formed  by  injecting  cultures  of  pus  cocci  which  have  been  rendered 
sterile  by  heat,  the  organisms  being  killed,  a  ferment  contained  in  the  bacterial 
cells  being  the  active  agent.  It  is  known  as  spurious  or  aseptic  pus.  It 
concerns  us  but  little  as  surgeons,  except  in  cases  of  pyemia  in  which  thrombi 
containing  toxins  induce  limited  secondary  abscesses. 

Impaired  health  or  an  area  of  lowered  vitality  predisposes  to  suppura- 
tion.    Diabetes  and   albuminuria  are  common  and  influential   predisposing 


I  lO 


Suppuration  and   Abscess 


causes,  because  in  these  diseases  tissue  resistance  is  at  a  low  ebb.  The 
lymphatic  glands,  medulla  of  bones,  serous  membranes,  and  connective  tis- 
sue are  especially  prone  to  suppurate. 

Pus  may  form  within  twenty-four  hours  after  bacteria  have  been  deposited, 
or  it  mav  not  be  formed  for  days.  The  older  surgeons  claimed  that  pus  could 
do  good  by  protecting  granulations  and  separating  disorganized  tissue.  It 
is  now  held  that  it  is  absolutely  harmful  by  melting  down  sound  tissue  and 
poisoning  the  entire  organism.  Modern  surgery  has  to  a  great  degree  abolished 
pus. 

If  pus  stands  for  a  time,  it  separates  into  two  portions — (i)  a  watery  por- 
tion, the  liquor  puris  or  pus-serum,  containing  peptone,  fat,  microbic  products, 
osmazone.  and  salts,  and  not  tending  to  coagulate;  (2)  a  solid  portion,  or 
sediment  of  micro-organisms  of  suppuration,  pus-corpuscles  (Fig.  44),  and 


.0  '  ':S 


rf  .'.''=■1:^°  :'.' 


:/.  ^,  ^,%y 


Fig.  44. — Fragmentati(in  ol  nucleus  in  leukocytes  undergoing  transformation  into  pus- 
corpuscles  (Senn). 


broken-down  tissue.  The  pus-corpuscles  are  either  white  blood-cells  or 
altered  connective-tissue  cells.  Some  of  them  are  dead,  some  have  ameboid 
movements,  some  are  fatty,  others  are  granular  and  contain  more  than  one 
nucleus,  and  all  are  degenerating.  A  pus-cell  is  waste  matter,  and  it  cannot 
aid  in  repair. 

Forms  of  Pus. — Laudable  or  healthy  pus,  a  name  long  in  vogue,  is  a  con- 
tradiction, no  pus  being  healthy.  In  former  days  free  suppuration  after  an 
operation  was  regarded  as  a  favorable  indication,  and  when  it  occurred  the 
surgeon  congratulated  himself  that  surgical  fever  was  at  an  end.  At  the 
present  day  suppuration  after  an  operation  is  an  evidence  of  previous  infection, 
of  lack  of  care,  or  of  infection  by  the  blood.  The  so-called  laudable  pus  is 
seen  coming  from  a  healing  ulcer,  and  is  an  opaque,  yellowish-white,  or  a 
greenish  fluirl  of  the  consistence  of  cream,  without  odor  or  with  a  very  slight 
odor  if  it  is  not  putrid,  and  having  a  specific  gravity  of  about  1030. 


Dififused   Cellulitis;    Purulent   Infiltration  III 

Malignant,  watery,  or  ichorous  pus  is  a  thin,  watery,  putrid  fluid.  It  is 
pus  filled  with  the  organisms  of  putrefaction. 

Stinking  pus  may  be  ichorous.  If  due  to  the  bacterium  coli  commune, 
it  is  very  foul,  but  not  thin.  Pus  of  this  nature  is  met  with  in  ischiorectal 
abscess  and  appendiceal  abscess. 

Sanious  pus  is  a  form  of  ichorous  pus  containing  blood  coloring-matter 
or  blood.  It  is  thin,  of  a  reddish  color,  and  very  acrid,  corroding  the  parts 
that  it  comes  in  contact  with.     It  is  found  notably  in  caries  and  carcinoma. 

Concrete  or  fibrinous  pus,  which  contains  flakes  of  fibrin  or  coagulated 
fibro-purulent  masses,  is  met  with  in  serous  cavities  (joints,  pleura,  etc.). 
These  masses  are  found  in  infective  endocarditis. 

Blue  Pus. — The  color  of  blue  pus  is  due  to  the  bacillus  pyocyaneus. 

Orange  Pus. — The  color  of  orange  pus  is  due  to  the  action  of  sarcina 
aurantiaca,  and  appears  in  violent  inflammations. 

Serous  pus  is  a  thin  serous  fluid  containing  a  few  flakes. 

So-called  tuberculous,  scrojulous,  or  curdy  pus  is  not  pus  at  all,  unless  the 
tuberculous  area  has  undergone  pyogenic  infection. 

So-called  gummy  pus  arises  from  the  breaking  down  of  a  gumma  whicii 
has  outgrown  its  own  blood-supply.     It  is  not  pus. 

Muco-pus  is  found  in  purulent  catarrh — that  is,  in  suppurative  inflamma- 
tion of  an  epithelial  structure.     It  contains  pus  elements  and  epithelial  cells. 

Caseous  pus  comes  from  the  fatty  degeneration  of  pus-corpuscles  or  in- 
flammatory exudations.  It  occurs  especially  in  tuberculous  processes.  A 
caseous  mass  may  calcify. 

Suppuration  is  announced  by  the  intensification  of  all  local  inflamma- 
tory signs.  The  heat  becomes  more  marked,  the  discoloration  dusky,  the 
swelling  augments,  the  pain  becomes  throbbing  or  pulsatile,  and  the  sense  of 
tension  is  greatly  increased.  The  skin  at  the  focus  of  the  inflammation  after 
a  time  becomes  adherent  to  the  parts  beneath,  and  fluctuation  soon  appears. 
This  adhesion  of  the  skin  is  a  preparation  for  a  natural  opening,  and  is 
known  as  pointing.  An  important  sign  of  pus  beneath  is  edema  of  the  skin. 
This  is  always  observed  in  a  superficial  abscess,  and  is  sometimes  noticeable 
in  empyema  or  pyothorax,  in  appendiceal  abscess,  and  in  perirenal  suppura- 
tion. The  above  symptoms  can  be  reinforced  and  their  significance  proved 
by  the  introduction  of  an  aseptic  tubular  exploring  needle  and  the  discovery 
of  pus.  Irregular  chills,  high  fever,  and  drenching  sweats  are  very  significant 
of  suppuration  in  an  important  structure  or  of  a  large  area. 

Diffused  Cellulitis  or  Phlegmonous  Suppuration ;  Purulent  Infil- 
tration.— This  process  may  involve  a  small  area  or  an  entire  limb,  and  is  due 
to  infection  by  the  streptococcus  pyogenes  or  streptococcus  of  erysipelas,  usu- 
ally associated  with  mixed  infection  with  other  bacteria.  The  streptococci 
are  intensely  virulent.  Barriers  of  white  corpuscles  will  not  restrain  them, 
and  tissues  break  down  before  cellular  multiplication  is  able  to  encompass 
the  bacteria.  The  bacteria  disseminate  through  the  lymph-spaces  and 
lymph-vessels.  The  disease  in  severe  cases  produces  enormous  swelling, 
areas  which  feel  boggy,  a  dusky  red  discoloration,  and  great  burning  pain. 
Gangrene  of  superficial  areas  is  not  unusual,  due  to  thrombosis  of  vessels  or 
coagulation  necrosis  from  toxins.  The  discharges  of  the  wound,  if  a  wound 
exists,  are  apt  to  dry  up,  and  the  wound  becomes  foul,  dry,  and  brown.     The 


112  Suppuration  and  Abscess 

adjacent  lymphatic  glands  are  much  enlarged.  The  disease  is  ushered  in  by 
a  chill,  which  is  followed  by  high  oscillating  temperature,  due  to  suppurative 
fever,  sapremia,  or  even  septic  infection  or  pyemia.  Sweats  are  noted  during 
falhng  temperature.  Diffuse  suppuration  tends  to  arise  in  infected  compound 
fractures,  in  e.xtravasation  of  urine,  and  after  the  infliction  of  a  wound  upon 
a  person  broken  down  in  health.  It  is  not  unusual  after  typhoid  or  scarlet 
fever,  and  is  typical  of  phlegmonous  erysipelas.  The  pus  is  sanious  and 
offensive,  and  burrows  widely  in  the  subcutaneous  tissue  and  intermuscular 
planes.  This  diffused  suppuration  may  widely  separate  muscles,  and  even 
lav  bare  the  bones.  It  is  a  very  grave  condition,  and  may  cause  death  by 
exhaustion,  septic  intoxication,  septic  infection,  pyemia,  or  hemorrhage  from 
a  large  vessel  which  has  been  corroded.  Cellulitis  of  a  mild  degree,  due 
usually,  but  not  always,  to  streptococci,  may  surround  an  infected  wound  or 
a  stitch-abscess.  Its  spread  is  manifested  by  red  lines  of  lymphangitis  running 
up  to  the  adjacent  lymphatic  glands.  Light  cases  may  not  suppurate,  the 
lymphatics  carrying  off  the  poison.  Any  case  of  cellulitis  is,  however,  a 
menace,  and  any  severe  case  is  highly  dangerous  (see  Erysipelas). 

Acute  Abscesses. — An  abscess  is  a  circumscribed  cavity  of  new  forma- 
tion containing  pus.  We  emphasize  the  fact  that  it  is  a  circumscrihed  cavity 
— circumscribed  by  a  mass  of  leukocytes  and  proliferating  connective-tissue 
cells.  A  purulent  infiltration  is  not  circumscribed,  hence  it  does  not  consti- 
tute an  abscess.  An  essential  part  of  the  definition  is  the  assertion  that  the 
pus  is  in  a  cavity  of  new  formation,  in  an  abnormal  cavity;  hence  pus  in  a 
natural  cavity  (pleural,  pericardial,  synovial,  or  peritoneal)  constitutes  a 
purulent  effusion,  and  not  an  abscess,  unless  it  is  encysted  in  these  locahties 
by  walls  formed  of  inflammatory  tissue. 

An  acute  abscess  is  due  to  the  deposition  and  multipHcation  of  pyogenic 
bacteria  in  the  tissues  or  in  inflammatory  exudates.  These  bacteria  attack 
exudates  or  tissues,  form  irritants  which  cause  inflammation  or  intensify 
existing  inflammation,  and  by  exerting  a  peptonizing  action  on  interceflular 
substance  and  the  fibrin  of  the  exudate  hquefy  tissue  and  the  products  of 
inflammation,  and  form  pus.  As  a  rule,  within  twenty-four  hours  after 
lodgment  of  the  bacteria  the  exudation  increases  in  amount,  the  migrated 
leukocytes  gather  in  enormous  numbers,  the  fibers  of  tissue  swell,  and  the 
connective-tissue  spaces  distend  with  cells  and  fluid.  The  connective-tissue 
cells,  acted  on  by  pus  cocci,  multiply  by  karyokinesis,  develop  many  nuclei, 
lose  their  stellate  projections,  degenerate,  and  constitute  one  form  of  pus- 
corpuscle,  leukocytes  forming  the  other.  All  the  small  vessels  are  choked 
with  leukocytes,  this  blocking  serving  to  cut  off  nourishment  and  tending  to 
produce  anemic  necrosis.  Liquefaction  occurs  at  many  foci  of  the  inflam- 
mation, drops  of  pus  being  formed,  the  amount  of  each  being  progressively 
added  to  and  many  foci  coalescing  (Fig.  45).  The  pus-cavity  is  circumscribed, 
not  by  a  secreting  pyogenic  membrane,  but  by  a  mass  of  fibroblasts,  whose 
cells  and  intercellular  material  have  not  as  yet  broken  down;  such  a  mass  of 
fibroblasts  is  often  called  embryonic  tissue,  and  it  is  circumscribed  by  a  zone 
of  inflammation  in  which  there  are  hordes  of  migrated  leukocytes  (Fig.  46). 
As  an  abscess  increases  in  size,  the  embryonic  tissue  from  within  outward 
liquefies  into  pus,  and  the  zone  of  inflammation  beyond  continually  enlarges 
and  forms  more  embryonic  tissue.     After  a  time  the  inflammation  reaches 


Acute  Abscesses 


113 


the  surface,  the  embryonic  tissue  glues  the  superficial  to  the  deeper  parts,  the 
superficial  part  inflames  and  becomes  embryonic  tissue,  and  the  intercellular 
substance  is  hquetied.  When  pus  has  all  but  reached  the  surface,  a  thin  layer 
of  tissue  only  being  undestroyed,  an  elevation  or  tit  of  thin  tissue  is  formed,  due 
to  the  fluid  pressure.     This  process  is  known  as  pointing.     The  elevation  or 


-Infiltralion  of  connective  tissue  of  cutis  (  :\  500)  w  itli  beginning  suppuration  in 
the  center  (Senn). 


point  thins  from  tension  and  liquefaction,  and  finally  gi\es  way  and  spon- 
taneous evacuation  occurs.  When  an  abscess  forms  in  an  internal  organ  or  in 
some  structure  which  is  not  loose,  like  connective  tissue, — for  instance,  in  a 
lymphatic  gland, — a  mass  of  pyogenic  bacteria,  floating  in  the  blood  or 
lymph,  lodges,  and  these  bacteria  by  means  of  irritant  products  cause  coagu- 
lation necrosis  of  the  adjacent  tissue  and 
inflammatory  exudation  around  it.  The 
area  of  coagulation  necrosis  becomes  filled 
with  white  blood-cells,  and  the  dry  ne- 
crosed part  is  liquefied  by  the  cocci.  Sup- 
puration in  dense  structures  causes  consid- 
erable masses  of  tissue  to  die  and  to  be 
cast  off,  and  these  masses  float  in  the  pus. 
Death  of  a  mass  with  dissolution  of  its 
elements  is  necrosis,  or  inflammatory  gan- 
grene. Pus  travels  in  the  line  of  least 
resistance.  It  may  reach  a  free  surface, 
or  may  break  into  a  cavity  or  joint,  may 
invade  bone  or  destroy  a  \'essel.  \\'hen 
an  abscess  ceases  to  spread  or  is  evacuated, 
the  fibroblastic  layer  forming  the  walls 
becomes    vascularized    and   is    converted 

into  granulation  tissue.  An  abscess  heals  by  the  collapse  of  its  walls  and 
fusion  of  the  granulations  (union  by  third  intention),  or  by  granulation  (union 
by  second  intention).  In  either  case  granulation  tissue  is  ultimately  con- 
verted into  fibrous  or  scar  tissue. 


Fig.  46. — Diagram  of  an  abscess:  A, 
Pus  ;  B,  layer  of  fibroblasts  ;  C.  tissue  in- 
filtrated with  leukocytes  ;  D,  zone  of  stasis  ; 
E,  zone  of  active  hyperemia;  F,  healthy 
tissue. 


114  Suppuration    and   Abscess 

Forms  of  Abscesses. — The  following  are  the  various  forms  of  ab- 
scesses: Acute,  which  follows  an  acute  inflammation.  Strumous,  cold,  lymph- 
atic, tuberculous,  or  chronic  abscess  is  due  to  tubercle^  and  does  not  contain  true 
pus  unless  there  is  secondary  infection.  It  presents  no  signs  of  inflammation. 
A  lymphatic  abscess  may  form  in  a  week  or  two,  and  hence  is  not  necessarily 
chronic,  which  term  may  also  be  used  to  mean  a  persistent  non-tuberculous 
abscess.  Caseous  or  cheesy  abscess,  a  cavity  containing  thick  cheesy  masses, 
is  due,  perhaps,  to  the  fatty  degeneration  of  inflammatory  exudate  and  pus- 
corpuscles,  but  most  commonly  results  from  the  caseation  of  a  tuberculous 
focus.  Circumscribed  abscess  is  one  limited  by  a  layer  of  fibroblasts.  Dif- 
fused abscess  is  an  unlimited  collection  of  pus,  in  reahty  not  an  abscess,  but 
either  a  purulent  effusion  or  a  purulent  infiltration.  Congestive,  gravitative, 
wandering,  or  hypostatic  abscess  is  a  collection  of  pus  or  tuberculous  matter 
which  travels  from  its  formation-point  and  appears  at  some  distant  spot  (as  a 
psoas  abscess).  Critical  or  consecutive  abscess  is  one  which  arises  during  an 
acute  disease.  Diathetic  abscess  is  due  to  a  diathesis.  Embolic  abscess  is 
due  to  an  infected  embolus.  Tympanitic  or  emphysematous  abscess  is  one  which 
contains  air  or  the  gases  of  putrefaction.  Encysted  abscess,  in  which  pus  is 
circumscribed  in  a  serous  cavity.  Fecal  or  stercoraceous  abscess  is  one  con- 
taining feces  in  consequence  of  a  communication  with  the  bowel.  Follicular 
abscess  is  one  arising  in  a  follicle;  hematic  abscess,  one  arising  around  blood- 
clot,  as  a  suppurating  hematoma;  marginal  abscess,  which  appears  upon  the 
margin  of  the  anus.  Pyemic  or  metastatic  abscess  is  the  embolic  abscess  of 
pyemia.  Milk  abscess  is  an  abscess  of  the  breast  in  a  nursing  woman;  ossi- 
fliient  abscess, arising  from  diseased  bone;  psoas  abscess,  a  tuberculous  abscess 
arising  from  vertebral  caries,  the  matter  following  the  psoas  muscle,  and 
usually  pointing  in  the  groin.  Sympathetic  abscess,  arising  some  distance 
from  the  exciting  cause,  such  as  a  suppurating  bubo  from  chancroid,  is  not  in 
reality  sympathetic,  because  infective  material  has  been  carried  from  the 
primary  focus.  Thecal  abscess  is  a  purulent  effusion  in  a  tendon-sheath. 
Tropical  abscess  is  an  abscess  of  the  liver,  so  named  because  it  occurs  chiefly  in 
tropical  countries:  it  usually  follows  dysentery;  urinary  abscess,  caused  by 
extravasated  urine;  verminous  abscess,  one  which  contains  intestinal  worms 
and  communicates  with  the  bowel;  syphilitic  abscess,  which  occurs  in  the 
bones  during  tertiary  syphilis,  and  which  is  gummatous  and  not  pyogenic. 
Brodie's  abscess  is  a  chronic  abscess  of  a  bone,  most  common  in  the  head  of 
the  tibia;  superficial  abscess,  occurring  above  the  deep  fascia;  deep  abscess, 
occurring  below  the  deep  fascia;  and  residual  or  Paget^s  abscess,  a  recurrence 
of  active  changes,  it  may  be  after  years,  about  the  residue  of  a  former  tuber- 
culous abscess. 

Symptoms  of  Acute  Abscess. — In  an  acute  abscess,  as  before  stated,  a 
part  becomes  inflamed  and  a  quantity  of  fibrol)lasts  are  formed;  fibroblastic 
tissue  is  liquefied  (as  above  noted)  and  pus  is  produced.  If  the  abscess  is  in 
the  brain,  in  the  tonsil,  or  in  the  neighborhood  of  the  rectum  or  vermiform 
appendix,  the  odor  of  the  pus  is  a])t  to  be  offensive.  An  acute  abscess  can 
occur  in  a  person  of  any  constitution. 

Local  Symptoms.: — Locally  there  is  intensification  of  inflammatory 
signs  and  enormous  increase  of  the  swelling.  At  first  the  area  is  hard,  but 
afterward  becomes  soft,  and  it  finally  fluctuates.     The  discoloration  becomes 


Acute  Abscesses  in  Various  Regions  1 1  5 

dusky.  The  pain  becomes  throbbing  and  the  sense  of  tension  increases. 
The  pain  is  greater  the  more  dense  the  impHcated  tissue  is  and  the  greater 
the  number  of  nerves  it  contains.  At  every  pulse-beat  the  tension  in  the 
abscess  increases  temporarily,  and  hence  the  pain  momentarily  increases. 
Pain  is  increased  by  a  dependent  position  of  the  part.  There  is  great  tender- 
ness. The  pain  may  be  felt  at  the  seat  of  suppuration  or  may  be  referred  to 
some  distant  point.  Tenderness  is  located  at  the  focus  of  disease.  The  cuta- 
neous surface,  if  the  abscess  is  adjacent,  is  seen  to  be  polished  and  edematous, 
and  after  a  time  pointing  is  observed  and  fluctuation  can  be  detected. 

Constitutional  Symptoms. — If  there  is  a  small  collection  of  pus  in  an 
unimportant  structure  there  may  be  no  obvious  constitutional  disturbance. 
If  the  abscess  contains  much  pus  or  affects  an  important  part,  disturbances 
generally  appear,  from  slight  rigors  or  moderate  fever  to  chills,  high  tempera- 
ture, and  drenching  sweats.  The  constitutional  condition  typical  of  an  ab- 
scess is  due  to  the  absorption  of  retained  toxins,  and  is  known  as  "  suppurative 
fever."  When  an  abscess  is  open  but  ill-drained,  or  when  it  is  unopened 
and  deep-seated,  long-continued  suppuration  causes  a  fever  which  is  markedly 
periodic:  the  temperature  rises  in  the  evening,  attaining  its  highest  point 
usually  between  4  and  8  p.  m.,  and  then  sinks  to  normal  or  nearly  normal  in  the 
early  morning  (from  4  to  8  A.  M.).  When  the  temperature  begins  to  fall,  pro- 
fuse perspiration  takes  place.  This  fever  is  known  as  hectic.  Prolonged 
suppuration  causes  albuminoid  changes  in  various  organs,  notably  in  the  liver, 
spleen,  and  kidneys.  Albuminoid  changes  are  especially  common  when  there 
has  been  mi.xed  infection  of  a  tuberculous  area  and  long-continued  suppura- 
tion.    It  also  occurs  as  a  result  of  syphilis. 

Dr.  J.  C.  DaCosta,  Jr.,  tells  us  ("  Chnical  Hematology")  that  "in  both 
trivial  and  extensive  pus  foci  the  number  of  leukocytes  may  be  normal  or  even 
subnormal ;  in  the  former  instance  because  systemic  reaction  is  not  provoked^ 
and  in  the  latter  because  it  is  overpowered.  Leukocytosis  may  also  be  absent 
in  case  toxic  absorption  is  impossible,  owing  to  the  complete  walling  off  of 
the  abscess.  In  all  other  instances  save  these,  a  definite  and  usually  well- 
marked  leukocytosis  occurs,  amounting  on  the  average  to  a  count  of  about 
twice  the  mean  normal  standard,  but  frequently  greatly  exceeding  this  figure 
in  the  individual  case." 

The  signs  and  symptoms  of  an  abscess  are  somewhat  modified  by  location, 
and  it  is  wise  to  discuss  acute  abscesses  in  different  situations. 

Acute  Abscesses  in  Various  Regions. — Abscess  0}  the  brain  in  about 
50  per  cent,  of  cases  results  from  suppurative  disease  of  the  middle  ear.  In 
abscess  of  a  silent  region  of  the  brain  symptoms  may  long  be  entirelv  absent. 
The  usual  symptoms  are  headache,  vomiting,  dehrium,  drowsiness,  optic 
neuritis,  and  in  about  one-half  of  the  cases  a  subnormal  temperature.  Local- 
izing symptoms,  spasmodic  or  paralytic,  may  be  present.  There  is  usually 
leukocytosis.  In  but  few  cases  are  there  fever  and  sweats.  In  extradural 
abscess  there  is  fever. 

Appendiceal  or  appendicular  abscess  results  from  intiammation,  usually 
with  perforation  of  the  vermiform  appendix,  plastic  peritonitis  leading  to 
agglutination  of  the  mesentery  and  omentum,  adhesion  of  the  bowels  and 
mesentery,  and  the  formation  of  a  barrier  of  leukocytes  and  a  mass  of  fibro- 
blasts.    This  process  circumscribes  the  pus.     If  the  pus  in  appendicitis  has 


Ii6  Suppuration  and  Abscess 

been  formed  by  colon  bacilli  or  staphylococci,  it  will  probably  be  circumscribed 
and  limited.  If  the  pus  has  been  formed  by  streptococci,  it  will  probably  not 
be  limited,  and  the  peritoneum  will  be  attacked  by  diffuse  septic  peritonitis. 
The  signs  of  appendicular  abscess  are  pain,  tenderness,  muscular  rigidity,  the 
existence  of  a  mass,  which  may  be  palpated  through  the  abdominal  wall  or 
rectum  and  which  is  dull  on  percussion,  occasionally  fluctuation  and  skin  edema 
in  the  right  iliac  fossa,  vomiting,  sometimes  constipation,  and  sometimes 
diarrhea.  The  patient  lies  upon  his  back,  usually  with  one  or  both  thighs 
flexed.  In  appendicular  abscess  there  is  fever,  usually  higher  at  night  than 
in  the  morning,  profuse  sweating  occurring  during  the  fall.  In  some  cases 
the  temperature  is  persistently  high.  In  some  the  elevation  is  trivial.  In 
some  chills  occur.  A  sudden  fall  of  temperature  with  shock  is  produced  by 
rupture  of  the  abscess-wall.  If  this  accident  happens,  general  peritonitis 
quickly  arises.  In  appendicular  abscess  there  is  marked  leukocytosis  unless 
the  walls  are  very  thick  or  unless  the  process  has  diffused  and  general  peri- 
tonitis has  taken  place,  in  which  conditions  it  may  be  absent.  Appendiceal 
abscess  may  be  assumed  to  exist  when  the  symptoms  of  appendicitis  persist 
after  the  fifth  or  sixth  day,  or  when,  after  the  symptoms  have  subsided,  they 
reappear  a  day  or  two  later  (page  729). 

Abscess  of  the  liver  may  not  be  announced  by  symptoms  until  rupture. 
It  may  follow  dysentery,  may  be  a  result  of  the  lodgment  of  infected  clots 
from  the  hemorrhoidal  veins,  may  follow  upon  the  infective  phlebitis  of  appen- 
dicitis, may  result  from  septic  cholangitis  or  suppuration  of  a  hydatid  cyst. 
We  usuallv  find  fever  of  an  intermittent  type,  profuse  sweats,  pain  in  the  back, 
the  shoulder,  or  the  right  hypochondriac  region,  enlargement  of  the  area  of 
hver-dulness,  also  hepatic  tenderness,  and  finally  constitutional  symptoms 
of  the  existence  of  pus.  Sometimes  there  are  fluctuation  and  skin  edema 
over  the  liver,  and  the  general  cutaneous  surface  may  be  a  little  jaundiced. 
The  symptoms  vary  as  the  pus  invades  adjacent  organs.  When  there  are 
pain  on  respiration  and  evidences  of  diaphragmatic  pleuritis  the  pus  is  prob- 
ably breaking  into  the  pleural  sac.  There  may  or  may  not  be  leukocytosis 
(see  page  749). 

Acute  retropharyngeal  abscess  is  due  to  pyogenic  infection  of  the  retro- 
pharyngeal tissues.  The  abscess  usually  forms  upon  one  of  the  lateral  halves 
of  the  pharynx.  It  may  be  due  to  traumatism,  to  acute  infectious  diseases, 
to  infective  processes  of  the  mucous  membrane  of  the  mouth,  ear,  and  naso- 
pharynx, or  to  pyogenic  infection  of  a  tuberculous  abscess.  In  the  great  ma- 
jority of  cases  the  disease  is  due  to  suppuration  of  the  deep  cervical  glands. 
There  is  pain,  difficulty  in  swallowing,  dyspnea,  nasal  voice,  bulging  into  the 
pharnyx,  which  is  detected  by  inspection  and  palpation,  enlargement  of  the 
deep  cervical  glands,  fever,  sweats,  and  great  weakness.  Tuberculous  retro- 
pharyngeal abscess  is  considered  on  f)age  124. 

Subphrenic  abscess  is  apt  to  begin  beneath  the  diay:)hragm,  though  in  some 
few  instances  the  pus  forms  above  this  muscle,  and  subsequently  gains  access 
to  the  region  beneath.  Such  an  abscess  may  contain  not  only  pus,  but  gas, 
and  in  some  cases  also  fluid  from  the  stomach  or  intestine.  It  may  arise  after 
perforation  of  the  bowel  or  stomach,  or  it  may  result  from  Pott's  disease, 
perinephric  abscess,  traumatism,  abscess  of  liver,  kidney,  spleen,  or  pancreas, 
empyema  or  pneumonia  (Greig  Smith).     The. signs  are  pain,  fever,  sweats, 


Acute  Abscesses  in  Various  Regions  117 

dyspnea,  cough,  and  the  physical  signs  of  a  collection  of  fluid  beneath  the  dia- 
phragm and  of  gas  in  the  cavity  of  the  abscess.  As  in  any  other  abscess  there 
may  or  may  not  be  leukocytosis  (page  109). 

Abscess  of  the  lung  gives  the  physical  signs  of  a  cavity;  the  expectoration  is 
offensive  and  contains  fragments  of  lung-tissue.  An  abscess  may  occasionally 
be  located  by  the  use  of  the  .r-rays.  Pyemic  abscesses  may  exist  and  yet  escape 
discovery.     (See  under  Surgery  of  Respiratory  Organs.) 

Abscess  of  the  mediastinum,  causes  throbbing  retrosternal  pain,  chills,  fever, 
sweats,  and  often  dyspnea.  A  tumor  may  appear  which  pulsates  and  fluctu- 
ates, but  the  pulsation  is  not  expansile. 

Perinephric  abscess  usually  causes  tenderness  and  pain  in  the  lumbar 
region  or  about  the  hip-joint,  which  pain  runs  down  the  thigh  and  is  accom- 
panied by  retraction  of  the  testicle.  Induration,  fluctuation,  or  edema  of 
the  skin  may  be  observed  in  the  lumbar  region.  The  constitutional  symptoms 
of  suppuration  usually  exist  (page  115). 

Abscess  of  the  antrtim  of  Highmore  causes  pain,  edematous  swelling  of  the 
overlving  soft  parts,  and  crepitation  on  pressure  upon  the  superior  maxillary 
bone.  Pus  may  escape  from  the  nostril  of  the  diseased  side  when  the  head 
is  bent  in  the  direction  of  the  healthy  side.  A  rhinoscopic  examination  dis- 
closes the  fluid  passing  into  the  nares.  The  antrum  on  the  side  of  the  abscess 
cannot  be  transilluminated  by  an  electric  light  in  the  mouth  (Garel's  sign). 

Alveolar  abscess  is  suppurative  dental  periostitis  due  to  diseased  teeth. 
The  simplest  form  is  a  gum-boil,  a  collection  of  pus  between  the  gum  and  the 
bone  "external  to  the  root  of  the  tooth  which  is  the  seat  of  inflammation" 
("Dental  Surgery,"  by  Sewill).  In  more  severe  cases  the  cheek  is  involved 
and  the  abscess  breaks  into  the  mouth  or  through  the  cheek.  In  any  case 
suppuration  begins  in  the  socket  of  a  tooth.  In  mild  cases  the  pus  escapes 
around  the  neck  of  the  tooth,  a  distinct  and  local  abscess  may  be  situated  at 
the  end  of  the  root,  absorption  of  bone  having  occurred,  or  a  considerable 
cavity  may  form  in  the  bone,  the  external  maxillary  plate  being  perforated. 
Alveolar  abscess  causes  intense  pulsatile  pain,  marked  swelling  of  the  gum 
and  cheek,  and  sometimes  very  great  edematous  and  dusky  swelling  of  the 
face.     A  sinus  may  follow  it. 

Abscess  of  the  larynx  induces  violent  cough,  pain,  interference  with  the 
voice,  swallowing,  and  breathing,  and  can  be  seen  with  a  laryngoscope. 

An  ischiorectal  abscess  is  situated  in  the  areolar  tissue  of  the  ischiorectal 
fossa.  The  pyogenic  organisms  usually  gain  entrance  to  the  lymphatics  by 
way  of  an  abrasion,  fissure,  or  ulceration  of  the  rectum  or  anus.  A  perfora- 
tion made  by  a  foreign  body  may  inaugurate  the  condition.  In  rare  cases 
bacteria  reach  the  fossa  in  the  blood-stream.  The  pain  is  severe  and  throb- 
bing; there  are  great  tenderness,  redness  and  edema  of  skin,  induration,  and 
usually  the  constitutional  symptoms  of  pus-formation.  Fluctuation  is  a  very 
late  sign  because  of  the  density  of  the  fascia. 

Prostatic  abscess  is  manifested  by  chills,  fever,  sweats,  frequency  of  micturi- 
tion, tenderness  of  the  perineum  and  rectum,  and  agonizing  pain,  developing 
during  an  attack  of  acute  prostitis. 

Abscess  of  the  breast  can  arise  from  absorption  of  pyogenic  bacteria  from 
a  fissure  or  abrasion  of  the  nipple.  Some  surgeons  maintain  that  the  bacteria 
enter  along  the  milk-ducts,  while  others  assert  that  they  gain  entrance  by  the 


1 1 8  Suppuration  and  Abscess 

lymphatics.  It  is  most  common  in  nursing  women.  Its  symptoms  are 
pulsatile  pain,  dusky  discoloration,  skin  edema,  fluctuation,  and  usually  con- 
stitutional disorder.     (See  Mastitis.) 

Orbital  abscess  is  a  diffuse  suppuration  due  to  cellulitis  or  a  collection  of 
pus  due  to  caries  or  necrosis  of  the  orbital  wall.  In  severe  orbital  cellulitis 
the  movements  of  the  eye  are  limited,  the  lids  are  very  red  and  edematous, 
the  conjunctiva  is  red  and  swollen  (chemosis),  and,  if  the  case  is  not  promptly 
relieved,  optic  neuritis  may  arise  and  sloughing  of  the  cornea  occur. 

Sicppiirative  thecitis  or  felon  is  a  form  of  diffuse  suppuration.     (See  Felon.) 

Palmar  abscess  is  a  purulent  effusion  (page  559). 

Furuncle  and  carbuncle  are  discussed  on  pages  896  and  897. 

Empyema  is  a  purulent  effusion  into  the  pleural  sac  (page  662).  It  is 
technically  an  abscess  if  it  becomes  encapsuled. 

Diagnosis. — The  diagnosis  of  an  abscess  rests  upon — (i)  its  history;  (2) 
fluctuation;  (3)  pointing;  (4)  surface  edema;  (5)  the  use  of  the  tubular  ex- 
ploring needle;  and  (6)  leukocytosis. 

Fluctuation  is  the  sensation  imparted  to  a  finger  held  against  a  sac  con- 
taining fluid  when  a  wave  is  started  in  the  fluid  by  striking  the  mass  with  a 
finger  of  the  other  hand.  Fluctuation  cannot  be  obtained  if  the  amount  of 
fluid  is  small.  It  should  never  be  sought  for  across  a  limb,  but  rather  along 
it,  because  a  false  sense  of  fluctuation  can  always  be  obtained  across  the  mus- 
cles of  the  Hmb.     Pointing  and  surface  edema  have  been  discussed. 

A  suspected  abscess  in  a  part  containing  large  blood-vessels  under  no  cir- 
cumstance should  be  opened  by  a  bistoury  without  knowing  that  the  diagnosis 
is  certainly  correct.  This  knowledge  is  obtained  in  some  cases  by  inserting 
a  small  aspirating  needle  and  observing  the  nature  of  the  fluid  which  exudes. 
This  operation  must  be  performed  with  aseptic  care;  otherwise,  if  there  is  no 
abscess,  infection  may  be  inaugurated;  if  there  is  an  abscess,  mixed  infection 
may  occur.  The  older  operators  used  a  grooved  exploring  needle,  but  many 
able  surgeons  object  to  its  use  on  the  ground  that  when  plunged  into  an  in- 
fected area,  pus  bathes  the  track  of  penetration  and  may  cause  infection  of 
other  tissues  and  diffusion  of  the  pyogenic  process.  The  tubular  exploring 
needle  is  the  proper  instrument. 

An  abscess  which  moves  with  the  pulse  because  it  rests  upon  an  artery 
may  be  confounded  with  an  aneurysm.  The  pulse  movements  of  such  an 
abscess  are  in  one  direction  only;  the  abscess  is  Hfted  with  each  pulse-beat, 
but  does  not  enlarge,  and  if  a  finger  is  laid  upon  either  side  of  it  the  fingers 
will  be  lifted,  but  not  separated.  The  pulse  movements  of  an  aneurysm  are 
in  all  directions;  they  are  expansile,  the  tumor  grows  larger,  and  the  fingers 
win  not  only  be  lifted,  but  will  also  be  separated.  The  tubular  exploring 
needle  can  be  used  in  doubtful  cases;  if  aseptic,  it  will  do  no  harm  even  to  an 
aneurysm.  A  rapidly  growing,  small-cell  sarcoma  feels  not  unlike  an  abscess; 
but  the  exploring  needle  discovers  blood,  and  not  pus.  A  cystic  tumor  is 
separated  from  an  absce.ss  by  the  absence  of  inflammation,  or,  if  it  inflames, 
by  the  nature  of  the  contained  fluid.  Ordinary  caution  will  prevent  one  con- 
founding an  abscess  with  strangulated  hernia.  A  tuberculous  abscess  is  sepa- 
rated from  an  acute  abscess  by  the  absence  of  inflammatory  signs  in  the 
former.  The  contents  of  the  acute  abscess  differ  from  those  of  the  chronic 
abscess.     When  an  abscess  exists  in  an  important  region  (brain,  appendix, 


Treatment  of  Abscess 


119 


liver,  etc.),  cultures  of  the  pus  should  be  taken  after  incision.  Such  studies 
often  give  valuable  information  as  to  the  probable  course  of  the  condition, 
and  an  accumulation  of  many  accurate  observations  will  add  greatly  to 
scientific  information.  Fig.  47  shows  a  convenient  case  for  carrying  cul- 
ture-tubes. 

Prognosis. — The  prognosis  varies  according  to  the  number  of  abscesses, 
their  location  and  size,  the  strength  of  the  patient,  and  the  virulence  of  the 
causative  bacteria. 

Treatment. — In  the  treatment  of  an  abscess  there  is  one  absolute  rule 
which  knows  no  exception,  namely,  that  whenever  and  wherever  pus  is  found 
the  abscess  should  be  evacuated  at  once,  and,  after  evacuating  it,  thorough 
drainage  must  be  provided  for.  It  should  be  opened  early,  if  possible  even 
before  pointing  or  fluctuation,  to  prevent  tissue  destruction,  subfascial  bur- 
rowing, and  general  contamination.  Drainage  is  continued  until  the  discharge 
becomes  scanty,  thin,  and  seropurulent. 

Alveolar  abscess  requires  prompt  incision  through  the  gum,  extraction  of 
the  diseased  tooth  in  most  cases,  and  the  rinsing  of  the  mouth  at  frequent 


Fig.  47. — Vischer's  case  for  carrying  culture-tubes  for  inoculation. 


intervals  with  hot  fluid.  Heat  should  not  be  applied  externally,  as  it  would 
favor  external  rupture.  If  spontaneous  rupture  externally  is  inevitable,  then 
an  incision  must  be  made  at  the  point  where  the  abscess  is  nearest  the 
surface.     The  cut  will  leave  less  scar  than  will  spontaneous  evacuation. 

Abscess  of  the  liver  is  often  operated  upon  in  two  stages.  An  incision  is 
made  along  the  edge  of  the  ribs  down  to  the  liver,  which  organ  is  then  stitched 
to  the  edges  of  the  wound.  In  a  day  or  two  after  the  first  operation  the  two 
layers  of  peritoneum  are  firml}^  adherent  and  the  abscess  can  be  opened  with- 
out danger  of  the  passage  of  pus  into  the  peritoneal  cavity.  The  abscess, 
located  by  an  aspirating  needle,  is  opened  by  the  Paquelin  cautery,  is  washed 
out  with  salt  solution,  and  a  tube  is  inserted.  If  care  is  taken  the  operation 
can  be  safely  completed  at  once.  If  this  course  is  determined  on,  after  the 
liver  is  exposed  by  incision,  the  exposed  surface  of  the  organ  is  surrounded 
with  iodoform  gauze,  the  abscess  is  located  by  an  aspirating  needle,  is  opened 
by  the  cautery,  is  irrigated  and  drained  as  directed  above.     Some  physicians 


I20  Suppuration  and  Abscess 

trv  to  locate  an  abscess  by  plunging  an  aspirating  needle  into  the  liver  before 
making  an  incision.     This  procedure  is  uncertain  and  dangerous. 

Abscess  of  the  liver  is  occasionally  reached  by  resecting  a  rib,  opening  the 
pleural  sac,  and  incising  the  diaphragm  (transthoracic  hepatotomy). 

Abscess  of  the  mediastinum,  Hke  all  other  abscesses,  requires  incision  and 
drainage.  This  is  effected  by  cutting  between  the  rib  cartilages  or  by  trephin- 
ing the  sternum. 

In  abscess  oj  the  Jung  an  incision  is  made  and  the  pleura  is  exposed.  The 
incision  is  usually  through  an  intercostal  space;  but  if  the  spaces  are  narrow, 
it  will  be  necessary  to  resect  a  rib.  If  the  two  layers  of  pleura  are  found 
adherent,  the  operation  is  proceeded  with.  If  they  are  not  adherent,  they  are 
stitched  together  with  a  catgut  suture,  and  the  surgeon  waits  forty-eight  hours 
before  continuing.  The  operation  is  completed  by  locating  the  pus  by  means 
of  an  aspirating  needle,  evacuating  it  by  the  cautery  at  a  dull-red  heat,  and 
inserting  a  drainage-tube  into  the  abscess-cavity. 

In  abscess  of  the  antrum  oj  Highmore  bore  a  gimlet-hole  through  the  supe- 
rior maxillary  bone,  above  the  canine  tooth,  or  perforate  the  bone  by  means  of 
a  trocar.  Irrigate  daily  with  boiled  water  or  normal  salt  solution.  Keep 
the  opening  from  contracting  by  inserting  a  small  tent  of  iodoform  gauze.  In 
persistent  cases  it  may  be  necessary  to  draw  a  tooth,  break  through  the  socket 
of  the  first  or  second  bicuspid  into  the  antrum,  and  insert  a  silver  or  hard- 
rubber  tube.  In  very  persistent  cases  osteoplastic  resection  of  a  portion  of  the 
upper  jaw  will  be  demanded. 

In  appendicular  abscess  incise,  support  the  abscess-walls  with  gauze, 
remove  the  appendix  in  most  cases,  but  not  in  all,  and  insert  a  drainage-tube 
and  strands  of  gauze  (page  738). 

An  ischiorectal  abscess  must  be  opened  early.  The  surgeon  never  waits 
for  fluctuation.  Fluctuation  is  a  very  late  symptom.  To  wait  for  it  entails 
great  destruction  of  tissue  and  serves  no  useful  purpose.  Place  the  patient 
on  his  side,  with  the  legs  drawn  up.  Insert  a  finger  in  the  rectum,  Hft  the 
abscess  toward  the  surface,  and  incise  it  from  the  surface.  The  incision  runs 
from  the  anal  margin  like  a  spoke  from  the  hub  of  a  wheel.  Irrigate  with 
salt  solution,  inject  iodoform  emulsion,  insert  a  drainage-tube,  dress,  and  let 
the  patient  know  he  is  in  danger  of  developing  a  fistula. 

A  retropharyngeal  abscess  must  be  opened  early,  because  if  spontaneous 
evacuation  occurs  the  patient  may  be  suffocated.  Some  surgeons  open  it 
from  within  the  mouth,  but  this  exposes  the  patient  to  the  development  of 
septic  bronchopneumonia  and  gastro-intestinal  disorder.  It  is  better  to 
open  it  from  the  neck  by  Hilton's  method,  the  incision  being  carried  through 
the  .sternocleidomastoid  muscle  or  posterior  to  it.  Drainage  is  inserted  and 
the  abscess  treated  in  the  usual  way. 

In  abscess  of  the  breast  make  an  incision  radiating  from  the  nipple,  or,  what 
is  better,  incise  under  the  breast  by  means  of  a  cut  at  the  inferior  thoracic 
mammary  junction,  and  enter  the  abscess  from  beneath. 

In  abscess  oj  the  brain  the  skull  should  be  trephined,  the  membranes  incised, 
and  the  abscess  sought  for,  opened,  and  rlrained  (page  619). 

In  suppuration  within  the  orbit  due  to  cellulitis,  incise  from  the  conjunctiva 
and  drain.  In  suppuration  due  to  caries  or  necrosis  of  the  upper  orbital  wall 
make  a  transverse  incision  through  the  upper  lid,  reach  the  pus  by  Hilton's 
method  (page  121),  remove  carious  or  loose  necrotic  bone,  and  drain. 


Treatment  of  Abscess  1 21 

In  an  ordinary  superficial  abscess,  after  cleansing  the  parts,  make  the  skin 
tense,  locate  the  superficial  vessels  and  nerves,  and  plan  the  incision  to  avoid 
them.  Incise  with  a  sharp-pointed  curved  bistoury  at  the  most  dependent 
part  of  the  abscess  or  through  the  region  of  pointing.  If  the  abscess  is  upon 
the  face  or  neck,  make  the  incision  in  the  line  of  the  skin  creases  so  as  to  limit 
the  scar.  The  incision  must  not  be  made  suddenly  and  fiercely,  neither  should 
it  be  made  with  hesitation  and  uncertainty.  As  Bryant  says:  "It  should  be 
done,  as  ought  every  other  act  of  surgery,  with  confidence  and  decision,  bold- 
ness and  rapidity  of  action  being  governed  by  caution  and  made  sul_)servient 
to  safety"  (Bryant's  "  Practice  of  Surgery").  Permit  the  pus  to  run  out  spon- 
taneously; pressure,  as  a  rule,  is  undesirable  because  it  may  damage  the  ab- 
scess-wall and  cause  diffusion  of  the  infection.  If  tissue  shreds  block  the 
opening,  they  must  be  picked  out  with  forceps.  If  the  atmospheric  pressure 
will  not  cause  the  pus  to  flow  out,  make  light  pressure  with  warm,  moist, 
aseptic  gauze  pads.  After  the  pus  has  come  away  gently  wash  the  cavity 
with  normal  salt  solution  or  boiled  water,  and  drain  with  a  tube  for  two  or 
three  days,  when  the  discharge  becomes  serous.  It  is  not  desirable  to  overdis- 
tend  the  abscess-cavity  with  fluid,  because  the  hydrostatic  pressure  might  break 
down  the  wall  of  young  cells  and  infection  be  diffused.  Do  not  irrigate  with 
powerful  disinfectants.  They  cannot  be  used  strong  enough  to  really  disin- 
fect, but  may  easily  be  used  strong  enough  to  cause  necrosis  of  an  abscess- 
wall.  Peroxid  of  hydrogen  is  not  to  be  used  unless  the  incision  is  large,  be- 
cause the  gas  it  generates  may  tear  the  abscess-wall  and  dift'use  the  infection. 
If  an  abscess  contains  putrid  pus,  after  evacuation  irrigate  with  hot  salt  solu- 
tion or  pero.xid  of  hydrogen  and  inject  iodoform  emulsion.  Pursue  rigid 
antisepsis  in  dealing  with  purulent  areas.  It  is  true  we  already  have  infec- 
tion with  pyogenic  bacteria,  but  infection  can  also  take  place  with  organ- 
isms of  putrefaction,  causing  pus  to  become  putrid,  or  with  other  bacteria, 
for  instance  those  of  tetanus.  If  a  tube  is  not  used  and  the  cavity  is  packed 
with  iodoform  gauze,  remember  that  gauze  will  not  drain  pus  and  requires 
to  be  changed  once  a  day.  An  abscess  should  be  dressed  with  hot,  moist 
antiseptic  dressings  (antiseptic  fomentation)  and  the  part  must  be  put  at 
rest.  When  the  discharge  becomes  thin  and  scanty,  dry  aseptic  or  antiseptic 
dressings  are  used. 

In  a  deep  abscess  or  an  abscess  situated  near  important  vessels,  do  not 
boldly  plunge  in  a  knife.  Hilton  says  to  "plunge  in  a  knife  is  not  courageous, 
as  it  is  without  danger  to  the  surgeon,  but  may  be  fatal  to  the  patient."  Re- 
member also  that  a  large  amount  of  pus  displaces  normal  anatomical  relations. 
Hilton'' s  method  of  opening  a  deep  abscess  (as  in  the  axilla  or  neck)  is  to  cut 
to  the  deep  fascia,  nick  the  fascia  with  a  knife,  and  then  push  into  the  abscess 
a  grooved  director  until  pus  shows  in  the  groove;  along  the  groove  push  a  pair 
of  closed  dressing  forceps;  after  they  reach  the  depths  open  them  and  withdravv- 
them  while  open,  and  so  dilate  the  opening;  then  insert  a  tube  and  irrigate. 

Always  endeavor  to  open  an  abscess  at  its  most  dependent  part,  remem- 
bering that  the  situation  of  this  part  may  depend  upon  whether  the  patient 
is  erect  or  recumbent.  If  we  do  not  make  the  opening  at  the  lowest  point,  all 
the  pus  will  not  run  out  and  the  walls  will  not  completely  collapse.  A  deep 
abscess  must  be  drained  thoroughly  until  the  discharge  becomes  seropurulent. 
When  the  tube  is  removed  it  is  wise  to  insert  a  tent  of  iodoform  gauze  just 


122  Suppuration  and  Abscess 

through  the  outlet  of  the  abscess.  This  tent  prevents  the  skin  from  closing 
over  the  channel.  It  is  removed  and  a  new  one  inserted  every  day  until  it  is 
clear  that  there  is  no  longer  danger  of  fluid  becoming  blocked  and  retained. 
When  an  abscess  contains  diverticula  or  pouches  they  should  be  slit  up  or  a 
counter-opening  ought  to  be  made.  A  counter-opening  is  made  by  entering 
the  dressing  forceps  at  the  first  incision,  pushing  them  through  the  abscess  to 
the  point  where  we  wish  to  make  our  counter-opening,  opening  the  blades, 
and  cutting  between  them  from  without  inward.  The  blades  are  then  closed 
and  projected  through  the  incision;  they  are  opened  to  dilate  the  new  door, 
and  closed  again  upon  a  drainage-tube,  which  is  pulled  through  from  opening 
to  opening  as  the  instrument  is  withdrawn.  When  pus  burrows,  insert  a 
grooved  director  in  each  channel  and  sht  the  sinus  with  a  knife.  An  abscess 
mav  make  an  opening  through  dense  fascia,  the  opening  being  small  like  the 
neck  of  an  hour-glass  (shirt-stud  abscess).  Always  examine  to  see  if  such  a 
condition  exists,  and  if  it  is  found,  incise  the  fascia. 

In  a  deep  abscess  containing  putrid  pus,  frequent  irrigation  is  desirable. 
In  such  a  case  two  tubes  may  be  employed  (Fig.  48).  The  tubes  are  pre- 
vented from  slipping  in  by  the  use  of  a  safety-pin.     The  irrigating  fluid  is 

passed  into  the  cavity  (d)  through 
the  tube  b,  and  it  runs  out  through 
the  tube  c. 

Rest  is  of  the  first  importance  in 
the  healing  of  an  abscess,  and  we 
try  to  obtain  it  by  bandages,  sphnts, 
and  pressure,  which  will  immo- 
biUze   adjacent    muscles    and    ap- 

Fig.  4S.— Drainage-lubes  for  abscess  requiring  irri-       proximate       the        absceSS-walls.       If 

^^"°"'  an    abscess    is    slow    to   heal,    use 

as  a  daily  injection  a  solution  of  corrosive  sublimate  of  the  strength  of 
I  :  1000,  or  three  drops  of  nitric  acid  to  5J  of  water,  or  3  grains  of  zinc  sulphate 
to  5j  of  water,  or  a  5  per  cent,  solution  of  carbolic  acid,  or  a  2  per  cent,  aqueous 
solution  of  pyoktanin,  or  20  drops  of  tincture  of  iodin  to  o]  of  water,  or  a  very 
dilute  solution  of  bichlorid  of  palladium.  Peroxid  of  hydrogen  is  a  dangerous 
agent  to  inject  into  the  cavity  of  a  deep  abscess  of  the  neck,  as  the  hberated 
gas  may  not  escape  from  the  opening,  but  may  pass  widely  into  the  tissues  and 
cause  great  distention.  The  author  saw  a  child  who  narrowly  escaped  death 
after  such  an  injection.  In  this  patient  the  gas  passed  beneath  the  pharyngeal 
mucous  membrane  and  the  sweUing  almost  occluded  the  air-passages.  The 
constitutional  treatment  of  an  abscess  depends  upon  the  severity  of  the  morbid 
process  and  the  importance  of  the  structures  involved.  In  a  serious  case 
the  patient  should  be  put  to  bed,  opiates  should  be  given  with  a  free  hand,  the 
bowels  be  kept  active  by  calomel  and  salines,  skin  activity  be  maintained,  the 
taking  of  nutritious  food  insisted  on,  and  stimulants  liberally  employed. 

Purulent  Effusions. — (See  Suppurative  Thecitis,  Palmar  Abscess,  Sup- 
purative Synovitis,  Purulent  Peritonitis,  Empyema,  etc.) 

Tuberculous  abscess,  called  also  chronic,  cold,  scrofulous,  and  lymph- 
atic, is  an  area  of  disease  produced  by  the  action  of  the  bacilli  of  tubercle  and 
circumscribed  by  a  distinct  membrane.  Ashhurst  says  that  the  term  "  chronic  " 
is  a  bad  one.     "It  refers  etymologically  only  to  time.     A  phlegmonous  ab- 


Tuberculous  Abscess  123 

scess,  if  deeply  seated,  may  be  of  slower  development  than  a  chronic  or  cold 
abscess  which  is  superficial."  A  tuberculous  abscess  is  most  common  in  con- 
nection with  tuberculous  disease  of  the  lymphatic  glands,  bones,  joints,  and 
subcutaneous  connective  tissues,  but  it  can  arise  in  the  brain,  in  the  viscera — 
in  fact,  in  any  tissue  in  which  there  is  a  tuberculous  lesion.  Tuberculous 
abscesses  are  most  common  before  the  twentieth  year.  Such  an  abscess  may 
be  small  or  may  contain  quarts  of  curdy  pus.  The  contents  of  a  true  tuber- 
culous abscess  are  not  genuine  pus,  but  are  partly  tuberculous  material.  True 
liquefied  pus  is  present  only  when  there  is  mixed  infection.  The  bacilli  of 
tubercle  cause  chronic  inflammation.  The  cells  of  the  tissue,  especially  the 
fixed  cells,  proliferate,  and  new  tissue  is  produced  by  the  prohferation.  The 
new  mass  of  cells,  if  examined  by  the  microscope,  is  found  to  consist  of  num- 
bers of  those  cell-clusters  known  as  tubercles  (page  177).  Each  tubercle 
enlarges,  new  tubercles  form,  and  many  old  ones  fuse  together.  The  cells, 
however,  do  not  become  vascularized,  new  vessels  are  not  projected  from  adja- 
cent capillaries,  and  the  cell-proliferation,  which  in  an  ordinary  inflammation 
would  lead  to  the  formation  of  new  vessels  in  a  tuberculous  lesion,  eventuates 
in  the  formation  of  epithehoid  ceUs  (page  177).  The  tuberculous  nodule  is 
imperfectly  nourished,  and  the  nourishment  becomes  less  as  the  nodule  grows 
and  is  finally  greatly  diminished  or  cut  off  by  closure  of  adjacent  blood-vessels 
by  proliferating  endothelial  cells. 

The  toxins  acting  on  a  cellular  area  of  impaired  nutrition  produce  coagu- 
lation necrosis  and  coagulation  necrosis  is  followed  by  caseation  (page  177). 
Caseation  begins  in  many  foci  near  the  center  of  the  tuberculous  nodule  and 
many  caseated  foci  run  together.  In  a  caseated  area  the  bacilU  die  for  want 
of  food.  It  is  important  to  remember  that  a  tuberculous  lesion  may  spread  at 
the  periphery  while  it  caseates  at  the  center.  When  an  area  of  caseated 
tubercle  is  partly  hquefied,  caseous,  scrofulous,  or  curdy  pus  is  formed;  and 
the  lesion  is  designated  a  tuberculous  abscess.  A  true  cold  abscess,  as  before 
stated,  does  not  contain  genuine  pus,  but  Hquefied  caseated  tubercle,  masses 
of  coagulated  fibrin,  and  bits  of  necrotic  tissue.  The  wall  of  a  cold  abscess 
is  composed  of  a  membrane  lined  with  yellowish  tuberculous  granulations. 
The  layer  of  lining  granulations  is  called  Volkmann's  layer.  The  membrane 
is  due  to  compression  of  adjacent  cells  and  in  old  cases  is  dense  and  fibrous. 
It  was  formerly  the  custom  to  refer  to  it  as  the  pyogenic  membrane,  the  suppo- 
sition being  that  it  secreted  tuberculous  pus.  This  view  is  completely  aban- 
doned; the  membrane  does  not  secrete  the  material  contained  in  the  abscess, 
but  surrounds  that  material  and  prevents  its  diffusion.  Roswell  Park  tells 
us  it  is  a  "prophylactic  membrane.'"  A  tuberculous  abscess  may  enlarge 
greatly  and  finally  undergo  spontaneous  evacuation;  it  may  be  encapsuled 
by  fibrous  tissue  while  the  tuberculous  focus  shrinks  and  remains  caseous  or 
becomes  calcareous;  or  it  may  be  converted  into  a  fibrous  nodule. 

Symptoms. — The  term  cold  abscess  is  emplo\ed  for  a  tuberculous  abscess 
because  it  presents  no  inflammatory  signs.  There  is  no  local  heat;  no  dis- 
coloration unless  pointing  occurs;  the  parts  look  paler  than  natural;  pain  is 
absent  in  the  abscess,  though  it  may  exist  at  the  point  of  origin  of  the  fluid. 
The  tuberculous  material  often  wanders  from  its  point  of  origin  under  the  influ- 
ence of  gravity.  Fluctuation  is  usually  easily  obtained  because  of  the  absence 
of  surrounding  exudation.     Constitutional  symptoms  are  trivial  or  absent 


124  Suppuration  and  Abscess 

unless  secondary  infection  occurs.  The  swelling  may  suddenly  appear  in 
some  spot — the  groin,  for  instance.  \Mien  it  appears  suddenly  it  has  traveled 
from  a  distant  and  older  area  of  disease.  The  abscess  may  last  for  years 
without  producing  pain  or  annoyance.  The  introduction  of  an  aseptic  tubular 
exploring  needle  will  settle  the  diagnosis.  The  constitution  is  invariably 
below  normal  because  of  the  tuberculous  infection,  and  the  temperature  may 
be  a  little  above  normal.  A  cold  abscess  which  is  infected  with  putrefactive  or 
pyogenic  organisms  exhibits  great  inflammation,  and  sapremia  or  septicemia 
rapidly  develops.  In  a  pure  tuberculous  abscess  there  is  no  leukocytosis,  but 
it  de\"elops  when  there  is  mixed  infection  with  pyogenic  bacteria.  In  tuber- 
culous disease  of  the  \-ertebras  the  fluid  may  find  its  way  to  the  lumbar  region, 
to  the  ihac  region,  or  to  the  immediate  neighborhood  of  Poupart's  ligament, 
above  or  below  it.  When  an  area  of  tuberculous  disease  undergoes  mixed 
infection  and  prolonged  suppuration  occurs,  alhiiminoid  degeneration  occa- 
sionally arises.  If  this  form  of  degenerative  disease  begins,  the  patient  is 
found  to  be  weak,  thin,  and  anemic.  Occasionally  capillary  hemorrhage 
occurs  under  the  skin  or  mucous  membranes.  The  organ  or  part  affected 
(liver,  lymph-glands,  kidney,  or  spleen)  is  enlarged  and  smooth,  and  diarrhea 
exists.  In  albuminoid  disease  of  the  kidneys  there  is  albuminuria  and  the 
development  of  symptoms  resembling  those  of  Bright's  disease.  It  is  thought 
by  some  that  this  disease  arises  because  the  constant  flow  of  pus  drains  the 
potash  salts  from  the  blood. 

Tuberculous  Abscesses  in  Various  Regions. — Tuberculous  abscess 
of  the  head  of  a  bone  (Brodie's  abscess)  arises  in  the  cancellous  structure  of  a 
long  bone,  most  often  in  the  head  of  the  tibia.  Pain  is  continued  but  not 
usually  very  severe,  is  of  a  boring  character,  and  is  worse  when  the  patient 
is  in  bed.  Attacks  of  synovitis  arise  from  time  to  time  in  the  adjacent  joint. 
There  is  no  such  thing  as  an  acute  abscess  of  bone.  A  pyogenic  inflammation 
of  such  severity  that  it  would  cause  an  acute  abscess  in  soft  parts,  in  bone 
causes  acute  necrosis.  The  tuberculous  organisms  obtain  access  to  the  bone 
by  means  of  the  blood,  and  find  in  the  bone  a  point  of  least  resistance. 

Retropharyngeal  or  postpharyngeal  abscess  is  often  tuberculous.  Such 
an  abscess  is  usually  due  to  caries  of  the  cervical  vertebra;,  but  can  arise  in  the 
connective  tissue  of  the  parts  or  as  a  tuberculous  adenitis.  An  abrasion  of  the 
mucous  membrane  may  admit  the  bacilli  to  the  connective  tissue  or  the  glands. 
A  swelling  projects  from  the  posterior  pharyngeal  wall,  and  there  is  great  inter- 
ference with  respiration  and  deglutition.  Caseous  matter  from  caries  of  the 
cervical  vertebra;  may  reach  the  posterior  mediastinum  by  following  the  esoph- 
agus, or  may  appear  in  front  of  or  behind  the  sternomastoid  muscle  in  the 
heck  (Edmund  Owen).  A  tuberculous  abscess  in  this  region  is  apt  to  un- 
dergo pyogenic  infection,  in  which  case  the  patient  develops  fever,  sweats, 
pain,  and  prostration. 

Dorsal  Abscess. ^The  tuberculous  matter  in  dorsal  abscess  arises  from 
dorsal  caries,  flows  into  the  posterior  mediastinum,  and  reaches  the  surface 
by  pas.sing  between  the  transverse  processes.  The  tuberculous  matter  from 
dorsal  caries  may  run  forward  between  the  intercostal  muscles  or  between 
these  muscles  and  the  pleura,  pointing  in  an  intercostal  space  at  the  side  of  the 
sternum  or  by  the  rectus  muscle.  It  may  open  into  the  gullet,  windpipe, 
bronchus,  pleural  sac,  or  pericardium.     It  may  descend  to  the  diaphragm 


Tuberculous  Abscess 


125 


and  travel  under  the  inner  arcuate  ligament  to  form  a  psoas  abscess,  or  under 
the  outer  arcuate  ligament  to  form  a  lumbar  abscess.  A  psoas  abscess  points 
external  to  the  femoral  vessels,  a  characteristic  which  distinguishes  it  at  once 
from  a  femoral  hernia. 

Iliac  abscess  arises  from  lumbar  caries,  the  swelling  hing  in  the  iliac  fossa 
and  pointing  above  Poupart's  ligament. 

Psoas  abscess  is  usually  due  to  lumbar  caries,  but  may  arise  from  dorsal 
caries.  The  fluid  usually  points  in  Scarpa's 
triangle  external  to  the  femoral  vessels, 
but  may  descend  much  lower  (Fig.  49). 
A  psoas  or  iliac  abscess,  by  following  the 
lumbosacral  cord  and  great  sciatic  nerve, 
forms  a  gluteal  abscess.  These  abscesses 
may  open  into  the  bowel,  bladder,  ureter, 
or  peritoneal  cavity. 

Lumbar  Abscess. — In  a  lumbar  ab- 
scess the  fluid  produced  by  dorsal  caries 
descends  beneath  the  outer  arcuate  liga- 
ment, or  the  fluid  from  lumbar  caries 
which  collected  anterior  to  or  in  the 
quadratus  lumborum  muscle  passes  be- 
tween the  last  rib  and  iliac  crest  in  the 
triangle  of  Petit,  the  small  space  bounded 
by  the  crest  of  the  ihum,  the  posterior 
edge  of  the  external  oblique  muscle,  and 
the  anterior  edge  of  the  latissimus  dorsi 

1     .1,  Fig:,  jq. — Psoas  abscess  (  Albert). 

muscle. =^ 

Chronic  abscess  of  the  breast  is  a  caseated  area  of  tuberculosis  of  the 
breast.  A  lump  is  detected,  which  slowly  enlarges  and  finally  ruptures, 
sinuses  being  formed.  The  axillary  glands  are  apt  to  be  implicated.  The 
patient  belongs  to  a  tuberculous  stock,  as  a  rule  gives  a  history  of  previous 
tuberculous  troubles  of  various  sorts,  and  has  usually  borne  children.  Chronic 
abscess  of  the  breast  causes  little  or  no  pain. 

Treatment  of  Tubercitlous  Abscess. — If  a  small  cold  abscess  exists  in  a  super- 
ficial structure,  open  it  with  aseptic  care,  rub  its  walls  with  bits  of  gauze  to 
remove  tuberculous  masses,  irrigate  with  i  :  1000  mercurial  solution,  inject 
with  iodoform  emulsion,  pack  with  iodoform  gauze,  and  dress  antiseptically. 
When  the  discharge  becomes  thin  and  scanty  the  packing  can  be  dispensed, 
with.  If  it  be  slow  in  heahng,  inject  or  swab  out  with  a  stimulating  fluid  as 
in  acute  abscess,  or  inject  with  iodoform  emulsion. 

Chronic  Abscess  of  Bone. — Make  an  incision  to  bare  the  bone.  Open 
the  abscess  with  trephine,  the  gouge,  or  the  chisel;  curet  with  a  sharp  spoon 
and  gouge;  cut  away  the  edges  of  the  bone  with  rongeur  forceps;  irrigate  the 
cavity  with  hot  corrosive  sublimate  solution  (i  :  1000),  dry  its  walls  with 
gauze,  and  paint  the  cavity  with  pure  carbolic  acid:  pack  with  iodoform  gauze 
and  apply  antiseptic  dressings.  It  is  better  not  to  employ  an  Esmarch  appa- 
ratus.    Bleeding  will  not  be  severe,  and  when  no  apparatus  is  used  one  can  be 

*  For  a  lucid  description  of  these  abscesses  see  Owen's  ''Manual  of  Anatomy,"  from 
which  much  of  the  above  is  condensed. 


126  Suppuration  and  Abscess 

sure  that  all  the  diseased  bone  has  been  removed,  because  sound  bone  bleeds 
and  dead  bone  does  not. 

Cold  Abscess  of  Lymphatic  Glands. — In  non-exposed  portions  of  the 
body  the  capsule  of  the  gland  should  be  incised  and  dissected  or  scraped  away 
and  the  cavity  swabbed  out  with  pure  carbolic  acid  and  packed  with  iodoform 
gauze.  If  the  abscess  is  allowed  to  burst,  it  will  cause  an  ugly  scar;  therefore 
in  exposed  portions  of  the  body  an  effort  should  be  made  to  prevent  a  scar  by 
incising  earlv  before  the  skin  is  involved.  When  only  a  little  caseated  matter 
exists  and  the  skin  is  not  discolored,  prepare  the  parts  antiseptically,  incise, 
rub  the  interior  with  gauze,  inject  iodoform  emulsion,  use  a  small  drainage- 
tube,  and  suture  the  wound.  It  used  to  be  a  custom  in  such  cases  to  carry  a 
silk  thread  by  means  of  a  needle  through  the  skin,  through  the  gland,  and  out 
at  its  lowest  point,  the  part  being  then  dressed  with  gauze.  In  three  days 
the  thread  was  removed  and  a  firm  compress  was  apphed.  The  plan  is  not 
satisfactory  and  incision  is  to  be  preferred.  When  the  gland  is  almost  entirely 
broken  down  and  the  skin  above  it  is  purple  and  thin,  insert  a  hypodermic 
needle  through  sound  skin  into  the  abscess,  draw  off  the  fluid  tuberculous 
matter,  and  inject  iodoform  emulsion  (lo  per  cent,  of  iodoform,  90  per  cent, 
of  sterile  glycerin  or  olive  oil).  This  procedure  is  to  be  repeated  when  the 
fluid  again  accumulates.  By  this  means  we  can  sometimes  effect  a  cure  in 
a  week  or  so.  When  an  abscess  breaks  or  is  at  the  point  of  breaking,  cut 
awav  all  purple  skin,  curet  the  abscess-walls  (the  abscess  having  become  a 
tuberculous  ulcer),  remove  the  remains  of  gland  and  capsule,  swab  the  cavity 
with  pure  carbolic  acid,  and  dress  with  iodoform  and  antiseptic  gauze. 

Tuberculous  glands  ought  to  be  extirpated  before  they  caseate  and  form 
an  abscess. 

Cold  Abscess  of  Mammary  Gland. — Many  operators  simply  incise, 
curet,  pack  with  iodoform  gauze,  and  dress  antiseptically.  It  is  wiser  to 
remove  the  entire  gland,  and  to  clear  out  the  axilla,  as  in  an  operation  for 
cancer,  in  order  to  prevent  both  recurrence  and  dissemination. 

Large  Cold  Abscesses  (Psoas  Abscess). — In  view  of  the  facts  that  these 
absces.ses  may  cause  no  trouble  for  years  and  that  an  operation  may  be  fatal, 
some  eminent  surgeons  are  opposed  to  an  operation  unless  the  abscess  is 
moving  toward  inevitable  rupture  or  is  disturbing  the  functions  of  organs  by 
pressure.  Most  practitioners  believe,  however,  that  this  mass  of  tuberculous 
matter  is  a  source  of  danger  through  being  a  depot  of  infective  organisms 
which  may  overwhelm  the  system,  and  that  death  will  rarely  result  from 
an  operation  performed  by  one  who  employs  with  intelligence  strict  antisepsis. 
In  no  other  cases  is  attention  to  every  detail  more  important,  as  a  mixed  in- 
fection can  easily  take  place,  and  will  probably  mean  death. 

The  elder  Senn  treats  many  cold  abscesses  by  the  following  method: 
With  the  most  scrupulous  care,  aspirate  the  abscess  and  draw  off  the  fluid 
contents.  Run  a  hot  3  per  cent,  solution  of  boracic  acid  into  the  abscess- 
cavity  so  as  to  overdistend  it,  allow  it  to  flow  (jut,  and  repeat  this  process  until 
fibrinous  shreds  and  necrotic  particles  cease  to  appear.  An  emulsion  of 
iodoform  (lo  per  cent,  in  glycerin)  is  injected,  about  four  or  five  drams  of  the 
emulsion  being  used  in  an  adult  and  half  of  this  amount  in  a  child.  The 
abscess  is  rubbed  and  squeezed  in  order  to  bring  the  iodoform  in  contact  with 
every  portion  of  the  wall,  the  puncture  is  sealed  with  collodion,  and  pressure 
is  applied  tf)  ajjj^roximate  the  walls.     Secure  rest  by  placing  the  patient  in  bed 


Tuberculous   Abscess  •  127 

or  using  splints.  When  the  cavity  partly  refills,  subject  it  to  the  same  treat- 
ment. If  the  case  is  being  improved  the  fluid  is  found  to  be  thicker.  If  three 
or  four  tappings  do  not  cure,  the  plan  is  abandoned  ("  Principles  of  Surgery  "). 

A  large  abscess  with  uncoUapsible  walls  should  not  be  treated  by  this 
method.  It  is  dangerous  to  inject  large  amounts  of  iodoform,  as  poisoning 
may  be  produced  (page  27).  If  aspiration  and  injection  fail  or  were  not  used, 
incise  the  most  dependent  portion  of  the  abscess,  scrape  its  wall  with  bits  of 
gauze,  and  overdistend  with  a  i  :  1000  solution  of  warm  corrosive  sublimate. 
Let  the  mercurial  solution  run  out  and  then  irrigate  the  cavity  with  hot  normal 
salt  solution,  which  will  remove  the  remains  of  the  corrosive  fluid.  Inject 
emulsion  of  iodoform  and  sew  up  the  wound.  After  suturing,  apply  dressings, 
approximate  the  walls  of  the  abscess  by  pressure,  and  put  the  patient  to  bed. 
If  the  abscess  fills  again,  the  operation  can  be  repeated.  This  operation  often 
succeeds,  but  it  may  fail,  and  it  is  not  a  proper  procedure  if  the  abscess-walls 
are  rigid  and  non-collapsible.  It  is  the  method  of  choice  in  cases  unsuitable 
for  aspiration  and  injection,  because  drainage  in  these  cases  is  usually  pro- 
ductive sooner  or  later  of  pyogenic  infection.  In  large  abscesses  with  thick 
and  rigid  walls  an  attempt  may  be  made  to  remove  the  pyogenic  membrane. 
A  very  large  incision  exposes  the  cavity,  which  after  curetting  and  rubbing 
with  gauze  and  washing  is  packed  with  iodoform  gauze.  Barker's  spoon  is 
most  useful  to  scrape  the  walls.  It  is  an  irrigating  curet,  and  while  it  is 
being  used  a  stream  of  sterile  hot  water  or  salt  solution  flows  from  it.  An 
operation  occasionally  performed  for  psoas  abscess  consists  in  an  incision  in 
the  groin,  an  incision  in  the  back,  removal  of  carious  vertebrae,  thorough 
cleansing  of  the  abscess-wall  and  through-and-through  tubular  drainage.  It 
has  been  found,  however,  that  this  operation  is  uncertain  and  dangerous. 
It  is  not  advisable  to  remove  carious  vertebrae,  and  through-and-through 
tubular  drainage  is  rarely  used  unless  mixed  infection  already  exists.  When 
a  large  abscess  breaks  spontaneously,  it  should  be  widely  opened  at  once, 
scraped,  rubbed  with  gauze,  swabbed  with  pure  carbolic  acid,  washed  out 
with  alcohol,  and  packed  with  iodoform  gauze.  In  the  treatment  of  a  cold 
abscess  give  nutritious  food,  cod-liver  oil,  quinin,  iron,  and  the  mineral  acids. 
Removal  to  the  seaside  is  often  indicated,  and  mechanical  appliances  may  be 
needed  for  diseases  of  the  bones  and  joints.  If  secondary  pyogenic  infection 
of  a  large  tuberculous  abscess  does  occur,  the  patient  will  develop  septic 
fever  and  will  almost  certainly  die  ((/.  v.). 

Dorsal  abscess  and  lumbar  abscess  are  treated  after  the  same  plan  as 
psoas  abscess,  although  one  incision  only  is  usually  necessary  unless  the  fluid 
has  traveled  to  a  distant  point. 

A  postpharyngeal  abscess  must  not  be  opened  through  the  mouth.  To 
open  it  in  this  manner  puts  the  patient  in  danger  of  suffocation  by  fluid  running 
into  the  larynx  during  or  after  the  operation.  Further,  mixed  infection  of  the 
abscess-area  will  be  certain  to  ensue.  Septic  pneumonia  will  be  apt  to  arise 
from  inhaled  infected  particles,  and  profound  gastro-intestinal  disturbance 
will  be  liable  to  develop  because  of  the  inevitable  swallowing  of  purulent, 
putrid,  and  tuberculous  masses.  Incise  the  neck  and  open  into  the  abscess 
by  Hilton's  method,  going  through  the  sternocleidomastoid  muscle  or  behind 
it.  Rub  the  wall  of  the  abscess  with  bits  of  gauze,  remove  any  loose  bone, 
irrigate  with  hot  normal  salt  solution,  inject  iodoform  emulsion,  insert  a  tube 
or  pack  with  iodoform  gauze. 


128  Ulceration  and  Fistula 


VII.    ULCERATION    AND    FISTULA. 

An  ulcer  is  a  loss  of  substance  due  to  molecular  death  of  a  superficial 
structure.  The  molecular  death  is  brought  about  by  bacteria.  Ordinary 
ulcers  are  caused  by  pus  organisms.  The  action  of  the  pus  organisms  is  the 
same  as  in  an  abscess.  A  broken  abscess  becomes  an  ulcer,  and  an  ulcer  is 
in  .structure  a  half-section  of  an  abscess.  The  floor  of  an  ulcer  consists  of 
granulation  tissue  and  corresponds  with  the  abscess-wall.  An  abscess  arises 
from  molecular  death  within  the  tissues;  an  ulcer,  from  molecular  death  of 
a  free  surface.  An  ulcer  may  increase  in  size  by  molecular  death  of  adja- 
cent structures  or  by  sloughing,  that  is  to  say,  by  death  of  \-isible  masses  of 
tissue.  A  wound  healing  by  granulation  is  often  wrongly  called  an  ulcer. 
An  ulcer  must  not  be  confounded  with  an  excoriation.  In  an  ulcer  the  corium 
is  always,  and  the  subcutaneous  tissue  is  generally,  destroyed,  and  a  scar  is 
left  after  heahng.  In  an  excoriation  the  mucous  layer  of  epithelium  is  ex- 
posed, or  this  is  destroyed  and  the  corium  is  exposed.  In  an  excoriation  the 
corium  is  never  destroyed,  and  no  scar  remains  after  healing,  x^n  ulcer  heals 
bv  granulation  (page  95).  Embr3^onic  tissue  by  vascularization  becomes 
granulation  tissue,  granulation  tissue  is  converted  into  fibrous  tissue,  the  fibrous 
tissue  contracts,  and  by  pulling  the  edges  of  the  ulcer  toward  each  other  lessens 
the  size  of  the  cavity.  When  the  granulations  reach  the  level  of  the  skin  the 
epithelium  at  the  edges  of  the  ulcer  proliferates  and  the  sore  is  soon  covered 
over  with  new  epithelium. 

Necrosis  of  a  superficial  part  may  arise  from — (i)  Inflammation.  The 
pressure  of  the  exudate  can  cut  off  the  circulation,  or  bacteria  may  directly 
destrov  tissue.  Suppuration  occurs.  (2)  The  action  of  pus  bacteria,  causing 
primary  cell-necrosis.  (3)  Bacteria  of  putrefaction  and  organisms  of  suppura- 
tion acting  upon  a  wound.  (4)  Traumatism  or  irritants,  producing  at  once 
stasis,  which  is  added  to  by  secondary  inflammation,  the  exudate  undergoing 
purulent  liquefaction.  (5)  Prolonged  pressure.  (6)  Deficient  blood-supply. 
(7)  Faulty  venous  return.  (8)  Degeneration  of  a  neoplastic  infiltration 
(gummatous,  mahgnant,  or  tuberculous).  (9)  Trophic  disturbance.  (10) 
Nutritional  disturbances  (as  scurvy).  Most  ulcers  are  due  to  pus  organisms, 
and  even  areas  of  necrosis  that  arise  from  something  else  (as  gummatous 
degeneration)  are  likely  to  suppurate. 

Classification. — Ulcers  are  classified  into  groui^s  according  to  the  con- 
dition of  the  ulcer  and  the  associated  constitutional  state.  In  the  first  group 
we  find  the  varicose,  hemorrhagic,  acute,  chronic,  irritable,  neuralgic,  etc. 
In  the  second  group  are  placed  the  tuberculous,  syphilitic,  senile,  scorbutic, 
etc.  All  ulcers,  whatever  their  origin,  are  either  acute  or  chronic,  and  such 
conditions  as  great  pain,  hemorrhage,  edema,  exuberant  granulations,,  phage- 
dena, sloughing,  eczema,  gout,  syphilis,  scurvy,  etc.,  are  to  be  looked  upon 
as  complications.  The  leg  is  so  common  a  site  of  ulcers  as  to  warrant  a  special 
description  of  ulcers  of  this  part.  In  describing  an  ulcer  state  the  patient's 
previous  history;  the  supposed  cause;  the  situation;  the  outline;  the  dura- 
tif)n;  and  the  mode  of  onset  of  the  ulcer.  State  if  the  ulcer  is  single  or  if 
multifjle  sores  exist,  and  if  there  is  or  is  not  pain.  Whether  or  not  any  healing 
has  ever  occurred,  and  the  patient's  constitutional  condition.     Set  forth  the 


Acute  or  Inflamed  Ulcer  of  the  Leg  129 

complications;  the  state  of  anatomically  related  glands;  the  condition  of  the 
edge,  the  floor,  and  the  parts  about  the  ulcer,  and  the  nature  and  quantity  of 
the  discharge. 

Acute  or  inflamed  ulcer  of  the  leg  may  follow  an  acute  inflammation 
and  may  be  acute  from  the  start,  or  may  be  first  chronic  and  then  become  acute. 
It  is  especially  common  in  drunkards,  and  among  those  of  dilapidated  con- 
stitutions. It  is  characterized  by  rapid  progress  and  intense  inflammation. 
There  is  rarely  more  than  one  ulcer.  In  outline  these  ulcers  are  usually  oval, 
but  may  be  irregular.  The  floor  of  an  acute  ulcer  contains  no  granulations, 
but  is  composed  of  the  raw  and  inflamed  tissues,  or  is  covered  with  a  mass  of 
gray  aplastic  lymph,  or  it  may  have  upon  it  large  greenish  sloughs.  The 
edges  are  thin  and  undermined.  The  discharge  is  very  profuse  and  ichorous, 
excoriating  the  surrounding  parts.  The  adjacent  cutaneous  surface  is  in- 
flamed and  edematous,  and  there  is  much  burning  pain.  In  some  cases  the 
glands  in  the  groin  enlarge.  Constitutionally,  there  is  gastro-intestinal  de- 
rangement, but  rarely  fever.  When  the  ulcer  spreads  with  great  rapidity 
and  becomes  deeper  as  well  as  larger  in  surface  area,  it  is  called  "  phagedenic." 
The  formation  of  sloughs  indicates  that  tissue  death  is  going  on  so  rapidly 
that  the  dead  portions  have  not  time  to  break  down  and  be  cast  off.  Limited 
stasis  produces  molecular  death;  more  extensive  stasis,  a  slough.  If  a  chronic 
ulcer  becomes  acute,  the  granulations  are  destroved. 

Treatment. — In  treating  an  acute  ulcer  of  the  leg,  give  a  dose  of  blue 
mass  or  calomel,  followed  in  eight  or  ten  hours  by  a  saline  (3ij  each  of  Rochelle 
and  Epsom  salts),  and  order  light  diet.  Deny  stimulants  except  in  a  case  of 
diphtheritic  ulcer.  Administer  opium  if  pain  is  severe.  Spray  the  ulcer 
with  hydrogen  peroxid,  use  the  scissors  and  forceps  to  get  rid  of  sloughs,  and 
after  sloughs  are  removed  wash  the  ulcer  with  corrosive  sublimate  solution 
(i  :  1000),  or  paint  it  with  pure  carbohc  acid.  Paint  the  skin  adjacent  to  the 
ulcer  with  equal  parts  of  tincture  of  iodin  and  alcohol.  Dress  with  hot  anti- 
septic fomentations.  Apply  a  bandage  from  the  toes  to  well  above  the  ulcer. 
Insist  on  the  patient  remaining  in  bed  with  the  leg  slightly  elevated.  Change 
the  dressings  before  they  become  cool  and  always  as  soon  as  they  are  satu- 
rated with  discharge.  Every  day  paint  the  parts  about  the  ulcer  with  equal 
parts  of  iodin  and  alcohol. 

Many  cases  do  very  well  after  antiseptization,  and  dusting  the  ulcer  with 
iodoform,  lead-water  and  laudanum  being  applied  to  the  inflamed  parts  around 
the  ulcer;  but  in  a  bad  case  hot  antiseptic  fomentations,  compression,  and 
elevation  are  more  useful  until  sloughs  separate.  If  the  discharge  is  offen- 
sive, apply  acetanilid,  aristol,  or  iodoform,  or  use  gr.  iij  of  chloral  to  5j  of 
water,  before  applying  hot  fomentations  or  ordinary  antiseptic  dressings.  A 
25  per  cent,  ointment  of  ichthyol  is  very  useful  when  applied  to  parts  around 
the  ulcer.  If  sloughs  continue  to  form,  touch  the  sloughing  area  with  a  i  :  8 
solution  of  acid  nitrate  of  mercury  or  with  a  solution  of  pure  carbolic  acid, 
and  reapply  antiseptic  fomentations.  If  an  ulcer  continues  to  spread,  clean 
with  peroxid  of  hydrogen,  dry  with  absorbent  cotton,  touch  with  nitrate  of 
mercury  solution  (i:  8),  and  apply  an  antiseptic  fomentation.  Repeat  appli- 
cation of  nitrate  of  mercury  every  day  until  the  ulcer  ceases  to  extend  and  granu- 
lations begin  to  form.  When  granulations  begin  to  form  moist  hot  dressings 
are  no  longer  necessary,  and  dry  aseptic  or  antiseptic  dressings  can  be  used. 
9 


130  Ulceration  and  Fistula 

If  an  ulcer  is  covered  with  a  great  mass  of  aplastic  lymph,  touch  daily  with  a 
solution  of  silver  nitrate  (gr.  xl  to  oj)  or  with  acid  nitrate  of  mercury  (i  :  15), 
and  dress  with  iodoform  and  antiseptic  fomentations.  Give  internally  tonics, 
stimulants,  and  nutritious  liquid  food.  In  any  case,  when  granulations  form, 
dress  antiseptically  with  dry  dressings,  or  employ  a  non-irritant  ointment,  such 
as  cosmolin.  If  granulations  form  slowly,  touch  them  every  day  with  a  solution 
of  silver  nitrate  (gr.  x  to  3j)  and  dress  antiseptically,  or  apply  a  stimulating 
ointment  (resin  cerate  or  3j  of  ung.  hydrarg.  nitratis  to  3vij  of  ung.  petrohi, 
or  an  ointment  of  copper  sulphate,  gr.  iij  to  3j),  or  dress  with  gauze  soaked 
in  a  solution  of  3  drops  of  nitric  acid  to  3J  of  gum  Arabic. 

Chronic  ulcer  of  the  leg  is  characterized  by  low  action  and  slow 
progress.  It  may  be  chronic  from  the  start,  or  it  may  result  from  acute  ulcer. 
Usually  it  is  found  as  a  solitary  ulcer  two  inches  above  the  internal  mal- 
leolus. Syphilitic  ulcers  often  occur  in  a  group,  are  usually  crescentic,  and 
are  frequent  upon  the  front  of  knee.  A  tuberculous  ulcer  may  have  no  granu- 
lations, but  is  usually  covered  with  pale  edematous  granulations,  which  signify 
the  existence  of  a  tendency  to  venous  stasis.  The  edges  of  the  tuberculous 
ulcer  are  undermined  and  irregular,  the  parts  about  it  are  livid  and  tender, 
and  the  discharge  is  thin  and  scanty  (page  181).  An  ordinary  chronic  ulcer 
is  circular  or  oval,  and  is  surrounded  by  congested,  discolored,  and  indurated 
skin,  this  induration  being  due  to  fibrous  tissue,  and  there  is  often  eczema  or  a 
brown  pigmentation  of  the  neighboring  skin.  The  floor  of  the  ulcer  is  uneven, 
and  usually  is  covered  with  granulations,  each  of  which  is  red  and  the  size  of 
a  pin-point,  but  which  may  be  exuberant  or  edematous.  If  granulations  are 
absent,  the  ulcer  has  the  appearance  of  a  piece  of  liver,  or  is  smooth  and 
glazed.  The  edges  are  thick,  turned  out,  and  not  sensitive  to  the  touch. 
Occasionally,  but  rarely,  they  are  thin  and  undermined.  Some  ulcers  are 
indurated  and  adherent;  this  adhesion  to  the  deeper  structures  prevents 
healing  by  antagonizing  contraction.  An  ulcer  may  fail  to  heal  because  of 
severe  infection;  because  of  want  of  rest;  because  of  absence  of  granulations 
resulting  from  deficient  blood-supply;  because  of  edematous  granulations;  be- 
cause of  exuberant  granulations;  because  of  adhesion  to  deep  structures,  and 
because  of  some  constitutional  disease. 

Treatment. — In  treating  a  chronic  ulcer,  give  a  saline  cathartic  every 
day  or  so.  Treat  any  existing  diathesis.  Insist  on  rest  and,  if  possible, 
elevation.     Asepticize  the  ulcer.     Draw  blood  by  shallow  scarifications  of  the 

bottom  and  edges  of  the  ulcer  and  the  skin 
about  it.  If  the  ulcer  is  adherent  to  deeper 
structures,  make  incisions  like  those  shown 
in  Fig.  50,  each  cut  going  through  the 
deep  fascia.  These  incisions,  besides  per- 
mitting contraction,  allow  granulations  to 
sprout  in  the  cuts  and  absorb  exudate. 
FiK.  so.— Incisions  for  adherent  ulcer.         After  incisiou  keep  the  part  elevated  and 

dressed  antiseptically  for  two  days.  In  two 
days  after  scarification  or  incision  scrape  the  ulcer  with  a  curet  until  sound 
tissue  is  reached.  Use  hot  antiseptic  fomentations  for  two  days  more,  then 
paint  the  parts  adjacent  to  the  ulcer  with  tincture  of  iodin  and  alcohol  (i  :  3), 
dress  the  parts  about  the  ulcer  with  ichthyol  ointment,  and  dress  the  ulcer 


Chronic  Ulcer  of  the  Leg  13 1 

antiseptically  or  with  sterile  gauze.  In  a  day  or  so  the  use  of  ichthyol  can  be 
discontinued  and  the  ulcer  can  be  dressed  antiseptically  with  sterile  gauze, 
normal  salt  solution,  boric  acid,  bichlorid  of  palladium,  chlorin-water,  a  solu- 
tion of  permanganate  of  potassium,  sulphur,  glutol,  protonuclein,  or  bovinin. 
Glutol  (formalin-gelatin)  is  very  useful  in  some  cases  and  so  is  protonuclein. 
When  healing  begins,  treat  as  outlined  for  healing  acute  ulcer  (page  129). 

Unna's  dressing  is  satisfactory  in  many  cases.  It  is  applied  as  a  fluid, 
painted  on  when  hot.  It  solidifies  on  cooling  and  resembles  rubber.  The  paint 
is  made  as  follows:  Dissolve  4  parts  of  the  best  gelatin  in  10  parts  of  water 
by  means  of  a  hot-water  bath.  While  the  fluid  is  hot  add  10  parts  of  glycerin, 
and  then  4  parts  of  powdered  white  oxid  of  zinc  and  stir  energetically  until  the 
mixture  is  cold.  Melt  the  paint  by  setting  the  receptacle  in  a  hot-water  bath. 
The  extremity  must  be  clean  and  thoroughly  dry.  Apply  the  paint  from  just 
above  the  roots  of  the  toes  to  just  below  the  knee.  Cover  the  layer  of  paint 
with  a  gauze  bandage;  put  over  this  another  layer  of  paint,  then  another 
bandage,  and  so  on  until  three,  four,  or  five  bandages  have  been  applied. 
To  prevent  wrinkling,  put  the  bandages  on  in  pieces.  The  outer  layer  of  the 
dressing  is  a  coat  of  the  paint.  This  dressing  is  worn  from  four  to  eight  weeks 
unless  it  loosens  sooner.  When  it  loosens,  it  is  changed.  If  the  ulcer  dis- 
charges freely  and  stains  the  dressing,  cut  a  trap-door  in  the  dressing  and 
through  this  cleanse  the  ulcer  and  apply  dressings  and  a  bandage  as  often  as 
necessary  (Michel,  in  "Chicago  Chnic,"  No.  8,  1900). 

An  excellent  treatment  if  the  patient  must  walk  about  is  camphor,  first 
recommended  by  Schulze  ("Miinchener  medicinische  Wochenschrift,"  March 
19,  1901).  It  is  most  conveniently  used,  as  Walbaum  shows,  as  spirits  of 
camphor  ("Miinchener  medicinische  Wochenschrift,"  June  25,  1901).  He 
applies  the  dressing  in  the  following  manner:  Clean  the  ulcer  with  green  soap, 
and  dress  it  daily  with  dressings  wet  with  acetate  of  aluminium.  In  about  three 
days  the  discharge  will  become  scanty  and  free  from  odor.  It  is  at  this  period 
that  camphor  should  be  used.  A  small  piece  of  gauze  wet  with  spirits  of 
camphor  is  applied  directly  and  only  to  the  ulcer.  Over  this  is  applied  a 
large  piece  of  dry  sterile  gauze,  a  rubber  dam,  a  large  piece  of  absorbent  cotton, 
and  a  bandage  from  the  toes  up.  Every  other  day  the  dressings  are  removed, 
the  ulcer  is  washed  with  a  2  per  cent,  solution  of  carbolic  acid,  and  the  dress- 
ings are  reapplied.     Usually  the  ulcer  is  healed  in  three  weeks. 

Complications. — Remove  by  scissors  and  forceps  any  badly  damaged 
tissue.  Take  out  dead  bone;  sHt  sinuses;  trim  overhanging  edges.  Treat 
eczema  locally  by  washing  with  ethereal  soap  and  applying  powdered  oxid 
of  zinc  or  borated  talcum,  the  leg  then  being  wrapped  in  cotton.  Unna's 
paint  is  very  useful  in  chronic  eczema.  If  the  part  is  crusted,  the  crusts 
should  be  removed  by  applying  some  oily  materials  and  washing  with  ethereal 
soap  and  water.  Ordinary  soap  should  not  be  used.  In  an  acute  case  soap 
and  water  always  do  harm  and  the  part  is  to  be  cleaned  by  "gently  wiping 
with  cold  cream  or  petrolatum"  (Stelwagon,  on  "Diseases  of  the  Skin").  If 
crusting  is  very  marked  it  may  be  necessary  to  remove  it  by  means  of  an  ordi- 
nary poultice,  or,  better,  a  starch  poultice  made  with  a  2  per  cent,  solution  of 
boracic  acid.  When  scales  or  crusts  are  slight  or  absent  or  when  they  have 
been  removed,  the  remedial  agent  should  be  applied.  The  remedies  for 
eczema  are  legion.     Among  them  are  a  solution  of  lead  acetate;  lead-water 


132 


Ulceration  and  Fistula 


and  laudanum;  a  powder  composed  of  30  grains  of  powdered  boracic  acid 
and  h  ounce  each  of  talc  and  zinc  oxid;  ung.  picis  liquidte,  5j,with  sufficient 
ung.  zinci  oxidi  to  make  5j;  i  ounce  of  liquor  carbonis  detergens  to  i  pint 
of  water.  In  every  case  of  eczema  place  the  patient  upon  a  plain  and  nutri- 
tious diet;  order  him  to  avoid  wines  and  liquors;  give  an  occasional  saline 
laxative;  keep  the  skin  and  kidneys  active,  and  if  the  patient  is  gouty  or  rheu- 
matic, give  appropriate  remedies.  The  value  of  arsenic  in  eczema  has  been 
much  overrated. 

Varicose  veins  demand  either  ligation  at  several  points,  excision,  cir- 
cumcision by  Schede's  method  (page  329),  or  the  continued  use  of  a  flannel 
roller  or  a  Martin  rubber  bandage.  Never  operate  on  varicose  veins  if 
phlebitis  exists,  unless  a  clot  has  formed,  in  which  case  apply  a  ligature  above 
the  clot.  Inflammation  is  met  by  rest,  elevation,  painting  the  neighboring 
parts  with  dilute  tincture  of  iodin,  and  applying  about  the  ulcer  ichthyol 
ointment.  For  calloused  edges,  blister,  employ  radiating  incisions,  or  cut  the 
edges  awav.  Ordinarv  thick  edges  should  be  strapped.  In  strapping  use 
adhesive  plaster  and  do  not  completely  encircle  the  limb  (Fig.  51).     When 

the  parts  are  adherent  the  ulcer 
is  immovable,  being  firmly  an- 
chored to  structures  beneath  it. 
In  such  a  condition  completely 
or  partly  surround  the  sore  with 
a  cut  through  the  deep  fascia 
(Fig.  50).  This  cut  sets  the 
ulcer  free  from  its  anchorage 
and  permits  it  to  contract. 
Edematous  granulations  require 
dry  dressings  and  pressure  by  a 
flannel  bandage,  a  rubber  ban- 
dage, or  adhesive  plaster.  If  the 
bottom  of  the  ulcer  is  jotil,  dry 
it  and  touch  with  a  solution  of 
acid  nitrate  of  mercury  (1:8)  or 
with  crystals  of  pure  carbolic 
acid.  Repeat  this  every  third  day  and  dress  with  hot  antiseptic  fomentations 
until  granulations  appear.  Superfluous  granulations  (proud  flesh)  should  be 
cut  away  with  scissors,  scraped  away,  or  burned  down  with  a  strong  solution  of 
silver  nitrate  or  with  the  solid  stick  of  lunar  caustic.  Absence  of  granulations 
or  scantiness  of  granulations  means  deficiency  of  blood-supply.  The  surgeon 
endeavors  to  bring  more  blood  to  the  part,  and  to  do  this  induces  inflamma- 
tion. The  usual  method  of  y^rocedure  is  to  apply  daily  to  the  sore  a  solution 
of  nitrate  of  silver  (ro  to  15  grains  to  the  ounce).  Argyrol  of  a  strength  of  25 
per  cent,  is  not  painful  and  is  as  efficient.  In  obstinate  cases  blister  the  ulcer 
or  scrape  it,  or  paint  it  with  tincture  of  iodin,  or  a{)])ly  pure  carbolic  acid,  or 
touch  it  with  the  actual  cautery. 

Irritable  ulcer  is  due  to  exposure  of  a  nerve  and  destruction  of  its  sheath 
(page  133).     Find  with  a  ])robe  the  painful  granulation  and  divide  it  with  a 
tenotome,  or  curct  <he  ulcer  or  burn  it  with  the  solid  stick  of  silver  nitrate. 
If  healing  entirely  fails,  skin-grajt.     Among  the  methods  of  skin-graft- 


Fig.  51.— Strapping  of  ulcer  of  leg  (after  Liston). 


Various  Ulcers  133 

ing  are — (i)  Reverdin's,  (2)  Thiersch's,  and  (3)  Wolfe's.  (See  Plastic 
Surgery.) 

When  a  man  having  an  ulcer  must  go.  out  and  about,  the  camphor  treatment 
can  be  employed  (page  131),  Unna's  dressing  may  be  applied  (page  131),  or 
the  patient  can  use  a  firmly  applied  roller,  or,  better  still,  a  Martin  bandage. 
Martin's  bandage,  which  is  made  of  red  rubber,  limits  the  amount  of  arterial 
blood  going  to  the  ulcer  and  favors  venous  flow  from  the  sore  and  its  neigh- 
borhood. The  bandage  should  be  used  as  follows:  Before  getting  out  of  bed 
spray  the  sore  with  hydrogen  peroxid  by  means  of  an  atomizer,  remove  the 
froth  with  absorbent  cotton,  wash  the  leg  with  soap  and  water,  dry  it  with  a 
towel,  dust  the  skin  with  borated  talcum  powder,  and  apply  the  bandage. 
All  of  these  things  should  be  done  before  putting  the  foot  to  the  floor.  At 
night,  after  getting  on  the  bed,  remove  the  bandage,  wash  it  with  soap  and 
water,  dry  it  with  a  towel,  hang  it  unrolled  over  the  back  of  a  chair  to  air,  and 
again  cleanse  the  leg  and  ulcer.  If  these  rules  are  not  strictly  observed,  the 
Martin  bandage  will  produce  pain,  suppuration,  and  eczema  of  the  leg. 

Tuberculous  Ulcers  (seepages  180,  181). 

Syphilitic  Ulcers  (see  page  233). 

A  healthy  ulcer  is  covered  with  small,  bright-red  granulations  which  do 
not  bleed  on  touching,  are  painless,  and  grow  rapidly.  The  edges  are  soft 
and  show  the  opalescent  blue  line  of  proliferating  epithelium.  The  sore  is 
movable,  the  discharge  is  purulent  and  yellow,  and  the  parts  about  are  not 
inflamed. 

Various  Ulcers. — The  fungous  or  exuberant  ulcer  is  produced  by 
interference  with  the  return  of  venous  blood  from  the  part,  and  it  is  specially 
common  after  burns  and  other  injuries  when  cicatricial  contraction  causes 
venous  obstruction.  The  granulations  are  large,  deep  red  in  color,  bleed 
when  touched,  form  rapidly,  and  mount  above  the  level  of  the  skin.  The 
discharge  from  a  fungous  ulcer  is  profuse,  thin,  and  bloody.  In  the  treatment 
of  such  an  ulcer  venous  return  must  be  favored  by  bandaging  and  by  elevation 
of  the  part.  If  the  edges  are  very  thick,  divide  them  in  a  number  of  places. 
The  superfluous  granulations  should  be  burnt  down  with  lunar  caustic  or 
should  be  cut  off.  Strapping  with  adhesive  plaster  or  the  use  of  a  rubber 
bandage  does  good.  The  sore  can  be  dressed  with  europhen,  aristol,  or  dry 
aseptic  gauze. 

A  varicose  ulcer  is  an  ulcer  complicated  by  varicose  veins.  It  is  usually 
single,  is  o\al,  round,  or  irregular  in  outline,  and  is  most  often  seen  above  the 
inner  malleolus.  Its  edges  are  thick,  everted,  and  swollen.  The  swelling  is 
largely  due  to  edema,  and  is  found  to  pit  on  pressure.  The  edges  are  not 
undermined,  but  slope  gently  to  the  floor  of  the  ulcer.  The  floor  is  usually 
covered  with  rather  large  granulations  which  bleed  freely  on  touching.  In  a 
varicose  ulcer  the  destruction  of  tissue  often  begins  at  the  margin  of  a  con- 
gested area  and  advances  toward  the  center.  Such  an  ulcer  is  usuall\-  sur- 
rounded by  eczema.  To  aid  the  healing  of  a  varicose  ulcer  it  is  first  of  all 
necessary  to  favor  the  return  of  venous  blood  from  the  part  by  position  and 
bandaging.  Martin's  bandage  is  very  useful.  It  may  be  necessary  to  operate 
on  the  veins. 

Erethistic,  irritable,  or  painful  ulcers  are  very  sensitive,  a  condition 
due   to   the   exposure   of   nerve-filaments   and   destruction    of   nerve-sheaths. 


134  Ulceration  and  Fistula 

Irritable  ulcers  are  especially  found  near  the  ankle,  over  the  tibia,  in  the  anus 
(fissure),  or  in  the  matrix  of  the  nail  (ingrowing  nail).  Curet  an  erethistic 
ulcer,  and  touch  with  pure  carbolic  acid  or  with  the  solid  stick  of  silver  nitrate. 
Chloral,  gr.  xx  to  the  ounce,  allays  the  pain;  so  do  cocain  and  eucain  for  a 
time.  In  some  cases  the  painful  granulation  can  be  located  with  a  probe  and 
the  nerve-filament  divided  with  a  tenotome. 

The  indolent  ulcer  shows- no  tendency  to  heal.  In  such  an  ulcer  there 
is  usually  venous  congestion  from  varicose  veins  or  from  cardiac  weakness. 
A  great  mass  of  scar-tissue  forms  at  the  base  and  edges,  which  fastens  the 
ulcer  to  bone  or  fascia,  so  that  the  edges  cannot  contract.  Healthy  granula- 
tions cease  to  form.  The  edges  of  such  an  ulcer  are  thick,  smooth,  immovable, 
and  free  from  tenderness.  Granulations  are  entirely  absent  or  there  are  seen 
here  and  there  a  few  unhealthy  granulations.  The  discharge  is  thin,  sero- 
purulent,  and  offensive.  The  parts  about  the  ulcer  are  congested  and  pig- 
mented. The  pigmentation  is  due  to  the  fact  that  in  an  area  of  chronic 
congestion  numbers  of  red  blood-cells  have  been  disintegrated.  Such  an 
ulcer  is  treated  by  making  incisions  to  loosen  the  base  and  edges,  so  that  con- 
traction can  take  place,  correcting  the  venous  congestion  by  means  of  posi- 
tion, the  use  of  compression,  in  some  cases  the  administration  of  cardiac 
stimulants,  and  in  all  cases  the  employment  of  stimulating  applications  to  the 
ulcer  in  order  to  increase  the  supply  of  arterial  blood. 

The  callous  ulcer  is  the  most  chronic  form  of  indolent  ulcer  and  is  sunken 
deeply  below  the  level  of  the  skin.  Its  border  is  hard  and  knobby.  Its  floor 
shows  no  granulations,  and  is  either  smooth  and  glistening  or  foul  and  liver- 
colored.  The  discharge  is  thin  and  scanty,  and  the  ulcer  varies  little  in 
appearance  from  week  to  week  or  even  from  month  to  month.  The  treat- 
ment consists  in  scraping  and  cauterizing  the  ulcer;  making  radiating  inci- 
sions through  the  margins  and  floor  or  elliptical  incisions  about  the  ulcer; 
applying  antiseptic  dressings  and  a  firm  bandage.  In  some  cases  the  ulcer 
should  be  strapped.  In  severe  cases  it  is  necessary  to  extirpate  the  ulcer  and 
apply  skin-grafts. 

Hemorrhagic  ulcers  bleed  easily  and  profusely.  Pressure  must  be 
applied;  it  is  sometimes  necessary  to  cut  or  burn  away  the  granulations. 

Phagedenic  Ulcer. — The  phagedenic  ulcer  results  from  the  profound 
microbic  infection  of  tissues  debilitated  by  local  or  constitutional  disease,  and 
is  commonly  venereal.  This  ulcer  has  no  granulations  and  is  covered  with 
sloughs;  its  edges  are  thin  and  undermined,  and  it  spreads  rapidly  in  all 
directions.  Such  an  ulcer  should  be  touched  with  strong  caustics  or  Paque- 
lin's  cautery,  and  dressed  with  iodoform  gauze  and  antiseptic  fomentations. 
Tonics  and  stimulants  should  always  be  administered. 

The  edematous  ulcer  may  result  from  impediment  to  the  venous  return 
or,  as  Nancrede  points  out,  may  be  produced  by  the  persistent  use  of  poultices 
or  wet  dressings  upon  any  ulcer.*  It  is  most  often  met  with  in  tuberculous 
processes  and  is  occasionally  seen  when  varicose  veins  exist.  The  granula- 
tions are  large  and  pale,  and  are  apt  to  bend  over  like  unsupported  vines. 
The  discharge  is  profuse  and  scropurulent.  The  edges  are  softened  and 
desquamating.  An  edematous  ulcer  requires  dry  dressings,  stimulation,  and 
compression. 

*  "  Principles  of  .Surgery." 


Various  Ulcers 


135 


A  rodent  or  Jacob's  ulcer,  Noli  me  tangere,  or  cancroid  ulcer  is  a 

superficial  epithelioma  developing  usually  from  sebaceous  glands,  sweat- 
glands,  or  hair  follicles.  It  requires  scraping  and  cauterization,  or,  what  is 
better,  excision  (page  273). 

Marjolin's  ulcer  is  an  epithelioma  arising  from  a  chronic  ulcer  or  an  old 
cicatrix.  The  malignant  change  begins  at  some  point  of  the  edge  of  the  ulcer, 
and  its  first  evidence  is  induration.  The  induration  spreads  slowly  and  comes  to 
involve  a  considerable  part  of  or  even  the  entire  ulcer.  Marjolin's  ulcer  is  the 
seat  of  scalding,  darting  pain;  the  discharge  is  profuse,  ichorous,  and  foul, 
and  the  floor  of  the  ulcer  is  uneven,  warty,  or  cauliflower-like.  The  ana- 
tomically related  lymph-glands  eventually  become  involved.  This  involve- 
ment is  rarely  early  because  induration  has  blocked  lymph-channels.  In 
order  to  confirm  the  diagnosis  a  bit  of  tissue  should  be  removed  and  the 
removed  piece  must  include  a  portion  of  the  edge  of  the  ulcer  and  of  some 


Fig.  52.— Marjolin's  ulcer. 


apparently  sound  tissue  beyond  it.  If  a  microscopical  examination  shows 
epithelial  infiltration  of  the  apparently  sound  tissue,  a  diagnosis  of  malignant 
disease  must  be  made.  In  an  early  stage  of  such  an  ulcer  free  extirpation 
and  removal  of  the  anatomically  related  glands  may  cure  the  patient.  In 
a  more  advanced  case,  if  an  extremity  is  involved,  amputate  and  clear  out  the 
related  lymphatic  area.     In  a  very  advanced  case  use  the  .v-rays. 

Decubitus,  or  bed-sore,  is  due  to  pressure  upon  an  area  of  feeble  circu- 
lation (page  151).     It  is  in  most  instances  a  condition  of  gangrene. 

Neuroparalytic  or  trophic  ulcer  is  due  to  impairment  of  the  trophic 
nerve-fibers  or  of  the  trophic  centers  in  the  cord. 

The  perforating  ulcer,  as  it  was  named  by  Vesigne,  commonly  affects 
the  plantar  surface  of  the  metatarsophalangeal  joint  or  the  pulp  of  the 
great  toe  or  little  toe  about  a  callosity  or  corn.  Very  rarely  it  affects 
the  palm  of  the  hand.  The  parts  about  the  corn  inflame,  and  pus  forms 
and  reaches  into  the  bone.     A  sinus  evacuates  the  pus  by  the  side  of  the 


136  Ulceration  and  Fistula 

corn.  A  portion  of  the  callous  mass  is  cast  off  and  a  shallow  ulcer  is  often 
exposed.  After  a  time  the  bone  is  laid  bare  or  the  joint  opened.  The  margins 
of  the  ulcer  or  sinus  are  surrounded  by  sprouting  granulations  and  these  are 
encircled  by  an  area  of  markedly  thickened  epidermis.  In  very  rare  cases 
more  than  one  ulcer  is  present.  The  discharge  from  a  perforating  ulcer  is 
thin  and  scanty  and  the  ulcer,  which  slowly  advances,  is  very  chronic.  It  is 
not  painful  and  is  slightly,  if  at  all,  tender.  The  foot  is  cold  and  often  edema- 
tous and  the  parts  about  the  ulcer  may  be  anesthetic.  The  ulcer  may  heal 
when  the  patient  is  kept  in  bed,  to  open  again  when  he  gets  about.  The  dis- 
ease is  far  more  common  among  males  than  among  females  and  is  most  often 
met  with  in  the  fourth  or  fifth  decades  of  life.  As  this  ulcer  may  be  present 
in  anesthetic  leprosy,  in  diabetes,  peripheral  neuritis,  syphihs,  in  a  paralyzed 
hmb,  and  tabes  dorsalis,  and  as  the  part  on  which  it  occurs  is  apt  to  be  sweaty, 
cold,  and  more  or  less  anesthetic,  and  as  the  sore  may  be  hereditary,  it  is  usually 
set  down  as  trophic  in  origin.  Treatment  of  a  perforating  ulcer  consists, 
according  to  Treves,  in  going  to  bed  and  poulticing.  Every  time  a  poultice 
is  removed  the  raised  epithelium  around  the  ulcer  is  cut  away  and  then  the 
poultice  is  reapplied.  In  about  two  weeks  an  ulcer  remains  surrounded  by 
healthy  tissue.  Treves  treats  this  sore  with  glycerin  made  to  a  creamy  con- 
sistency with  salicylic  acid,  to  each  ounce  of  which  ttlx  of  carbolic  acid  have 
been  added.  He  directs  the  patient  to  wear  during  the  rest  of  his  life  some 
form  of  bunion-plaster  to  keep  off  pressure.  Nerve-stretching  has  been  recom- 
mended as  the  proper  treatment  for  perforating  ulcer.  If  in  a  perforating 
ulcer  the  bone  is  diseased,  it  must  be  removed.  No  matter  what  treatment 
is  employed,  the  sore  is  apt  to  reappear  in  the  old  situation  or  an  adjacent 
region,  when  the  part  is  subjected  to  pressure.  Some  advise  the  use  of  an 
artificial  leg,  the  knee  being  kept  bent.  It  may  be  necessary  to  amputate 
the  toe  or  the  foot. 

The  scorbutic  ulcer  is  covered  with  a  dark-brown  crust,  beneath  which 
are  pale  and  bleeding  granulations.     The  parts  adjacent  are  of  a  violet  color. 

Epitheliomatous,  sarcomatous,  tuberculous,  and  syphilitic  ulcers  and  ulcers 
of  the  stomach  and  duodenum  are  considered  under  these  respective  diseases. 

Fistula. — A  fistula  is  an  abnormal  communication  between  the  surface 
and  an  internal  part  of  the  body,  or  between  two  natural  cavities  or  canals. 
The  first  form  is  seen  in  a  rectal  fi.stula,  a  urethral  fistula,  or  a  biliary  fistula; 
and  the  second  form  is  seen  in  a  vesicovaginal  fistula.  Fistulae  may  result 
from  congenital  defect,  as  when  there  is  failure  in  the  closure  of  the  branchial 
clefts,  and  can  arise  from  sloughing,  traumatism,  and  suppuration.  Fistulae 
are  named  from  their  situation  and  communications.  For  instance,  a  pleural 
fistula,  an  intestinal  or  fecal  fistula,  a  rectal  fistula,  an  anal  fistula,  a  gastric 
fistula,  a  bronchial  fistula,  a  vesical  fistula,  a  bihary  fistula,  etc.  Many  fis- 
tulae are  tuberculous  and  lead  to  some  deeply  placed  tuberculous  focus.  A 
fistula  in  communication  with  an  internal  organ  may  be  maintained  by  an 
obstruction  the  removal  of  which  cures  the  fistula. 

A  sinus  is  a  tortuous  track  opening  usually  upon  a  free  surface  and  leading 
down  into  the  cavity  of  an  imperfectly  healed  abscess.  A  sinus  may  be  an 
unhealed  portion  of  a  wound.  Many  sinuses  are  due  to  pus  burrowing  sub- 
cutaneously.  A  sinus  fails  to  heal  because  of  the  presence  of  some  irritant 
fluid,  as  saliva,  urine,  or  bile;  becau.se  of  the  existence  of  a  foreign  body,  as 


Fistula  137 

dead  bone,  a  bit  of  wood,  a  bullet,  a  septic  ligature,  etc. ;  or  because  of  rigidity 
of  the  sinus-walls,  which  rigidity  will  not  permit  collapse.  Sinuses  may  be 
maintained  by  want  of  rest  (muscular  movements)  and  general  ill  health. 
The  walls  of  a  tuberculous  sinus  are  lined  with  a  material  identical  with  the 
pyogenic  membrane  of  a  cold  abscess. 

Treatment. — In  treating  a  fistula  or  a  sinus,  remove  any  causative 
obstruction  and  any  foreign  body,  lay  the  channel  open,  curet,  brush  with 
pure  carboUc  acid,  and  pack  with  iodoform  gauze.  In  obstinate  cases 
entirely  extirpate  the  fibrous  walls,  sew  the  deeper  parts  of  the  wound  with 
buried  catgut  sutures,  and  approximate  the  skin  surfaces  with  interrupted 
sutures  of  silkworm-gut.  To  stimulate  a  sinus  to  granulation  it  is  some- 
times necessary  to  touch  it  throughout  with  the  actual  cautery,  nitric  acid, 
pure  carbolic  acid,  nitrate  of  silver  fused  on  a  metallic  probe,  in  a  solution 
of  a  strength  of  gr.  xl  to  the  ounce,  or  argyrol  of  a  strength  of  50  per  cent. 
Fresh  air  is  a  necessity  to  the  patient,  and  nutritious  food  and  tonics  must  be 
ordered. 


138  Mortification,  Gangrene,  or  Sphacelus 


VIII.  MORTIFICATION,  GANGRENE,  OR  SPHACELUS. 

Mortification,  or  gangrene,  is  death  in  mass  of  a  portion  of  the  living  body 
— the  dead  portions  being  large  enough  to  be  visible — in  contrast  to  ulceration, 
or  molecular  death,  in  which  the  dead  particles  have  been  liquefied,  cannot 
be  seen,  and  are  cast  away.  When  all  the  tissues  of  a  part  are  dead,  the  pro- 
cess is  spoken  of  as  sphacelus.  Gangrene  is  in  reality  a  form  of  necrosis, 
but  clinically  the  term  necrosis  is  restricted  to  molar  death  of  bone  or  to  death 
of  parts  below  the  surface  en  masse.  In  gangrene  a  portion  of  tissue  dies 
because  of  anemia,  and  the  dead  portions  may  either  desiccate  or  putrefy. 
Gangrene  may  be  due  to  tissue  injury,  either  chemical  or  mechanical,  to  heat 
or  cold,  to  failure  of  the  general  health,  to  circulatory  obstruction,  to  nerve 
disorder,  the  nerves  involved  being  the  vasomotor  or  possibly  the  trophic,  or 
to  microbic  infection.  A  microbic  poison  can  directly  destroy  tissues.  It 
can  indirectly  destroy  them  by  causing  such  inflammation  that  the  products 
obstruct  the  circulation,  but  gangrene  can  occur  when  no  bacteria  are  present. 
The  essential  cause  of  gangrene  is  that  the  tissues  are  cut  off  from  a  due  supply 
of  nourishment,  and  cell-nutrition  is  no  longer  possible.  In  other  words, 
the  essential  cause  of  gangrene  is  the  cutting  off  of  arterial  blood.  Nancrede 
says:  "Indeed,  except  when  the  traumatism  physically  disintegrates  tissues, 
as  a  stone  is  reduced  to  powder,  heat  or  strong  acids  physically  destroy  struc- 
ture, or  cold  suspends  cellular  nutrition  so  long  that  when  this  nutrition  be- 
comes a  physical  possibility  vital  metabolism  cannot  be  resumed,  gangrene 
always  results  from  total  deprivation  of  pabulum."  * 

Classification. — Gangrene  is  divided  into  the  following  three  great 
groups: 

(i)  Dry  gangrene,  which  is  due  to  circulatory  interference,  the  arterial 
supply  being  decreased  or  cut  off.     The  tissues  dry  and  mummify. 

(2)  Moist  gangrene,  which  is  due  to  interference  not  only  with  arterial 
ingress,  but  also  with  venous  return  or  capillary  circulation,  the  dead  parts 
remaining  moist. 

(3)  Microbic  gangrene,  arising  from  virulent  bacteria.  In  this  form 
the  bacterial  process  causes  the  gangrene,  and  is  not  merely  associated  with  it. 

The  above  classification,  if  unqualified,  suggests  erroneous  ideas.  It  in- 
dicates that  there  is  an  essential  difference  between  dry  gangrene  and  moist 
gangrene,  which  is  not  the  case.  If,  when  gangrene  begins,  the  tissues  are 
free  from  fluid,  the  patient  develops  dry  gangrene;  if  they  are  full  of  fluid,  he 
develops  moist  gangrene.  If  the  arterial  supply  is  gradually  cut  off,  the  tissues 
are  sure  to  be  free  from  fluid,  and  the  gangrene  wiU  certainly  be  of  the  dry 
form.  If  arterial  blood  is  suddenly  cut  off,  the  gangrene  may  be  dry  or  moist, 
according  as  to  whether  the  tissues  are  or  are  not  drained  of  fluid.  When 
gangrene  results  from  inflammation,  strangulation,  and  infection,  it  is  certain 
to  be  of  the  moist  variety,  because  the  tissues  are  sure  to  be  filled  with  fluid. 

Nancrede  says,  in  his  very  valuable  work  on  the  "Principles  of  Surgery": 
"Yet,  let  accidental  inflammation  have  preceded  the  final  blocking  of  an 
artery,  or  let  Ligation  of  the  main  artery  cause  gangrene  because  the  collateral 

*  "  Principles  of  Surgery." 


Non-senile  Dry  Gangrene  139 

circulation  cannot  become  developed,  and  if  an  aneurysmal  sac  is  so  situated 
as  to  interfere  with  a  free  return  of  venous  blood  and  lymph,  this  anemic 
gangrene  will  in  both  instances  prove  moist  and  not  dry." 

There  are  many  gangrenous  processes  which  belong  under  one  or  other 
of  the  above  heads,  namely:  congenital  gangrene,  a  rare  form  existing  at  birth; 
constitutional  gangrene,  arising  from  a  constitutional  cause,  as  diabetes; 
cutaneous  gangrene,  which  is  limited  to  skin  and  subcutaneous  tissue,  as  in 
phlegmonous  erysipelas;  gaseous  or  emphysematous  gangrene,  in  which  the 
subcutaneous  tissues  are  filled  with  putrefactive  gases  and  crackle  on  pressure; 
hospital  gangrene,  which  is  defined  by  Foster  as  specific  serpiginous  necrosis, 
the  tissues  being  pulpefied:  some  consider  it  a  traumatic  diphtheria;  cold 
gangrene,  a  form  in  which  the  parts  are  entirely  dead  (sphacelus) ;  hot  gan- 
grene, which  is  associated  with  inflammation,  as  shown  by  heat;  dermatitis 
gangrcenosa  infantum,  or  the  multiple  cachectic  gangrene  of  Simon;  idiopathic 
gangrene,  which  has  no  ascertainable  cause;  mixed,  which  is  partly  dry  and 
partly  moist;  primary,  in  which  the  death  of  the  part  is  direct,  as  from  a  burn; 
secondary,  which  follows  an  acute  inflammation;  multiple,  as  gangrenous 
herpes  zoster;  diabetic  or  glycemic  gangrene,  which  arises  during  the  existence 
of  diabetes;  gangrenous  ecthyma,  a  gangrenous  condition  of  ecthyma  ulcers; 
pressure,  which  is  due  to  long  compression;  purpuric  or  scorbutic,  which  is 
due  to  scurvy;  Raynaud's  or  idiopathic  symmetrical,  which  is  due  to  vascular 
spasm  from  nerve  disorder;  senile,  the  dry  gangrene  of  the  aged;  venous  or 
static,  which  is  due  to  obstruction  of  circulation,  as  in  a  strangulated  hernia; 
trophic,  which  is  due  to  nutritive  failure  by  reason  of  disorder  of  the  trophic 
nerves  or  centers;  thrombotic,  which  is  due  to  thrombus;  embolic,  which  is  due 
to  embolus;  and  decubitus,  decubital  gangrene,  or  bed-sores  due  to  pressure. 

Dry  gangrene  arises  from  deficiency  of  arterial  blood.  For  this  reason 
Nancrede  calls  it  anemic  gangrene. 

This  form  of  gangrene  is  far  more  apt  to  result  from  the  gradual  than  from 
the  sudden  cutting  off  of  the  supply  of  arterial  blood,  and  is  more  common  if 
the  blood-vessels  are  atheromatous  than  if  they  are  healthy;  but  even  in  a 
person  with  healthy  arteries  gangrene  will  ensue  upon  blocking  of  the  main 
artery,  if  the  collaterals  fail  to  supply  the  part  with  blood.  This  form  of 
gangrene  can  occur  after  laceration,  ligation,  or  the  lodgment  of  an  embolus 
in  the  main  artery  of  a  limb;  but  in  such  accidents  considerable  fluid  usually 
remains  in  the  tissues  and  the  gangrene  is  apt  to  be  moist  rather  than  dry. 

Non-senile  Dry  Gangrene. — An  embolus  may  cause  dry  gangrene  in 
rare  instances.  If  it  does  so,  it  is  probable  that  the  blocking  was  not  at  once 
complete.  When  an  embolus  lodges  in  an  artery  and  causes  dry  gangrene, 
the  case  runs  the  following  course:  sudden  severe  pain  at  the  seat  of  impaction, 
and  also  tenderness;  pulsation  above,  but  not  below,  this  point,  after  obstruc- 
tion has  become  complete;  the  hmb  below  the  obstruction  is  blanched,  cold, 
and  anesthetic;  within  forty-eight  hours,  as  a  rule,  the  area  of  gangrene  is 
widespread  and  clearly  evident;  the  limb  becomes  reddish,  greenish,  blue, 
and  then  black;  the  skin  becomes  shriveled  and  its  outer  layer  stony  or  like 
horn  because  of  evaporation.  The  entire  part  may  become  dry;  but  usually 
there  are  spots  where  some  fluid  remains,  and  these  spots  are  soft  and  moist, 
and  the  dead  tissue,  where  it  joins  the  living,  is  sure  to  be  moist.  The  moist 
areas  become  foul  and  putrid,  but  the  dry  spots  do  not.     In  dry  gangrene,  at 


I40 


Mortification,  Gangrene,  or  Sphacelus 


the  point  of  contact  of  the  dead  and  Hving  tissues,  inflammation  arises  in  the 
latter  structures,  a  bright-red  line  forms,  and  exudation  and  ulceration  take 
place.  This  hne  of  ulceration  in  the  sound  tissues  is  called  the  "  line  of  de- 
marcation." It  is  Nature's  effort  at  amputation,  and  in  time  may  get  rid  of  a 
large  portion  of  a  hmb,  and  then  heal  as  any  other  ulcer.  A  hne  of  demarca- 
tion rarely  causes  hemorrhage,  because  it  ulcerates  through  a  vessel  only  after 
inflammation  has  caused  occlusion  by  thrombosis.  In  dry  gangrene  from 
arterial  obstruction  there  is  gastro-intestinal  derangement  and  also  some  fever. 
The  gangrene  does  not  extend  up  to  the  point  of  obstruction,  but  only  to  a 
region  in  which  the  anastomotic  circulation  is  sufficiently  active  to  permit  of 
the  formation  of  a  line  of  demarcation.  Below  this  point  inflammatory  stasis 
arises,  but  before  this  can  go  on  to  ulceration  the  parts  die.  In  cases  where  the 
arterial  obstruction  is  sudden  and  complete  the  limb  swells  decidedly.  This  is 
due  to  the  sudden  loss  of  vis  a  tergo  in  the  arterial  system,  venous  reflux  occur- 
ring and  fluids  transuding.  In  such  a  case  the  tissues  contain  fluid  and  putrefy, 
and  the  process,  though  due  to  the  cutting  off  of  the  arterial  circulation,  is 
moist  gangrene.  Dry  gangrene  attacks  the  leg  more  often  than  the  arm. 
A  thrombus  in  an  artery  rarely  causes  gangrene  except  in  the  aged,  as  the 
collateral  circulation  has  time  to  adjust  itself;  but  gangrene  may  follow 
thrombus  formation,  and  when  it  does  it  comes  on  more  slowly  than  does  gan- 
grene from  embolus,  and  is  certain  to  be  of  the  dry  form. 

Treatment  oj  Non-senile  Dry  Gangrene. — When  injury  or  blocking  of  a 
healthy  artery  causes  us  to  fear  the  onset  of  dry  gangrene,  the  patient  should 
be  placed  in  bed  and  the  part  elevated  a  little,  kept  wrapped  in  cotton-wool 
and  surrounded  with  bottles  filled  with  warm  water.  If  gangrene  begins,  wait 
for  a  line  of  demarcation,  and  while  waiting  dress  the  dying  and  dead  parts 
antiseptically,  wrap  the  extremity  in  cotton  and  keep  it  warm,  and  see  to  it 
that  the  patient  gets  plenty  of  sleep  and  nourishment.  It  is  also  advisable  to 
give  tonics  and  stimulants.  When  a  line  of  demarcation  forms,  amputate  well 
above  it. 

Senile  gangrene,  chronic  gangrene,  Pott's  gangrene  (Fig.  53),  is  a 
form  of  gangrene  due  to  feeble  action  of  the  heart  plus  obliterating  endarteritis 

or  atheroma  of  periph- 
eral vessels.  The  ves- 
sels do  not  carry  a  nor- 
mal amount  of  blood, 
and  may  at  any  time  be 
occluded  by  thrombosis. 
In  a  drunkard,  or  in  a 
victim  of  syphilis  or  tu- 
bercle, the  changes  sup- 
posed to  characterize  old 
age  may  appear  while  a 
man  is  young  in  years. 
It  was  long  ago  said, 
Senile  gangrene  most  often 


Fig.  53.— Senile  gangrene  of  the  feet  (Gross). 


with  truth,  "a  man  is  as  old  as  his  arteries.' 
occurs  in  a  toe  or  the  foot. 

Symptoms.— k  man  whose  vessels  are  in  the  state  above  indicated  is  gener- 
ally in  feeble  health  and  has  a  fatty  heart  and  an  arcus  senilis  (a  red  or  white 


Treatment  of  Senile  Gangrene  141 

line  of  fatty  degeneration  around  the  cornea).  His  toes  and  feet  feel  cold  and 
numb,  and  they  "go  to  sleep"  very  easily,  and  he  suffers  from  cramp  of  the 
legs  and  feet.  He  is  dyspeptic  and  short  of  breath,  and  his  urine  is  frequently 
albuminous.  The  arteries  are  felt  as  rigid  tubes,  like  pipe-stems.  He  is  in 
danger  of  edema  of  the  lungs  and  of  dry  gangrene  of  the  toes.  A  slight  injury 
of  a  toe — for  instance,  cutting  a  corn  too  close — will  produce  extensive  in- 
flammatory stasis  followed  by  thrombosis,  which  completely  cuts  off  the  blood- 
supply  and  causes  gangrene  of  the  part.  Gangrene  is  usually  announced  by 
the  appearance  of  a  purple  and  anesthetic  spot,  followed  by  a  vesicle  which 
ruptures  and  liberates  a  small  amount  of  bloody  serum  and  exposes  a  dry 
floor.  In  the  parts  about  the  gangrenous  area  there  is  often  burning  pain. 
The  tissues  immediately  adjacent  to  the  dead  spot  are  in  a  condition  of  edema 
and  stasis,  the  parts  being  purple,  the  color  disappearing  slowly  under  pres- 
sure and  returning  slowly  when  pressure  is  removed.  The  parts  a  little 
further  removed  are  hyperemic,  the  color  disappearing  rapidly  on  pres- 
sure and  returning  rapidly  when  pressure  is  removed.  The  dead  parts 
do  not  putrefy  at  all  or  do  so  but  slightly,  hence  the  odor  is  never 
very  offensive  and  is  usually  trivial.  They  are  anesthetic,  hard,  leathery, 
and  wrinkled,  and  resemble  a  varnished  anatomical  specimen  or  the  ex- 
tremitv  of  a  mummy  (hence  the  term  mummification).  Before  the  line 
of  demarcation  forms  there  is  burning  pain;  after  it  forms  pain  is  rarely 
present.  If  embolism  or  thrombus  in  a  diseased  vessel  caused  the  gangrene, 
the  pain  is  severe  at  the  point  of  impaction.  In  senile  gangrene  the  periphery 
is  always  dry,  the  part  nearer  the  body  being  generally  somewhat  moist. 
The  process  may  be  very  limited  or  it  may  spread  up  to  the  knee.  As  it 
spreads  the  area  of  hyperemia  advances  at  the  margin,  the  area  of  stasis  fol- 
lows, and  the  zone  of  gangrene  becomes  more  extensive.  When  tissues  are 
reached  the  blood-supply  of  which  is  sufficiently  good  to  permit  of  inflamma- 
tion. Nature  tries  to  limit  the  gangrene  by  the  formation  of  a  line  of  demarca- 
tion. A  line  of  demarcation  may  begin,  but  prove  abortive,  the  tissue  mor- 
tifying above  it.  This  proves  that  tissue  near  the  line  is  in  a  state  of  low 
vitality.  When  a  limited  area  is  gangrenous,  constitutional  symptoms  are 
trivial  or  absent;  but  when  a  large  area  is  involved,  the  fever  of  septic  absorp- 
tion exists.  Death  may  ensue  from  exhaustion  caused  by  sleeplessness  and 
pain,  from  septic  absorption,  or  from  embolism  of  internal  organs.  In  many 
cases  of  senile  gangrene  clots  are  formed  in  the  superficial  femoral  artery  or 
its  branches  (Heidenhain),  an  observation  it  is  important  to  bear  in  mind 
when  amputating. 

Prevention  of  Senile  Gangrene  in  the  Predisposed. — Such  a  patient  must 
avoid  injuring  his  toes  and  feet.  Cutting  his  corns  carelessly  is  highly  dan- 
gerous, and  any  wound,  however  slight,  requires  rest  and  antiseptic  dressing. 
The  victim  of  general  atheroma  must  wear  woolen  stockings,  put  a  rubber 
bag  containing  warm  water  to  his  feet  on  cold  nights,  and  attend  to  his  gen- 
eral health.  A  little  whiskey  after  each  meal  is  indicated,  and  occasional 
courses  of  nitroglycerin  are  desirable. 

Treatment  of  Senile  Gangrene. — When  gangrene  occurs,  if  it  is  limited  to 
one  toe  or  a  portion  of  several  toes,  if  it  is  a  first  attack,  if  there  is  no  fever  or 
exhausting  diarrhea,  if  there  is  no  tendency  to  pulmonary  congestion,  if  the 
appetite  is  fair  and  sleep  refreshing,  it  is  best  to  avoid  radical  interference. 


14^ 


Mortification,  Gangrene,  or  Sphacelus 


Await  the  formation  of  a  Hne  of  demarcation.  While  awaiting  the  line  of 
demarcation  dress  the  part  antiseptically  and  raise  the  foot  several  inches 
from  the  bed  and  surround  the  part  with  bottles  of  moderately  warm  water. 
Very  warm  water  may  do  harm.  Give  the  patient  nourishing  diet,  stimulants, 
and  tonics;  see  to  it  that  he  sleeps,  and  during  the  spread  of  the  gangrene 
watch  for  fever,  diarrhea,  pulmonary  congestion,  and  kidney  failure.  When 
a  line  of  demarcation  forms,  dress  with  warm  antiseptic  fomentations  and 
iodoform,  and  every  day  pick  away  dead  bits  with  the  scissors  and  forceps. 
In  many  cases  healing  will  occur;  but  even  when  the  parts  heal,  the  patient 
will  always  be  in  deadly  peril  of  another  attack.  If  the  gangrene  shows  a 
tendency  to  spread,  if  it  involves  more  than  a  portion  of  several  toes,  if  it  is 
not  a  first  attack,  if  there  is  sleeplessness,  fever,  exhausting  diarrhea,  anorexia, 
or  a  strong  tendency  to  pulmonary  congestion,  do  not  delay,  but  at  once 
amputate  high  up.  If  the  gangrene  shows  no  tendency  to  limit  itself,  or 
if  the  patient  develops  sepsis  or  exhaustion,  at  once  amputate  high  up. 
The  best  point  at  which  to  amputate  is  above  the  knee,  so  that  the  deep 
femoral  artery,  which  rarely  becomes  atheromatous,  will  nourish  the  flap  and 
gangrene  will  not  occur.  It  has  been  pointed  out  that  the  superficial  femoral 
artery  and  its  branches  often  contain  a  clot.  Never  amputate  below  the 
tubercle  of  the  tibia.  Some  operators  disarticulate  at  the  knee-joint.  Heiden- 
hain  affirms  that  so  long  as  the  gangrene  is  limited  to  one  or  two  toes  we 
should  merely  treat  it  antiseptically,  elevate  the  limb,  and  wait  for  the  dead 
part  to  be  cast  off  spontaneously;  if,  however,  it  extends  to  the  dorsum  or  .sole 
of  the  foot,  we  should  amputate  at  once  above  the  knee.  He  further  states 
that  gangrene  of  the  flaps  almost  always  occurs  in  amputations  below  the 
knee,  and  high  amputation  is  indicated  in  advancing  gangrene  with  or 
without  fever.*  When  amputation  has  been  performed  and  the  Esmarch 
band  has  been  removed  and  no  arterial  bleeding  takes  place  from  the  super- 
ficial femoral  artery,  a  clot  is  lodged  in  that  vessel.  If  such  a  condition  exist, 
insert  into  the  artery  a  fine  rubber  catheter  or  a  filiform  bougie  and  break  up 
the  clot.  When  blood  flows  we  are  sure  that  the  clot  has  been  washed  out.f 
Moist  or  Acute  Gangrene. — In   moist  or  acute  gangrene  (Fig.  54)  the 

dead  part  remains  moist 
and  putrefies.  As  Nan- 
crede  points  out,  there 
are  two  forms  of  moist 
gangrene:  "that  limited 
to  the  areas  actually 
killed  by  a  traumatism, 
with  some  surrounding 
tissue  which  dies,"  and 
"that  which  tends  to  spread  widely,  this  latter  being  usually  caused  by  specific 
micro-organisms,  an  intense,  widespread,  pyogenic  inflammation  resulting,  in- 
volving the  subcutaneous  and  intermuscular  cellular  planes,  by  strangulation  of 
the  vessels  of  which  all  blood-supply  to  the  remaining  soft  parts  is  destroyed."! 

*  Deutsche  mediciiiische  Wochenschiift,  1891,  ]i.   10.S7. 

t  Severeanu.      See  Mancozct's  report  before   the  second    Pan-American    Medical   ("on- 


F'g   54  — Acute  gangrene  (Gross). 


gress. 


JNancrede's  "  Principles  of  Surgery." 


Moist  Gangrene  from  Inflammation  143 

In  a  case  of  gangrene  the  parts  remain  moist,  either  because  the  main  artery- 
has  become  suddenly  blocked,  and  the  tissue  fluids  are  not  urged  by  sufficient 
vis  a  tergo  to  cause  them  to  flow  out  of  the  limb,  or  because  the  main  vein  is 
blocked.  It  may  arise  in  a  limb  after  ligation,  obstruction,  or  destruction 
of  its  main  artery,  main  vein,  or  both;  after  long  constriction,  as  by  a  tight 
bandage;  after  crushes  and  lacerated  wounds;  and  after  thrombosis  of  the 
vein.  Moist  gangrene  may  follow  acute  inflammation,  or  may  be  due  to 
local  constriction  (strangulated  hernia),  crushing,  chemical  irritants,  heat, 
and  cold. 

Moist  gangrene  of  a  limb  is  seen  typically  when  the  main  vein  or  artery 
or  both  vein  and  artery  are  constricted,  damaged,  or  destroyed.  The  leg 
swells  greatly  and  is  pulseless  below  the  obstruction;  the  skin,  at  first  pale, 
cold,  and  anesthetic,  becomes  livid,  mottled,  or  purple  or  greenish.  A  green- 
ish color  signifies  putrefaction.  Blebs  are  formed  which  contain  a  reddish 
or  brown  fluid.  ''These  blebs,  being  caused  by  the  accumulation  of  serum 
beneath  epithehum  which  has  lost  its  vital  connection  with  the  derm,  can  be 
slipped  around  upon  the  surrounding  true  skin,  the  epithelium  readily  sepa- 
rating for  long  distances  around,  as  in  a  cadaver"  (Nancrede).  The  ex- 
tremity swells  enormously,  there  may  be  pain  at  the  seat  of  obstruction,  but 
there  is  no  pain  in  the  gangrenous  area,  and  sapremic  symptoms  quickly 
develop.  The  bullae  break  and  disclose  the  brown  derm  and  sometimes  the 
deeper  structures,  which  are  swollen  and  edematous.  The  fetor  is  horrible. 
Slight  or  moderate  fever  usually  exists.  In  mild  cases  a  line  of  demarcation 
soon  forms.  In  severe  cases  in  which  virulent  saprophytes  are  present  the 
process  spreads  with  great  rapidity,  neighboring  glands  enlarge,  the  tempera- 
ture is  much  elevated,  no  line  of  demarcation  forms,  there  is  profound  ex- 
haustion, and  gases  of  decomposition  accumulate  in  the  tissues,  distend  them, 
and  cause  crackling  when  the  parts  are  pressed  upon.  Such  severe  cases 
are  in  reality  examples  of  foudroyant  or  emphysematous  gangrene. 

Moist  gangrene  from  inflammation  is  due  to  pressure  of  the  exudate 
cutting  off  the  blood-supply,  or  to  loss  of  blood-circulation  because  of  microbic 
involvement  of  vessels  and  clotting  of  blood.  It  occurs  typically  in  phleg- 
monous erysipelas.  When  an  inflammation  is  about  to  terminate  in  gangrene 
all  the  signs  of  inflammation,  local  and  constitutional,  increase;  swelling 
becomes  very  great  and  may  be  due  partly  to  fluid  and  partly  to  gas.  If  gas 
is  present  pressure  will  cause  crackling.  The  color  becomes  livid  or  purple. 
The  anatomically  related  glands  are  enlarged  and  the  symptoms  of  sapremia 
or  suppurative  fever  exist.  When  gangrene  is  actually  present,  the  signs  of 
inflammation  have  passed  away,  bullae  and  emphysema  are  noted,  with  great 
swelling  and  all  the  other  symptoms  of  molar  death.  The  sudden  cessation 
of  pain  is  very  suggestive  of  gangrene.  The  constitutional  symptoms  are 
those  of  suppurative  fever  and  sapremia,  or  possibly  of  septic  infection. 

When  a  wound  becomes  gangrenous  the  surface  looks  like  yellow  or  gray 
tow,  the  discharge  becomes  profuse  and  very  fetid,  and  the  parts  about  swell 
enormously  and  gradually  become  gangrenous. 

Treatment  0}  Moist  Gangrene. — In  extensive  moist  gangrene  of  a  limb,  if 
the  condition  is  of  the  form  described  as  mild,  in  which  there  are  not  severe 
symptoms  of  sepsis  and  in  which  the  gangrene  is  not  rapidly  progressive, 
wait  for  a  line  of  demarcation,  and  amputate  clear  of  and  above  it.     While 


144  Mortification,  Gangrene,  or  Sphacelus 

waiting  for  the  hne  to  form,  dress  the  dead  parts  antiseptically,  wrap  the 
extremity  in  cotton,  apply  warmth,  and  slightly  elevate  the  limb.  Give  opium, 
tonics,  nourishing  food,  and  stimulants.  In  the  severe  form  of  moist  gangrene 
(reallv  foudrovant  gangrene),  amputate  at  once  high  above  the  gangrenous 
process.  In  inflammatory  gangrene,  such  as  is  sometimes  associated  with 
phlegmonous  erysipelas,  relieve  tension  by  incisions,  cut  away  the  dead  parts, 
brush  the  raw  surface  with  pure  carbolic  acid,  dust  with  iodoform,  and  dress 
with  hot  antiseptic  fomentations.  Stimulate  freely,  administer  nourishment 
at  frequent  intervals,  and  treat  the  patient  in  general  as  we  would  a  case  of 
sapremia,  or  suppurative  fever.  A  gangrenous  wound  is  treated  as  pointed 
out  in  the  section  on  Sloughing. 

Acute  microbic  gangrene,  fulminating  gangrene,  emphysematous 
gangrene,  gangrenous  emphysema,  gangrene  foudroyante,  or  traumatic 
spreading  gangrene,  results  from  a  virulent  infection  of  a  wound.  The 
condition  mav  be  due  to  a  mixed  infection  with  virulent  streptococci  and 
organisms  of  putrefaction;  or  to  infection  with  the  bacilli  of  malignant  edema, 
and  putrefactive  organisms.  Some  cases  are  due  to  the  bacillus  of  malignant 
edema  alone;  some  are  due  to  the  bacillus  aerogenes  capsulatus  of  Welch  and 
Flexner.  The  injury  is  usually  severe — often  a  crush  which  destroys  the 
main  artery  and  renders  an  anastomotic  circulation  impossible.  In  such 
severe  accidents  the  limb  is  much  swollen  and  the  pulse  below  the  seat  of 
injurv  is  imperceptible,  and  the  surgeon  is  often  at  this  time  uncertain  whether 
to  amputate  at  once  or  wait.  Emphysematous  gangrene  is  commonest  after 
compound  fractures,  and  begins  within  forty-eight  hours  of  the  accident. 
The  extremity  becomes  enormously  swollen  from  edema  and  gas.  The 
gangrene  does  not  begin  at  the  periphery,  as  does  ordinary  moist  gangrene, 
but  at  the  wound  edges,  which  turn  red,  green,  and  finally  black;  the  ex- 
tremity soon  undergoes  a  hke  change  and  becomes  mortified.  The  skin  peels 
off,  emphysematous  crackling,  due  to  gas  formed  and  retained  in  the  tissues, 
can  be  detected  over  large  areas,  and  the  extremity  becomes  anesthetic 
and  pulpy.  The  gases  formed  in  the  tissues  are  sulphid  of  hydrogen, 
sulphid  of  ammonium,  volatile  fatty  acids,  and  ammonia.  Great  fetor  is 
soon  noted.  The  gangrene  spreads  up  and  down  from  the  wound,  and  red 
lines,  due  to  lymphangitis,  run  from  above  the  wound.  The  adjacent  lymph- 
glands  swell,  and  in  thirty-six  hours  the  gangrene  may  involve  an  entire  limb. 
No  line  of  demarcation  forms.  The  system  is  soon  overwhelmed  with  pto- 
mains,  and  the  patient  suffers  from  putrid  intoxication,  with  delirium,  and 
often  passes  into  profound  collapse  with  coma  and  subnormal  temperature. 
Traumatic  spreading  gangrene  must  not  be  confused  with  erysipelas.  In 
erysipelas  the  color  is  red,  pressure  instantly  drives  it  out,  and  on  the  release 
of  pressure  it  at  once  returns.  In  early  gangrene  the  color  is  purple,  pressure 
fails  to  drive  it  out  at  all  or  only  does  so  very  slowly,  and  if  the  surface  is 
blanched  by  pressure,  on  the  release  of  pressure  the  color  crawls  slowly  back. 
Sometimes  emphysematous  gangrene,  in  the  form  of  gangrenous  cellulitis, 
follows  a  trivial  injury  such  as  a  puncture,  the  entrance  of  a  splinter,  an 
abrasion,  or  a  slight  cut.  The  region  about  the  injury  becomes  red,  then 
livid,  and  finally  green  or  black.  Enormous  swelling  takes  place,  partly  due 
to  edema,  partly  to  gas,  and  the  swelling  and  discoloration  spread  rapidly. 
Red  lines  subsequently  becoming  greenish  run  toward  enlarged  lymphatic 


Special  Forms  of  Gangrene  145 

glands  above  the  gangrenous  fjart.  The  tissues  are  rapidly  separated  and 
destroyed  and  the  bone  is  often  quickly  exposed  and  infected.  The  symptoms 
point  to  overwhelming  sepsis.  There  is  high  fever  and  delirium,  and  coma 
and  death  are  apt  to  ensue.  The  patient  may  die  in  from  twenty-four  to 
forty-eight  hours. 

Treattnejtt. — In  acute  spreading  gangrene  of  an  e.xtremity  following  a 
severe  injury  no  delay  is  admissible.  To  wait  for  a  line  of  demarcation 
is  to  expect  the  impossible,  and  a  delay  dooms  the  patient  inevitabl}'  to 
death.  Amputation  must  be  performed  at  once  high  up,  the  flaps  should 
be  brushed  with  pure  carbolic  acid,  and  then  every  effort  is  to  be  made  to 
sustain  the  patient's  strength  by  the  administration  of  food  and  stimu- 
lants. Antistreptococcic  serum  may  possibly  be  useful.  In  cases  of  acute 
spreading  gangrene  following  trivial  injuries  it  may  be  possible  to  arrest 
the  process  by  free  incisions,  thorough  drainage,  hot  antiseptic  fomenta- 
tions, stimulants,  etc.,  but  in  some  cases  amputation  is  necessary.  Some 
surgeons,  notably  Doerfler  ("  Miinchener  medicinische  Wochenschrift," 
April  23  and  30,  1901),  oppose  amputation  in  cases  of  spreading  gangrene 
following  trivial  or  moderately  severe  injury.  Doerfler  maintains  that  cases 
which  recover  after  amputation  would  have  recovered  if  amputation  had 
not  been  performed.     From  this  positive  statement  I  am  obliged  to  dissent. 

Hospital  gangrene  or  sloughing  phagedena  is  a  disease  that  has  prac- 
ticallv  disappeared  from  civilized  communities.  It  formerly  occurred  in 
crowded,  ill-ventilated  hospitals.  Some  consider  it  traumatic  diphtheria. 
Koch  thinks  it  is  due  to  streptococci.  Jonathan  Hutchinson  says:  "  Hospital 
gangrene  is  set  up  by  admitting  to  the  wards  a  case  of  syphilitic  phagedena." 
It  may  show  itself  as  a  diphtheritic  condition  of  a  wound,  as  a  process  in  which 
sloughs  which  look  like  masses  of  tow  form,  or  as  a  phagedenic  ulceration. 
The  surrounding  parts  are  inflamed  and  painful,  and  buboes  form  in  adjacent 
lymphatic  glands.     The  system  passes  into  a  low  septic  state. 

Treatment. — In  treating  hospital  gangrene  ether  should  be  given,  the  large 
sloughs  removed  with  scissors  and  forceps,  the  parts  dried  with  gauze  and 
cauterized  with  bromin.  The  surgeon  should  take  a  tumblerful  of  water 
and  into  it  pour  the  bromin,  which  will  fall  to  the  bottom  of  the  glass.  The 
drug  can  be  drawn  up  with  a  syringe  and  injected  into  the  depths  of  the 
wound.  The  wound  should  be  plentifuU}-  sprinkled  with  iodoform  and 
dressed  with  hot  antiseptic  fomentations.  When  the  sloughs  separate,  the 
sore  can  be  treated  as  an  ordinary  ulcer.  The  constitutional  treatment  is 
that  employed  for  sepsis. 

Special  Forms  of  Gangrene.— Symmetrical  or  Raynaud's  gangrene 
arises  in  severe  cases  of  Raynaud's  disease.  It  is  a  dry  gangrene.  Ray- 
naud's disease  is  a  vasomotor  neurosis,  seen  particularly  in  children  and  voung 
female  adults  but  sometimes  met  with  in  men.  Chlorotic  and  hvsterical 
women  seem  more  apt  than  others  to  suffer  from  it.  The  condition  is  much 
commoner  in  winter  than  in  summer,  and  cold  seems  to  be  an  exciting  cause. 
The  essential  cause  of  Raynaud's  disease  is  uncertain.  In  some  acute  cases 
associated  with  fever,  albuminuria,  and  splenic  enlargement,  it  seems  to  be  a 
part  of  an  acute  infectious  disease.  It  can  occur  in  a  variety  of  toxic  con- 
ditions and  in  a  number  of  infectious  diseases  (typhoid  fever,  for  instance). 
It  may  develop  in   the  course  of  gout  and  also  of  diabetes.     In  many  cases 


146  Mortification,  Gangrene,  or  Sphacelus 

neuritis  exists;  in  some  there  is  obhterative  endarteritis  of  the  peripheral  ves- 
sels. Some  cases  seem  to  be  purely  hysterical.  The  fact  that  attacks  of 
Raynaud's  disease  are  sometimes  accompanied  by  hemoglobinuria  has  sug- 
gested malaria  as  a  possible  cause.  Raynaud's  disease  is  characterized  by 
attacks  of  cold,  dead  bloodlessness  in  the  fingers  or  toes  as  a  result  of  expo- 
sure to  cold  or  of  emotional  excitement  (local  syncope).  In  the  more  severe 
cases  there  are  capillary  congestion  and  mottled,  hvid  swelling  (local 
asphyxia).  In  some  few  cases  the  skin  of  the  face  or  trunk  is  attacked. 
Local  syncope  is  thought  to  be  due  to  vascular  spasm,  and  local  asphyxia  to 
some  contraction  of  the  arterioles,  with  dilatation  of  the  capil'aries  and  venules. 
It  is  after  local  asphyxia  that  gangrene  may  appear.  A  chilblain  is  an  ajea 
of  local  asphyxia.  The  patient  complains  of  pain,  tingling,  numbness,  cold- 
ness, and  stiffness  in  the  affected  parts.  Attacks  of  Raynaud's  disease  occur 
again  and  again,  and  may  never  eventuate  in  gangrene. 

Ravnaud's  disease  is  rarely  fatal  and  is  often  recovered  from. 

Raynaud's  gangrene  is  most  commonly  met  with  upon  the  ends  of  the 
fingers  or  the  toes,  but  it  may  attack  the  lobes  of  the  ears,  the  tip  of  the  nose, 
or  the  skin  of  the  arms  or  the  legs.  Sometimes  the  disease  is  seen  upon  the 
trunk.  When  gangrene  is  about  to  occur  the  local  asphyxia  at  that  point 
deepens,  anesthesia  becomes  complete,  and  the  part  blackens  and  feels  cold 
to  the  touch.  The  epidermis  raises  into  blebs,  which  rupture  and  expose  dry 
surfaces.  A  line  of  demarcation  forms,  and  the  necrosed  area  is  removed 
as  a  slough.  Widespread  gangrene  from  Raynaud's  disease  is  rare;  there  is 
not  often  an  extensive  area  involved — rather  a  small  superficial  spot.  Recov- 
ery is  the  rule. 

Treatment  of  Raynaud's  Disease  and  oj  Raynaud's  Gangrene. — If  an  indi- 
vidual suffers  from  attacks  of  Raynaud's  disease,  every  effort  should  be  made 
to  improve  the  general  health  and  to  avoid  chilling  the  surface  of  the  body. 
During  the  attack  employ  gentle  massage,  place  the  extremity  in  warm 
water,  and,  if  pain  is  severe,  give  morphia  hypodermatically.  Amyl  nitrite 
is  without  value  in  this  condition.  When  attacks  of  Raynaud's  disease  are 
so  severe  as  to  threaten  gangrene,  put  the  patient  to  bed;  if  the  feet  are 
affected,  elevate  the  legs  slightly,  wrap  the  extremities  in  cotton-wool,  and 
apply  warmth.  If  the  hands  are  affected,  wrap  them  in  cotton-wool,  elevate 
them  shghtly,  and  apply  warmth.  Massage  is  useful.  When  gangrene  occurs, 
dress  the  part  antiseptically  until  a  line  of  demarcation  forms,  and  then  re- 
move the  dead  parts  by  scissors,  forceps,  and  antiseptic  fomentations.  If 
amputation  becomes  necessary,  which  will  rarely  be  the  case,  wait  for  a  line  of 
demarcation. 

Diabetic  gangrene  resembles  in  many  points  senile  gangrene,  but  the 
dead  portions  remain  somewhat  moist  and  putrefy.  Some  attribute  it  directly 
to  the  presence  of  sugar  in  the  blood.  Some  think  diabetes  causes  gangrene 
indirectly  by  rendering  the  tissues  less  resistant  to  infection  and  less  capable 
than  normally  of  repair.  Many  hold  that  it  is  of  neurotic  origin,  being  the 
result  of  nerve  degeneration.  Heidenhain  believes  that  it  is  due  to  arterial 
sclerosis.  That  most  of  the  victims  of  diabetic  gangrene  .suffer  from  arterio- 
sclerosis is  certain.  It  seems  probable  that  the  gangrene  is  due  to  infection 
of  tissues  predisposed  to  infection  by  the  presence  of  sugar  and  weakened 
by  changes  in   the  nerves  and   blood-vessels.      Diabetic   gangrene   is    most 


Diabetic  Gangrene  147 

usually  met  with  upon  the  feet  and  legs  of  elderly  people,  but  it  may  arise 
at  any  age  and  may  attack  the  genital  organs,  thigh,  lung,  buttock,  eye, 
back,  finger,  or  neck.  It  may  affect  only  a  single  area,  may  attack  several 
areas,  or  may  be  symmetrical.  It  may  arise  in  any  stage  of  diabetes, 
from  the  earliest  to  the  latest.  It  may  begin  as  a  perforating  ulcfer.  As 
in  senile  gangrene,  a  trivial  injury  is  apt  to  be  the  exciting  cause,  but  it  may 
arise  without  any  antecedent  injury.  If  an  injury  is  causative,  a  condition 
like  cellulitis  arises,  spreads  rapidly,  and  eventuates  in  gangrene.  When  the 
gangrene  follows  a  traumatism,  there  are  no  prodromic  symptoms.  When 
it  arises  spontaneously  in  the  skin,  it  is  often  preceded  by  pain  of  a  neuralgic 
nature  and  attacks  of  "  livid  or  violaceous  discoloration  of  the  skin,  with 
lowered  surface  temperature  and  sometimes  loss  of  sensation"  (Elliot). 
Diabetic  gangrene  is  often  superficial,  but  may  become  deep  if  it  follows  an 
injury  or  ulceration.  The  gangrenous  area  is  somewhat  moist  as  a  rule,  but 
may  be  dry.  The  parts  about  are  livid  and  may  be  covered  with  vesicles. 
It  spreads  slowly,  but  more  rapidly  tlian  senile  gangrene.  There  is  little  ten- 
dency to  the  formation  of  any  line  of  demarcation,  although  occasionally 
spontaneous  healing  occurs. 

Treatment. — Surgeons  have  become  shy  of  amputating  in  such  cases,  but 
the  experience  of  Kuster,  of  Berlin,  proves  conclusively  that  an  amputation 
should  be  performed  at  once  in  diabetic  gangrene  of  the  leg,  and  should  be 
done  above  the  knee.  If  operation  is  performed  below  the  knee,  the  flaps 
will  become  gangrenous.  It  has  been  noted  that  sugar  will  sometimes  disap- 
pear from  the  urine  after  an  amputation.  Of  11  amputations  by  Kuster,  6 
recovered  and  5  died;  and  of  these  5,  3  had  albumin  in  urine  as  well  as  sugar.* 

Heidenhain  warmly  advocates  early  high  amputation,  with  the  making 
of  short  flaps.  When  the  patient  dies  after  operation,  he  usually  does  so  in 
coma.  In  any  case  after  operation,  treat  the  diabetes  by  means  of  drugs  and 
diet.  Codein  is  often  of  great  value.  It  amputation  is  refused  or  if  the 
gangrene  is  not  upon  an  extremity,  treat  the  gangrenous  area  by  hot  antiseptic 
fomentations,  the  daily  removal  of  portions  of  dead  tissue,  the  administration 
of  antidiabetic  drugs,  and  the  use  of  suitable  articles  of  diet.  Never  fail  to 
examine  the  urine  in  every  surgical  case,  and  especially  in  every  case  of  gan- 
grene, for  diabetes  might  be  present  when  it  had  not  been  suspected. 

Operations  on  Diabetics. — Surgical  operations  upon  diabetics  are  regarded 
as  very  dangerous  and  are  employed  by  most  surgeons  only  in  emergen- 
cies. In  operations  upon  such  subjects  gangrene  may  arise  in  the  wound 
or  diabetic  coma  may  develop.  It  is  important  to  remember  that  glycosuria 
may  result  from  a  surgical  condition  (head  injury,  sepsis,  etc.),  and  this  tem- 
l)orary  diabetes  will  be  relie\ed  by  operation.  I  have  seen  it  in  appendicitis, 
and  in  such  cases  operation  is  not  contraindicated,  but  is  imperative.  Llew- 
ellyn Phillips  in  a  recent  article  ("Lancet,"  ^lay  10  and  17,  iqo2)  refers  to 
the  temporary  glycosuria  produced  by  injury  and  sepsis.  He  thinks  that  dia- 
betes may  directly  cause  cataract  and  balanoposthitis.  but  produces  gangrene 
indirectly  by  causing  nerve  degeneration  and  arteriosclerosis.  Phillips  points 
out  that  a  surgical  condition  and  glycosuria  may  exist  independent  of  and 
uninfluenced  by  each  other,  and  many  such  ca^es  can  be  operated  upon, 

*  See  the  convincing  article  of  Charles  .\.  Powers,  in  Anier.  jour,  of  Med.  Sciences, 
Nov.   II,  1892. 


148  Mortification,  Gangrene,  or  Sphacelus 

although  operation  should  be  avoided  if  there  is  serious  disease  of  some  im- 
portant organ  (the  hver,  for  instance) .  Philhps,  in  the  valuable  article  referred 
to.  insists  that  the  percentage  of  sugar  is  not  a  measure  of  the  degree  of 
danger;  that  albuminuria  adds  greatly  to  the  danger:  that  the  presence  of 
acetone  in  the  urine,  and  also  the  presence  of  ammonia,  gives  a  bad  prognosis. 
Philhps's  conclusions  as  to  when  to  operate  and  when  to  refuse  operation  are 
as  follows  ("Lancet,"  ]May  10  and  17.  1902):  An  operation  for  malignant 
disease  in  a  diabetic  can  be  performed  if  the  operation  would  be  proper  on  a 
non-diabetic  individual.  Large  abdominal  tumors  can  be  removed.  Cos- 
metic operations  are  justifiable  if  the  general  health  is  good  and  there  is  not 
marked  arterial  disease  or  nerve  degeneration.  Operation  is  justifiable  in 
all  emergencies  without  regard  to  the  condition  of  the  urine.  In  a  diabetic 
with  a  surgical  malady  it  is  often  possible  to  lessen  danger  by  preliminan,' 
treatment.  Only  an  operation  of  the  greatest  urgency  should  be  performed 
if  over  i  gram  of  ammonia  is  excreted  during  twenty-four  hours;  and  if 
aceto-acetic  acid  or  much  albumin  is  present,  every  case  but  the  most  urgent 
should  be  postponed  and  subjected  to  medical  treatment. 

I  would  add  to  the  conclusions  of  Phillips  that  the  anesthetic  is  a  danger 
to  the  kidneys  irritated  by  the  secretion  of  sugar,  and  it  is  desirable,  when 
possible,  to  use  local  anesthesia,  or.  as  Robt.  T.  ^lorris  advises,  nitrous  oxid 
and  oxygen  ("Medical  News."  June  29.  1901). 

Gangrene  from  Ergotism. — Ergotism  is  a  diseased  condition  resulting 
from  eating  bread  made  v.-iih  rye  which  has  been  attacked  by  a  fungus  (Clavi- 
ceps  purpurea).  In  former  days  it  was  not  unusual  to  have  epidemics  of 
ergotism  from  time  to  time,  but  at  present  the  disease  is  found  in  individuals 
or  at  most  in  a  few  of  a  community.  Ergotism  is  ver\-  rare  in  the  United 
States.  It  is  never  seen  in  unweaned  children.  The  ingestion  of  ergot  in 
quantity  sufficient  to  produce  chronic  poisoning  causes  tonic  contraction  of 
the  peripheral  blood-vessels,  degeneration  of  the  inner  coat,  and  thrombosis 
of  some  arterioles.  It  is  also  maintained  that  degeneration  of  the  posterior 
columns  of  the  spinal  cord  takes  place. 

The  eating  of  bread  made  of  diseased  rye  provokes  gastro-enteritis.  the  evi- 
dences of  which  are  abdominal  pain  of  a  crampy  character,  vomiting,  diarrhea 
and  exhaustion.  The  patient  complains  of  formication  and  itching  of  the 
skin  of  the  extremities:  severe,  cramp-like,  and  tingling  pains  in  the  limbs, 
and  disorder  of  vision.  The  pulse  becomes  small  and  slow.  In  some  cases 
very  painful  spasms  attack  the  muscles  of  the  extremities  and  finally  tonic 
spasm  is  noted  and  the  patient  probably  perishes  from  exhaustion  after  de- 
veloping general  convulsions  and  passing  into  coma.  In  other  cases  certain 
areas  exhibit  "gradual  blood-stasis"  (Osier),  anesthesia,  and  finally  gan- 
grene. The  gangrene  is  dry  and  peripheral.  It  usually  attects  the  fingers  or 
toes,  but  may  involve  an  entire  limb,  and  may  be  .symmetrical.  Chronic  ergot- 
ism is  usually  recovered  from,  but  acute  ca.ses  die  in  from  seven  to  ten  days.* 

Trealmeni. — Ergotism  is  treated  by  forbidding  the  eating  of  the  poison- 
ous bread,  allaying  gastro-enteric  inflammation,  favoring  elimination  and 
administering  nourishment  and  stimulants.  If  gangrene  is  threatened,  en- 
deavor to  prevent  it  by  gentle  massage  and  the  application  of  warmth.  If 
superficial  gangrene  occurs,  dress  with  hot  antiseptic  fomentations  and  elevate 

*Pick,  in  Heath's  "Surgical  Dictionan. " 


Noma  149 

the  part,  and  every  day  take  scissors  and  forceps  and  remove  the  loose  crusts. 
If  deeper  and  more  extensive  gangrene  arises,  wait  for  a  Hne  of  demarcation 
and  amputate  above  it. 

Gangrene  from  Frost-bite. — Frost-bite  is  most  common  in  the  fingers, 
toes,  nose,  and  ears,  but  the  genital  organs,  the  cheeks,  the  chin,  the  feet  and 
legs,  and  the  hands  and  arms  may  be  attacked.  Cold  causes  a  primary  con- 
traction of  the  vessels  and  pallor  and  numbness  of  the  part.  After  reaction 
the  vessels  dilate,  the  part  reddens  and  swells,  and  a  burning  sensation  or 
actual  pain  is  experienced.  In  a  trivial  frost-bite  the  swelling  and  redness 
usuallv  disappear  after  a  few  days,  but  in  some  cases  the  redness  is  permanent, 
and  in  manv  cases  the  redness  returns  under  the  influence  of  shght  cold  (see 
Chilblains). 

In  a  more  severe  frost-bite  the  affected  part  becomes  purple  and  covered 
with  vesicles,  and  gangrene  may  or  may  not  follow.  When  a  part  has  been 
badlv  frozen  the  peripheral  portion  dries.  The  part  is  deprived  of  all  blood 
because  of  contraction  of  the  vessels  and  because  plasma  coagulates  at  a  few 
degrees  above  freezing.  Cold  disorganizes  the  blood,  breaking  up  white 
corpuscles  with  the  liberation  of  fibrin  ferment  and  coagulation  of  plasma, 
and  destruction  of  red  corpuscles  with  the  liberation  of  hemoglobin  subse- 
quenrlv  takes  place.  The  thrombosis  which  is  established  prevents  circula- 
tion, and  the  tissue-cells  are  damaged  beyond  repair.  The  part  is  bloodless 
and  anesthetic,  and  a  line  of  demarcation  forms.  Hence  we  note  that  severe 
frost-bite  causes  dry  gangrene.  If  a  part  which  is  not  so  badly  frozen  is 
brought  suddenly  into  a  warm  atmosphere,  hyperemia  takes  place  when  the 
blood  runs  into  the  frosted  tissues,  blebs  form,  and  moist  gangrene  may  result. 
Areas  of  superficial  gangrene  are  not  uncommon. 

Treatment  of  Frost-bite  and  oj  Gangrene  from  Frost-bite. — A  frost-bite  in 
which  the  skin  is  livid  and  not  as  yet  gangrenous  should  be  treated  by  frictions 
with  snow  or  rubbing  with  towels  soaked  in  iced  water.  As  the  skin  becomes 
warmer  and  congestion  disappears  the  part  should  be  wrapped  in  cotton- 
wool. A  sufferer  from  frost-bite  should  not  suddenly  be  brought  into  a  warm 
room.  \\Tien  gangrene  follows  frost-bite,  if  only  small  areas  are  invohed,  allow 
the  dead  parts  to  come  away  spontaneously,  applying  in  the  mean  while  hot 
antiseptic  fomentations.  If  separation  be  delayed  by  cartilage,  ligament,  or 
bone,  cut  through  the  retaining  structure.  If  amputation  becomes  necessary, 
await  a  line  of  demarcation,  as  it  is  not  possible  to  be  certain  how  high  tissue 
damage  extends,  and  to  amputate  through  devitalized  parts  would  mean 
renewed  gangrene. 

Noma. — Noma  is  a  rapidly  spreading  gangrenous  process  which  is  most 
apt  to  begin  upon  the  mucous  membrane  of  the  gums  or  cheeks.  Xoma  of 
this  region  is  known  as  cancrum  oris.  Occasionally  it  begins  in  the  ears,  the 
genitals,  or  the  rectum.  When  it  attacks  the  vulva  it  is  called  noma  ptidendi. 
It  may  originate  in  the  mouth  and  subsequently  attack  other  regions.  Xoma 
is  a  very  rare  disease,  is  chietly  met  with  in  children  between  the  ages  of  three 
and  ten,  but  it  can  attack  older  persons.  (O.  Zusch.  in  "  Mijnchener  medicin- 
ische  Wochenschrift."  for  May  14.  igoi.  reports  a  case  in  a  man  sixty-six 
years  of  age.)  It  occurs  in  girls  oftener  than  in  boys.  The  disease  is  most 
frequently  encountered  in  children  recovering  from  an  acute  disease.  It  is 
seen  after  scarlatina,   typhoid,   pneumonia,   dysentery,   and  especially  after 


150  Mortification,  Gangrene,  or  Sphacelus 

measles;  in  fact,  Osier  says  that  over  one-half  the  cases  follow  measles. 
Children  of  tuberculous  tendencies  seem  more  liable  than  others.  Young  chil- 
dren who  live  amid  filth  and  squalor  in  damp  and  ill-lighted  apartments  are 
most  prone  to  suffer,  but  that  such  conditions  are  not  essential  to  the  genesis 
of  the  disease  is  shown  by  the  report  of  an  epidemic  of  noma  in  the  Albany 
Orphan  Asylum.  In  this  excellently  situated,  well-lighted,  and  well-ventilated 
building  the  children  are  carefully  fed  and  cared  for,  and  yet  sixteen  cases  of 
noma  occurred  after  an  epidemic  of  measles.  (See  "An  Epidemic  of  Noma," 
by  Geo.  Blumer  and  Andrew  MacFarlane,  in  "  Amer.  Journal  of  Med. 
Sciences,"  Nov.,  1901.)  The  disease  is  thought  by  many  to  be  due  to  pus 
organisms.  Lingard  describes  a  bacillus  which  he  considers  causative. 
Blumer  and  MacFarlane  conclude  that  the  disease  begins  as  a  simple  infec- 
tion and  a  mixed  infection  takes  place  later.  The  mixed  infection  is  not  always 
due  to  the  same  organism,  but  is  usually  due  to  a  long  organism  of  a  leptothrix 
type  ("  Amer.  Journal  of  Med.  Sciences,"  Nov.,  igoi). 

Symptoms. — The  disease  begins  as  a  sloughing  ulcer,  and  thrombosis  and 
gangrene  soon  begin.  The  edges  of  the  ulcer  are  dark  red  and  indurated.  The 
gangrene  usually  spreads  with  very  great  rapidity,  but  in  some  cases  it  remains 
apparently  stationary  for  days  at  a  time.  There  is  little  or  no  pain.  The 
odor  is  horrible.  The  disease  is  frightfully  destructive,  and  if  the  mouth  is 
involved  is  apt  to  destroy  the  cheeks,  lips,  eyelids,  and  large  portions  of  the 
jaws.  There  is  usually  fever,  but  the  temperature  may  be  normal  or  even 
subnormal.  The  pulse  is  rapid  and  exhaustion  appears  early  and  deepens 
rapidly.  The  mortality  is  large;  Bruns  says  70  per  cent.;  Rilliet  and  Barthez 
say  95  per  cent.  ("Amer.  Journal  of  Med.  Sciences,"  Nov.,  1901).  The 
cause  of  death  is  exhaustion,  pyemia,  or  septic  bronchopneumonia. 

Treatment. — Administer  an  anesthetic  and  destroy  the  gangrenous  area 
with  the  Paquelin  cautery.  In  noma  of  the  mouth  chloroform  is  used  instead 
of  ether  because  the  hot  iron  is  to  be  applied  in  a  region  surrounded  with 
anesthetic  vapor  and  ether  vapor  is  inflammable.  In  noma  in  some  other 
region  ether  can  be  given.  After  cauterization  directions  are  given  to  wash 
the  part  every  few  hours  with  peroxid  of  hydrogen,  irrigate  it  with  hot  salt 
solution  or  boracic  acid  solution,  and  dress  it  with  compresses  soaked  in 
Labarraque's  solution  (Blumer  and  MacFarlane,  in  "  Amer.  Journal  of  Med. 
Sciences,"  Nov.,  1901).  Nourishing  food  is  given  at  frequent  intervals, 
alcohol  is  administered,  and  strychnin  is  used  to  combat  weakness.  If  the 
surgeon  succeeds  in  arresting  the  gangrene  it  will  probably  be  necessary  later 
to  perform  a  plastic  operation  in  order  to  replace  loss  of  substance. 

Sloughing  is  a  process  by  which  visible  portions  of  dead  tissue  are  sepa- 
rated. These  visible  portions  are  called  "sloughs";  if  they  were  large,  they 
would  be  called  "gangrenous  masses."  A  large  septic  slough  is  a  gangrenous 
mass;  a  small  gangrenous  mass  is  a  slough;  there  is  no  difference  in  the  pro- 
cess, which  corresponds  to  the  formation  of  a  line  of  demarcation. 

Treatment. — Sloughing  requires  thorough  and  frequent  irrigation  with 
an  antiseptic  fluid,  removal  of  the  sloughs,  and  antiseptic  treatment.  An 
irrigator  can  be  improvised  from  an  ordinary  bottle  (Fig.  55).  Antiseptic 
fomentations  are  applied  until  granulation  is  well  advanced.  In  some  cases 
continuous  irrigation  with  a  hot  antiseptic  fluid  is  useful ;  in  other  cases  con- 
tinued immersion  in  a  hot  antiseptic  solution  is  employed. 


Decubitus,  Decubital  Ganerene,  or  Bed-sore 


151 


-^J 


Phagedena  is  a  process  of  ulceration  (most  common  in  venereal  sores)  in 
which  the  surrounding  tissues  are  rapidly  eaten  up,  the  sore  becoming  jagged 
and  irregular,  with  a  sloughy  floor  and  thin  edges.  The  dis- 
charge is  thin  and  reddish,  and  the  encircling  tissues  are 
deeply  congested.  This  ulcer  has  no  tendency  to  heal. 
Phagedena  may  attack  wounds,  but  in  this  age  is  almost 
never  seen.  When  it  does  so  the  wound  discharge  is  ar- 
rested, the  parts  about  the  wound  become  dark  red  and 
swollen,  a  black  slough  forms  upon  the  wound  and  the  process 
spreads  rapidly  in  all  directions.  The  process  when  it  at- 
tacks a  wound  is  similar  to  or  identical  with  a  mild  case  of 
hospital  gangrene,  differing  from  the  gangrene  in  the  fact 
that  in  most  cases  a  line  of  demarcation  forms  and  the  de- 
pression is  not  so  great.  Phagedena  is  probably  due  to 
mixed  infection  with  pus  organisms. 

The  treatment  of  phagedena  consists  in  repeated  touch- 
ing with  tincture  of  chlorid  of  iron  and  the  local  use  of  iodo- 
form, the  employment  of  continued  irrigation  or  immersion 
in  hot  antiseptic  fluids,  or  the  application  of  the  cautery, 
chemical  or  actual.  After  using  the  cautery  the  part  is 
dressed  with  hot  antiseptic  fomentations.  Whatever  else  is 
done,  tonics,  stimulants,  and  nutritious  diet  must  be  given 
and  opium  is  often  required. 

Decubitus,  Decubital  Gangrene,  or  Bed=sore.— A 

bed-sore  is  the  result  of  local  failure  of  nutrition  in  a  person 
whose  tissues  are  in  a  state  of  low  vitality  from  age,  disease, 
or  injury.  The  arterial  condition  of  the  aged  favors  the 
development  of  bed-sores.  Such  sores  are  due  to  pressure, 
aided  it  may  be  by  some  slight  injury  or  by  the  irritation  pro- 
duced by  urine,  feces,  sweat,  crumbs  or  other  foreign  bodies  in  the  bed  or  by 
wrinkling  of  the  sheets.  The  pressure  destroys  vascular  tone,  stasis  results, 
thrombosis  occurs,  and  gangrene  follows.  In  some  cases,  after  pressure  is  re- 
moved there  are  stasis,  vesication,  suppuration,  and  the  formiation  of  an  ugly 
ulcer,  surrounded  by  a  zone  of  swelling  and  hyperemia.  These  ordinary 
pressure-sores  arise  like  splint-sores  due  to  the  pressure  of  a  splint  upon  the 
tissues  over  a  bony  prominence.  They  occur  over  the  heels,  elbows,  scapula:, 
trochanters,  sacrum,  and  nucha.  The  pressure  interferes  with  the  blood-supply, 
the  weakened  tissues  inflame,  vesication  occurs,  sloughs  form,  and  an  ugly  ulcer 
is  exposed.  When  a  bed-sore  is  about  to  forin,  the  skin  becomes  red  and 
edematous.  Pressure  with  the  finger  drives  the  color  out  rather  slowly.  The 
color  becomes  purple  or  black,  a  slough  forms  and  separates,  and  a  large, 
irregular,  foul  cavity  is  exposed.  The  discharge  is  profuse  and  offensive. 
The  parts  about  are  swollen  and  red.  If  the  sore  is  not  upon  an  anesthetic 
part,  much  suffering  is  produced  by  it.  Bed-sores  are  most  common  in 
paralyzed  parts;  such  parts  are  anesthetic,  and  injurious  pressure  is  not  painful 
and  does  not  attract  attention,  and  in  such  parts  there  is  vasomotor  paresis. 

The  acute  bed-sores  of  Charcot  are  seen  during  certain  diseases  and 
after  some  injuries  of  the  nervous  system.  These  sores  are  usual  over  the 
sacrum  in  acute  myelitis,  and  may  appear  in  four  or  five  days  after  the  begin- 


F'g  55-  — Im- 
provised appara- 
tus for  the  irriga- 
tion of  a  wound. 


152  ^Mortification,  Gangrene,  or  Sphacelus 

ning  of  that  disease  or  the  infliction  of  an  injury  upon  the  spinal  cord.  The 
surgeon  sees  acute  bed-sores  upon  the  buttock  of  the  paralyzed  side  after 
brain-injuries,  and  over  the  sacrum  in  spinal  injuries.  Some  beheve  these 
sores  are  due  to  vasomotor  disorder;  but  others,  notably  Charcot,  attribute 
them  to  disturbance  of  the  trophic  nerves  or  centers. 

Treatment  of  Bed-sores. — The  "ounce  of  prevention"  is  here  invalu- 
able. From  time  to  time,  if  possible,  alter  the  position  of  the  patient,  keep 
him  clean,  maintain  the  blood-distribution  to  the  skin  by  frequent  rubbing 
with  alcohol  and  a  towel,  keep  the  sheet  clean  and  smooth,  and  in  some  situa- 
tions use  a  ring-shaped  air-cushion  to  keep  pressure  from  the  part.  When 
congestion  appears  {paratrimma,  or  beginning  sore),  at  once  use  an  air-cushion 
or  a  water-bed  and  redouble  the  care  to  frequently  change  the  position  of  the 
patient.  Not  only  protect,  but  also  harden,  the  skin.  Wash  the  part  twice 
daily  and  apply  spirits  of  camphor  or  glycerol  of  tannin;  or  rub  with  salt  and 
whiskey  (oij  to  Oj) ;  or  apply  a  mixture  of  oSS  of  powdered  alum,  f  §ij  of 
tincture  of  camphor,  and  the  whites  of  four  eggs;  or  paint  with  corrosive  subli- 
mate and  alcohol  (gr.  ij  to  .3j) ;  or  apply  tannate  of  lead  or  equal  parts  of  oil 
of  copaiba  and  castor  oil;  or  paint  upon  the  part  a  protective  coat  of  flexible 
collodion. 

When  the  skin  seems  on  the  verge  of  breaking,  paint  it  with  a  solution  of 
nitrate  of  silver  (gr.  xx  to  .5J).  When  the  skin  breaks,  a  good  plan  of  treat- 
ment is  to  touch  once  a  day  with  a  solution  of  silver  nitrate  (gr.  x  to  oj)  and  cover 
with  zinc-ichthyol  gelatin.  We  can  wash  the  sores  daily  with  i  :  2000  corrosive 
sublimate  solution,  dust  with  iodoform,  and  cover  with  soap  plaster,  with  lint 
spread  with  zinc  ointment,  or  with  dry  aseptic  gauze.  When  sloughs  form, 
cut  most  of  them  off  with  scissors  after  cleaning  the  parts,  slit  up  sinuses,  and 
use  antiseptic  fomentations.  In  sloughing  Dupuytren  employed  pieces  of 
lint  wet  with  lime-juice  and  dusted  the  sore  with  cinchona  and  charcoal. 
In  obstinate  cases  use  the  continuous  hot  bath.  When  the  sloughs  separate, 
dress  antiseptically  or  with  equal  parts  of  resin  cerate  and  balsam  of  Peru. 
If  healing  is  slow,  touch  occasionally  with  a  solution  of  silver  nitrate  (gr.  x 
to  Sj).  Bed-sores,  being  expressive  of  lowered  vitality,  demand  that  the 
patient  shall  be  stimulated,  shaU  be  well  nourished,  and  shall  sleep  soundly. 

Lud wig's  Angina  {Angina  Ludovici). — This  disease  is  a  streptococcus 
infection  about  the  submaxillary  gland  and  the  cellular  tissue  beneath  the 
mucous  membrane  of  the  floor  of  the  mouth  and  of  the  upper  portion  of  the 
neck.  The  inflammation  eventuates  in  suppuration  and  gangrene.  The 
disease  arises  as  a  painful  swelHng  in  the  neighborhood  of  the  submaxillary 
gland.  The  .swelling  rapidly  increases,  involves  the  neck  and  floor  of  the 
mouth,  causes  great  difficulty  in  opening  the  mouth  and  in  swallowing  and 
may  lead  to  edema  of  the  glottis.*  The  constitutional  symptoms  are  those 
of  septicemia  or  pyemia.  The  disease  may  arise  in  an  apparently  healthy 
man  or  during  or  after  an  infectious  fever.  The  streptococci  enter  from  the 
mouth  by  way  of  abrasions,  wounds,  ulcerations,  or  dental  caries.  It  may 
be  caused  V^y  delayed  development  of  the  third  molar,  necrosis  of  the  tooth  and 
alveolar  process  taking  place  and  an  abscess  forming  (G.  G.  Ross,  "Annals 
of  Surgery,"  June,  1901). 

*  Tillman' .s  "Text-hook  of  Suij^ci  y,"  lian.ilated  by  I>.  '\  .   i  ilton. 


Post-febrile  Gangrene  153 

Treatment. — At  once  incise  below  the  body  of  the  lower  jaw,  open  the 
submaxillary  space,  cut  away  gangrenous  tissue,  paint  the  wound  with  pure 
carbolic  acid,  pack  with  iodoform  gauze,  and  apply  hot  antiseptic  fomenta- 
tions.    The  constitutional  treatment  is  that  of  septicemia. 

Carbolic  Acid  Gangrene. — Dressings  moistened  with  a  solution  of 
carbolic  acid  of  a  strength  of  from  3  to  5  per  cent,  may,  if  wrapped  for  a 
number  of  hours  around  a  finger  or  toe,  cause  dry  gangrene.  There  is  but 
little  danger  when  such  dressings  are  applied  to  the  tissues  of  the  trunk, 
because  these  thicker  tissues  are  better  nourished  and  cannot  be  completely 
surrounded  with  the  wet  dressings.  The  application  of  strong  acid  rarely 
causes  gangrene,  but  Levan  found  14  reported  cases  in  which  it  did  (J. 
Levan,  in  "  Centralbl.  f.  Chir.,"  August  14,  1897).  The  continuous  applica- 
tion of  a  weak  solution  is  very  dangerous  and  ought  never  to  be  employed. 
The  author  has  seen  3  cases.  Harrington  saw  18  cases  of  gangrene  in  5 
years  in  the  Massachusetts  General  Hospital,  and  collected  132  cases  from 
literature  ("Boston  Med.  and  Surg.  Jour.,"  May  2,  1901).  Carbolic  acid 
gangrene  is  due  to  great  exudation  into  the  cellular  tissue,  blocking  the  circu- 
lation (Housell),  and  the  production  of  arterial  thrombi,  a  condition  to  which 
the  patient  is  predisposed  by  the  injury  and  often  by  tight  bandaging.  The 
dressing  is  frequently  applied  by  a  druggist;  it  produces  anesthesia  of  the 
part,  and  the  dressing  is  often  not  removed  for  days  although  gangrene  may 
be  progressing  beneath.  In  the  author's  3  cases  there  was  no  smokiness  of 
the  urine  or  any  other  evidence  of  absorption  of  the  drug. 

Treatment. — If  the  gangrene  is  very  superficial,  recovery  may  be  obtained 
by  using  hot  fomentations  and  picking  the  dead  parts  gradually  away.  In 
most  cases  the  finger  or  toe  is  completely  destroyed,  a  line  of  demarcation 
forms,  and  amputation  is  required. 

Post=febrile  Gangrene. — Dry  or  moist  gangrene  may  follow  any  fever, 
but  is  most  frequent  after  typhoid  (may  follow  typhus,  influenza,  measles, 
scarlet  fever,  etc.).  Keen  tells  us  that  the  gangrene  resulting  from  arterial 
obstruction  is  apt  to  be  dry,  and  that  from  venous  obstruction  is  usually 
moist.  The  same  observer  has  collected  203  cases.*  It  is  most  usual  in  the 
lower  extremities,  but  may  appear  in  the  upper  extremities,  cheeks,  ears,  nose, 
genitals,  lungs,  etc.  Some  writers  have  assigned  as  the  cause  weakness  of 
cardiac  action,  but  most  observers  believe  an  obstructing  clot  is  the  usual  cause. 
This  clot  may  come  from  the  heart,  but  is  in  most  cases  secondary  to  end- 
arteritis due  to  the  action  of  the  toxins  of  the  bacilli  of  the  specific  fever. 
Keen  shows  that  in  some  cases  gangrene  is  due  to  obstruction  of  peripheral 
vessels  and  not  of  a  main  trunk.  In  rare  cases  gangrene  arises  after  throm- 
bophlebitis. Gangrene  may  begin  as  early  as  the  fourteenth  day  of  the  fever, 
but  usually  appears  late  in  the  disease  and  may  arise  far  into  convalescence. 
In  the  course  of  a  continued  fever  frequent  examinations  should  be  made  to 
see  that  gangrene  is  not  arising.  Particular  examination  from  time  to  time 
should  be  made  of  the  lower  extremities,  and  in  voung  girls,  of  the  genitals. 
If  gangrene  arises  in  an  extremity,  apply  antiseptic  dressings,  wait  for  a  fine 
of  demarcation,  and  then  amputate.  If  gangrene  occurs  in  other  regions, 
remove  the  dead  tissue  and  employ  hot  antiseptic  fomentations. 

*  Keen  on  the  -'Surgical  Complications  and  Sequels  of  Tviilioii]  Fever." 


154  Mortification,  Gangrene,  or  Sphacelus 

Rules  when  to  Amputate  for  Gangrene. — In  dry  gangrene,  due  to 
obstruction  of  a  non-diseased  artery,  wait  for  a  line  of  demarcation.  In 
senile  gangrene,  if  it  affect  only  one  or  two  toes,  let  the  dead  parts  be  cast  off 
spontaneously.  If  a  greater  area  is  involved  or  the  process  spreads,  amputate 
above  the  knee  without  waiting  for  the  line.  In  ordinary  moist  gangrene,  if 
there  are  not  severe  symptoms  of  sepsis,  and  if  the  gangrene  is  not  rapidly 
progressi\e,  wait  for  a  line  of  demarcation.  In  the  severer  cases  amputate 
at  once  high  up.  In  trmimatic  spreading  gangrene  amputate  at  once.  In 
diabetic  gangrene  amputate  at  once,  high  up.  In  ergot  gangrene,  in  carbolic 
acid  gangrene,  in  post-jehrile  gangrene,  in  Raynaud's  gangrene,  and  in  frost 
gangrene  wait  for  a  hne  of  demarcation. 


Causes  of  Thrombosis 


155 


IX.  THROMBOSIS  AND  EMBOLISM. 

Thrombosis  is  the  ante-mortem  coagulation  of  blood  in  the  heart  or  in  a 
vessel,  the  coagulum  remaining  at  its  point  of  origin  and  plugging  up  the 
vessel  partially  or  completely.  The  process  is  known  as  thrombosis;  the 
clot  is  called  the  thrombus.  This  process  is  an  essential  part  in  the  arrest 
of  hemorrhage;  it  occurs  in  phlebitis  and  arteritis,  and  affords  a  frequent 
basis  for  embolism.  Thrombi  may  form  in  the  veins,  in  the  arteries,  and  in 
the  heart.  Clotting  is  due  to  destruction  of  white  blood-cells,  fibrin  ferment 
being  set  free,  causing  the  union  of  calcium  and  fibrinogen  and  thus  forming 
fibrin.  Thrombosis  is  more  common  in  the  veins  than  in  the  arteries,  the 
slow  blood-current  and  the  existence  of  valves  favoring  the  deposit,  though 
not  causing  it.  A  thrombus  forms  gradually,  being  deposited  layer  by  layer; 
hence  it  is  stratified  or  laminated.  Fig.  56  shows  a  thrombus  in  a  vein.  All 
thrombi  are  either  septic  or  aseptic,  and  they  are  also 
spoken  of  as  fibrinous,  red,  hemostatic,  leukocytic,  etc. 

Causes  of  Thrombosis. — The  essential  cause  of  all 
intravascular  thrombi  is  damage  to  the  endothelial  coat. 
Anv  condition  which  causes  the  blood  to  contain  an  ex- 
cess of  fibrin-forming  elements  favors  thrombosis,  in  the 
sense  that  a  slight  injury  of  the  vascular  endothelium  will 
be  followed  by  clot  formation.  Among  conditions  favor- 
ing thrombosis  we  must  note  particularly  slowing  of 
circulation,  however  caused.  A  special  predisposing 
condition  is  the  retarded  circulation  in  tuberculosis, 
influenza,  and  fevers,  the  blood  clotting  behind  the 
vein-valves  after  the  endothelium  has  been  damaged 
by  toxins.  Among  other  favoring  states  are  inflamma- 
tions; wounds;  fractures;  the  pressure  of  a  bandage  or 
of  a  sphnt;  varicose  veins;  hgation  of  a  vessel;  injuries  of  a  vessel;  foreign 
bodies  in  a  vessel;  atheroma  in  arteries;  sutures  in  a  vessel;  certain  diseases, 
such  as  gout,  typhoid  fever,  pregnancy,  and  septic  processes;  phlebitis  or 
arteritis  arising  in  the  vessel  or  from  extension  of  surrounding  inflammation; 
and  entrance  of  specific  organisms. 

It  has  been  asserted  that  so  long  as  the  endothelium  of  a  vessel  is  uninjured 
a  clot  does  not  form.  Slowing  of  the  blood-current  in  aseptic  conditions,  it 
is  now  taught,  will  not  cause  thrombosis.  One  of  the  functions  of  the  endo- 
thelial coat  is  to  keep  the  blood  fluid  by  preventing  corpuscular  disintegration. 
A  thrombus  can  form  only  when  fibrin  ferment  is  set  free,  and  fibrin  ferment 
can  be  set  free  only  when  white  corpuscles  disintegrate.  \\'hen  moving  blood 
coagulates,  the  third  corpuscles  first  settle  out,  and  then  the  leukocytes.  This 
is  known  as  the  white  or  "  ante-mortem  "  thrombus — the  clot  of  moving  blood. 
Thrombi  from  moving  blood  are  rarely  pure  white;  they  contain  some  red 
corpuscles,  forming  mi.xed  thrombi.  The  red  thrombus  plugs  vessels  which 
are  cut  across  or  ligated;  it  also  occurs  in  septic  processes  and  is  formed  after 
death.  A  thrombus  soon  undergoes  a  change.  An  aseptic  clot  usually  "  organ- 
izes"— that  is,  the  clot  is  absorbed  and  replaced  by  fibrous  tissue.  The  walls 
of  the  injured  vessel  become  filled  with  leukocytes,  leukocytes  invade  the  clot, 


Fig.  56. — Thrombus  in  the 
saphenous  vein  (Green). 


156  Thrombosis  and  Embolism 

the  vascular  endothelium  proliferates,  and  the  young  cells  follow  the  colonies 
of  leukocytes  into  the  thrombus.  The  thrombus  is  gradually  removed  by 
leukocytes  and  replaced  by  fibroblasts,  the  new  tissue  is  vascularized  and 
becomes  granulation  tissue,  the  granulation  tissue  is  converted  into  fibrous 
tissue,  and  the  fibrous  tissue  contracts.  In  some  instances  a  thrombus  is 
implanted  on  the  wall  of  the  vessel,  and  the  tube  is  not  permanently  occluded. 
Such  a  condition  may  be  obtained  by  the  application  of  a  lateral  ligature 
about  a  small  tear  in  a  large  vein.  In  most  instances,  after  the  formation  of 
an  intravascular  thrombus,  the  vessel  is  converted  into 
a  narrow  cord  of  fibrous  tissue.  A  thrombus  may  de- 
generate and  break  down  (fatty  degeneration) ,  giving 
rise  to  emboli  or  undergoing  calcification.  A  calcified 
thrombus  in  a  vein  is  known  as  a  phlebolith.  An 
infected  thrombus  may  undergo  Hquef action,  infective 
emboli  being  set  free  (Fig.  57). 

It  was  taught  for  many  years  that  when  an  artery 
is  Hgated  a  thrombus  quickly  forms  and  reaches  to 
the  first  collateral  branch.  This  view  was  formulated 
in  preantiseptic  days.     It  is  now  known  that  when 

F'»- 57- — Infected  thrombus  ......  111  •  n 

of  a  vein  (schematic).  aseptic  hgation  IS  performed  the  thrombus  is  small 
and  rarely  reaches  the  first  collateral  branch;  and 
is  often  actually  absent,  vascular  obhteration  being  obtained  by  prolifera- 
tion of  connective-tissue  cells  and  of  cells  from  the  endothelial  coat.  If 
any  infection  takes  place  the  clot  will  reach  the  first  collateral  branch.  The 
old  rule  of  surgery  was  as  follows:  If  an  artery  is  cut  near  a  large  branch,  tie 
the  branch  as  well  as  the  artery,  in  order  to  permit  of  the  formation  of  a  lengthy 
clot.     This  rule  is  no  longer  followed  unless  infection  exists  or  is  anticipated. 

A  clot  in  a  vein  often  extends  a  long  distance.  The  author  has  seen  in  a 
post-mortem  examination  a  venous  thrombus  reaching  from  the  ankle  to  the 
vena  cava.     A  spreading  clot  of  this  sort  is  known  as  a  propagated  thrombus. 

Symptoms. — The  symptoms  are  dependent  on  the  seat  of  the  obstruc- 
tion. An  organ  or  a  part  of  an  organ  may  exhibit  functional  aberration. 
The  local  signs  in  a  vessel  accessible  to  touch  or  sight  are  the  presence  of  a 
clot;  if  it  be  in  an  artery,  anemia  and  the  absence  of  pulse  below  the  clot; 
if  it  be  a  vein,  swelling  and  edema  below  it.  There  is  usually  pain  at  the 
seat  of  trouble,  and  anesthesia  below  it.  Moist  gangrene  may  follow  venous 
thrombosis,  and  dry  gangrene,  arterial  thrombosis.  Thrombosis  of  the 
mesenteric  vein  is  followed  by  gangrene  of  the  bowel.  Thrombophlebitis  is 
a  spreading  inflammation  of  a  vein  in  which  a  septic  thrombus  forms.  We 
see  this  condition  sometimes  in  the  lateral  sinus  of  the  brain  as  a  result  of 
suppuration  in  the  middle  ear;  in  any  of  the  cerebral  sinuses  after  infected 
compound  fracture  of  the  skull;  and  in  the  uterine  veins  in  puerperal  sepsis. 
Infective  thrombophlebitis  is  an  early  step  in  pyemia.  Thrombo-arteritis 
is  a  spreading  inflammation  of  an  artery  in  which  a  sepdc  thrombus  forms 
or  in  which  a  septic  embolus  lf)dges.  It  occasionally  attacks  an  aneurysmal 
sac. 

Treatment, — If  a  thrombus  forms  in  a  large  vessel  of  a  limb,  raise  the 
limb  a  few  inches  from  the  bed,  keep  it  perfectly  quiet  to  avoid  detachment 
of  fragments  (emboli),  apply  a  bandage  lightly  from  the  toes  up,  and  place 


Embolism 


157 


Fig.  5.^. — Embolus  impacted 
at  bifurcation  of  a  branch  of  the 
pulmonary  artery  (Green). 


warm  bottles  around  the  extremity.  The  great  danger  is  the  formation  of  em- 
boli, hence  movements  and  rough  handling  are  to  be  avoided.  Gangrene  is 
another  danger,  hence  it  is  vi^ise  to  favor  venous  return  and  the  development  of 
the  collateral  circulation  by  warmth,  elevation,  and  bandaging.  In  septic 
thrombophlebitis,  if  the  vessel  is  accessible,  tie  it 
above  and  below  the  clot,  open  the  vessel,  remove 
the  clot,  irrigate,  and  pack  the  wound  with  iodo- 
form gauze.  The  general  treatment  for  a  septic 
condition  should  be  stimulant  and  supporting.  Mas- 
sage is  unsafe  in  any  condition  of  thrombosis,  and 
is  particularly  dangerous  in  septic  thrombosis. 
In  thrombo-arteritis  treat  as  in  the  thrombophle- 
bitis. If  gangrene  follows  thrombosis,  treat  as 
previously  directed  (page  140). 

Embolism  signifies  vascular  plugging  by  a 
foreign  body  (usually  a  blood-clot)  which  has  been 
brought  from  a  distance.  The  foreign  body  is 
called  an  embolus.     Emboli  may  arise  either  in  the 

venous  or  in  the  arterial  system,  but  lodge  only  in  an  artery,  in  capillaries, 
or  in  the  veins  of  the  liver.  The  initial  thrombus  may  form  upon  a  dis- 
eased heart-valve  or  in  a  vein.  It  may  be  composed  of  fat,  micro- 
organisms, air,  or  a  portion  of  a  tumor.  An  embolus  is  arrested  when  it 
reaches  a  vessel  whose  diameter  is  less  than  its  own.  It  is  usually  caught 
just  above  a  bifurcation.     When  an    embolus  lodges,  it  at  once  partially 

or  entirely  obstructs  the  circulation,  and  in- 
creases in  size  by  thrombosis.  Fig.  58  shows 
an  impacted  embolus.  A  non-septic  embolus 
usually  "organizes,"  and,  as  described  on 
page  155,  is  replaced  ultimately  by  fibrous 
tissue.  A  soft  embolus  may  disintegrate 
and  permit  the  re-establishment  of  the 
circulation.  An  embolus  may  cause  an 
aneurysm.  A  septic  embolus  breaks  down, 
forms  a  metastatic  abscess,  and  sends  other 
emboli  onward  in  the  blood-stream. 

An  embolus  is  more  serious  than  a 
thrombus:  it  causes  sudden  plugging,  which 
makes  dangerous  anemia  inevitable,  and 
it  will  produce  gangrene  if  the  collateral 
circulation  fails.  Embolism  of  the  mesen- 
teric artery  causes  necrosis  of  the  intestine. 
In  organs  with  terminal  arteries  (spleen,  kidney,  brain,  and  lung)  there  is 
no  collateral  circulation  and  embolism  causes  infarction.  For  instance,  if 
an  embolus  lodges  in  the  lung  it  produces  an  area  of  anemia;  the  removal 
of  all  propulsion  upon  the  venous  blood  causes  it  to  flow  back  and  stag- 
nate, and  vascular  elements  exude,  forming  a  wedge-shaped  area  of  red 
tissue,  the  embolus  being  the  apex  of  the  wedge.  This  is  known  as  the  red 
infarction,  and  is  often  seen  in  the  lung  (Fig.  59).  The  white  infarction, 
seen  in  the  brain  and  kidney,  is  not  due  to  retrogression  of  venous  blood, 


a  V 

F'g-  59- — Diagram  of  a  hemorrhagic 
infarct :  a,  Artery  obliterated  by  an  em- 
bolus (e) ;  V,  vein  filled  with  a  second- 
ary thrombus  (ih)  ;  /,  center  of  infarct, 
which  is  becoming  disintegrated ;  2, 
area  of  extravasation  ;  j,  area  of  col- 
lateral hyperemia  (O.  Weber). 


158  Thrombosis  and  Embolism 

but  is  due  to  anemia  and  resulting  coagulation-necrosis.  A  septic  em- 
bolus causes  septic  thrombosis  and  a  septic  infarction,  and  a  septic  in- 
farction is  followed  by  suppuration  and  the  production  of  a  pyemic  abscess. 
If  emboli  arise  from  a  thrombus  in  one  of  the  veins  of  the  pulmonary  circu- 
lation, they  usually  lodge  in  the  lungs,  and  rarely,  though  occasionally,  pass 
through.  Emboli  formed  in  vessels  of  the  systemic  circulation  lodge  most 
often  in  the  lungs,  brain,  kidney,  or  spleen  (Nancrede).  Emboli  passing 
into  the  portal  vein  lodge  in  the  liver  and  operations  upon  the  rectum  may  be 
followed  by  hepatic  embohsm  and  abscess  of  the  liver. 

Symptoms. — The  symptoms  depend  upon  the  organ  involved.  They 
are  sudden  in  onset,  and  are  due  to  loss  of  function,  which  may  be  permanent 
or  which  may  be  followed  by  inflammation,  softening,  or  gangrene.  Embo- 
lism of  the  cerebral  arteries  may  cause  aphasia,  paralysis,  or  coma.  Embo- 
lism of  the  pulmonary  artery  may  cause  almost  instant  death.  Embolism 
of  a  large  artery  of  a  limb  produces  symptoms  identical  with  thrombus, 
except  more  sudden  and  decided.  This  condition  is  frequently  followed  by 
gangrene.  Embolism  of  the  superior  mesenteric  artery  produces  sym.ptoms 
similar  to  those  caused  by  acute  intestinal  obstruction,  and  results  in  gangrene 
of  a  portion  of  the  intestine. 

Treatment. — The  treatment  of  aseptic  embolism  depends  upon  the  part 
involved.  In  a  limb,  keep  the  part  warm  in  order  to  stimulate  the  collateral 
circulation,  elevate  the  extremity  several  inches  from  the  bed,  apply  a  bandage 
lightly  from  the  periphery,  and  insist  on  perfect  quiet.  Massage  is  unsafe. 
If  gangrene  ensues,  await  a  line  of  demarcation  and  amputate.  In  septic 
thrombo-arteritis  in  an  accessible  region  it  would  be  good  surgery  to  act  as 
in  septic  thrombophlebitis.  After  an  operation  upon  veins  (as  the  operation 
for  varicocele,  for  varix  of  the  leg,  or  for  hemorrhoids),  after  any  cutting 
operation,  and  after  the  infliction  of  a  fracture,  avoid  as  much  as  possible, 
and  for  some  time,  movements  or  handling,  as  fragments  of  thrombus  may 
be  detached. 

Fat =em holism  was  first  described  in  1884  by  von  ReckHnghausen.  It 
is  a  process  which  leads  to  an  accumulation  in  the  capillaries  of  hquid  fat  after 
injuries  of  adipose  tissue,  high  tension  having  forced  the  fat  into  the  open 
mouths  of  veins.  Some  Httle  fat  may  get  into  the  blood  by  means  of  the 
lymphatics.  Fat-embolism  occasionally  arises  during  osteomyelitis,  after 
extensive  bruises,  crushes,  or  lacerations,  and  after  amputations,  fractures, 
resections,  or  rupture  of  the  hver.*  This  fluid  fat  accumulates  especially 
in  the  capillaries  of  the  lungs  and  brain.  It  may  plug  systemic  capillaries. 
If  the  patient  recovers,  he  does  so  because  the  fat  has  been  forced  through 
the  vessels;  if  he  dies,  the  death  results  from  mechanical  hindrance  to  function 
and  nutrition.  Normal  blood  contains  a  small  amount  of  finely  emulsified 
fat  (from  i  to  3  parts  per  1000).  In  a  number  of  physiological  and  patho- 
logical conditions  the  circulating  blood  contains  considerable  free  fat.  It 
may  be  found  in  a  pregnant  woman,  a  nunsing  baby,  a  fat  individual,  or  in 
any  one  during  dige.stion.  "It  has  been  noted  in  the  following  conditions: 
chronic  alcoholism;  diabetes  mellitus;  certain  diseases  of  the  Hver,  heart, 
and  pancreas;  chronic  nephritis;  splenitis;  tuberculosis;  malarial  fever, 
typhus  fever,  Asiatic  cholera;  and  poisoning  by  phosphorus  and  by  carbon 

*  G.  ir.  Makins,  in   Heath's  Dictionary. 


Fat-embolism 


159 


:iU^^ 


Fig.  60. — Fat-embolism  of  the  lung  after  fracture 
of  the  femur.  The  fat-globules  and  masses,  stained 
black  with  osmic  acid,  lie  in  the  capillaries  of  the 
lung.     X  150.     (Hektoen.) 


monoxid.     Lipemia  commonly  occurs  as  the  result  of  lacerated  wounds  of 
the  blood-vessels   situated  in  fatty  tissue,  and   after   fractures   of   the    long 
bones    involving    injury    of    the    fatty    matter"    ("  CUnical    Hematology," 
by   John    C.    DaCosta,    Jr.).      In 
lipemia  fatty  embolism  may  occur 
if  the  amount  of  fat  becomes  exces- 
sive or  if  vascular  damage  favors 
plugging. 

Symptoms. — The  symptoms 
are  those  of  edema  of  the  lungs  and 
exhaustion,  often  with  coma  or  de- 
lirium, and  sometimes,  in  the  begin- 
ning, are  wrongly  thought  to  be  due 
to  shock.  There  are  restlessness, 
dyspnea,  rapid  pulse  and  respira- 
tion, normal  or  subnormal  tem- 
perature, and  pallor  followed  by 
cyanosis.  The  chest  exhibits  many 
coarse    rales,    but    on     percussion 

gives  a  clear  note.  If  pulmonary  edema  becomes  marked,  the  patient 
spits  up  a  bloody  froth.  If  life  is  prolonged  a  day  or  two,  oil  is  found 
in  the  urine.  Small  amounts  of  oil  may  be  found  in  the  urine  after 
serious  injuries  or  operations  when  no  symptoms  of  embolism  exist.  For 
instance,  for  two  or  three  days  after  a  fracture  it  is  often  present. 
Nevertheless,  the  presence  of  the  oil  is  always  a  cause  of  anxiety,  and  is 
often  a  warning.  It  is  maintained  by  Groube  that  the  amount  of  fat 
in  the  urine  is  in  inverse  ratio  to  the  amount  in  the  blood;  the  greater  the 
amount  excreted  in  the  urine,  the  less  the  amount  retained  in  the  blood. 
Hence,  fat  in  the  urine  makes  the  surgeon  anxious,  and  a  sudden  dimi- 
nution of  the  amount  in  the  urine  is  a  sign  of  grave  danger  if  there  de- 
velops increasing  difficulty  in  respiration  ("  Rev.  de  Chir.,"  July,  1895).  The 
inverse  ratio  said  to  be  maintained  between  fat  in  the  blood  and  fat  in  the 
urine,  if  it  really  exists,  is  similar  to  a  finding  of  Lepine  in  diabetes,  that  is, 
if  a  diabetic  is  given  diuretics,  the  sugar  in  the  urine  increases  and  the  sugar  in 
the  blood  decreases.  These  symptoms  never  occur  until  at  least  twelve  hours 
after  the  accident,  and  rarely  before  the  third  day.  The  symptoms  occur 
at  a  later  period  than  those  of  shock,  and  at  an  earher  period  than  those  of 
ordinary  embolism  of  the  lung.  If  some  of  the  oil  is  forced  through  the 
vessels  of  the  lung,  it  will  lodge  in  other  regions  and  produce  other  symptoms. 
Oil  may  appear  in  the  urine  as  above  stated.  Urinary  suppression  may 
occur.  Delirium  may  arise,  there  may  be  twitching,  convulsions,  or  paralysis, 
or  the  patient  may  pass  into  coma.  Severe  cases  of  fat  embolism  are  com- 
monly fatal;  milder  cases  are  often  recovered  from.  I  have  lost  a  case 
operated  upon  for  carcinoma  of  the  breast  from  this  cause. 

Treatment. — The  treatment  consists  in  the  administration  of  stimu- 
lants,'such  as  strychnin,  alcohol,  and  carbonate  of  ammonium,  the  use  of  ex- 
ternal heat;  the  emplovment  of  oxygen  by  inhalation;  and  the  administration 
of  diuretics  and  of  nitroglycerin  hypodermatically.  Artificial  respiration  may 
tide  a  patient  over  a  crisis.     If  an  external  wound  exists,  the  drainage  must 


i6o  Thrombosis  and  Embolism 

be  free,  and  the  damaged  part  should  be  thoroughly  immobilized.  In  order 
to  prevent  fat-embolism  after  a  severe  injury  insist  on  rest.  Massage  used 
early  after  some  injuries  is  dangerous,  as  it  may  force  fluid  fat  into  the  vessels. 
When  a  severe  contusion  causes  the  formation  of  a  large  cavity  filled  with 
blood,  Groube  advises  incision,  to  lessen  the  danger  of  fat-embolism.* 

Air=emboIism, — Air  may  enter  a  vein  during  a  surgical  operation  or 
it  may  be  injected  accidentally  while  giving  a  hypodermatic  injection,  hypo- 
dermoclysis,  or  a  saline  infusion  into  a  vein.  It  is  very  rarely  that  any  symp- 
toms follow.  It  was  long  thought  that  such  an  accident  must  be  extremely 
dangerous.  The  experiments  of  my  colleague.  Professor  Hare,  indicate  that 
quantities  of  air  may  be  injected  into  the  veins  of  a  dog  without  apparent 
harm.  The  entry  of  a  small  amount  of  air  into  the  veins  of  a  human  being 
^\^ll  not  be  apt  to  induce  dangerous  symptoms,  but  it  may  be  fatal.  The 
more  rapidly  it  is  introduced  and  the  greater  the  amount,  the  greater  is  the 
danger.  The  manner  in  which  it  can  induce  death  is  doubtful.  Some  main- 
tain that  it  causes  the  blood  in  the  right  side  of  the  heart  to  froth,  and  thus 
prevents  normal  action  of  the  valves,  the  heart  becoming  unable  to  propel 
blood  through  the  lungs.  If  a  surgeon  divides  a  large  vein,  air  may  be 
sucked  in,  and  there  is  particular  danger  in  such  an  accident  if  a  vein  at  the 
root  of  the  neck  or  a  cerebral  sinus  is  torn  or  incised,  or  if  the  damaged  vessel 
hes  in  scar  tissue  and  cannot  collapse. 

Symptoms. — There  is  a  sucking  sound  and  serious  symptoms  may  or 
may  not  follow.  Twice  I  have  wounded  the  subclavian  vein  and  have  heard 
this  sound,  but  no  alarming  symptoms  developed.  If  serious  symptoms  are 
produced,  they  arise  suddenly,  and  consist  of  extreme  failure  of  circulation, 
gasping  for  air,  convulsions,  and  possibly  death. 

Treatment. — Compress  the  vein  with  the  finger  and  clamp  it  quickly. 
Suspend  the  anesthetic,  lower  the  head,  employ  artificial  respiration  and 
inhalation  of  oxygen,  and  give  strychnin  hypodermatically. 

*Rev.  de  Chin,  July,  1895. 


Sapremia  i6i 


X.  SEPTICEMIA  AND  PYEMIA. 

Septicemia,  or  sepsis,  is  a  febrile  malady  due  to  the  introduction  into 
the  blood  of  pyogenic  organisms  or  the  products  of  pyogenic  organisms  or  of 
saprophytic  bacteria.  There  is  no  one  special  causative  organism,  and  any 
microbe  which  produces  inflammatory  and  febrile  products  may  cause  it. 
Either  streptococci  or  staphylococci  may  be  present.  Pneumococci  are  a 
not  very  unusual  cause.  Septicemia  arises  by  absorption  of  septic  matter 
by  the  lymphatics.  Clinically  we  distinguish  two  forms  of  septicemia:  (i) 
sapremia,  septic  or  putrid  intoxication;  and  (2)  septic  infection,  true  or  pro- 
gressive septicemia.  In  these  conditions  the  area  of  infection  is  usually  dis- 
covered by  the  surgeon;  but  when  it  cannot  be  located,  the  disease  is  called  by 
the  Germans  cryptogenetic  septicemia. 

Sapremia,  Septic  or  Putrid  Intoxication. — This  condition  is  due  to  the 
absorption  of  poisonous  ptomains  from  a  putrefying  area.  The  bacteria 
do  not  enter  the  blood,  but  their  toxins  do,  and,  as  these  toxins  are  active 
poisons,  the  condition  is  comparable  to  poisoning  by  successive  alkaloidal 
injections,  the  symptoms  and  prognosis  depending  upon  the  dose.  Not 
unusually  there  is  absorption  not  only  of  the  toxins  of  saprophytic  bacteria, 
but  also  the  toxins  of  pyogenic  micro-organisms.  Even  if  some  of  the  bacte- 
ria enter  the  blood,  they  do  not  multiply  in  this  fluid.  Slight  symptoms 
and  recovery  follow  a  small  dose;  grave  symptoms  and  death  follow  a  large 
one.  The  poison  does  not  multiply  in  the  blood,  and  a  drop  of  the  blood  of 
a  person  laboring  under  putrid  intoxication  will  not  produce  the  disease  when 
introduced  into  the  blood  of  a  well  person;  in  other  words,  the  disease  is  not 
infective.  Considerable  putrid  material  must  be  absorbed  to  cause  sapremia. 
What  is  known  as  surgical  fever  is  due  to  the  absorption  of  a  small  amount 
of  putrid  or  fermented  wound  fluid,  and  is  in  reality  a  mild  form  of  sapremia. 
If  sapremia  arises,  it  does  so  soon  after  the  infliction  of  a  wound,  and  after  a 
large  rather  than  small  wound,  when  a  considerable  amount  of  wound  fluid  is 
pent  up  under  pressure.  It  may  follow  labor  where  putrid  fluid  is  retained  in 
the  womb,  may  follow  an  injury  of  or  an  operation  upon  a  joint,  may  follow 
amputation  where  decomposing  blood-clot  or  wound  fluid  is  pent  up  within 
the  flaps,  or  may  ensue  upon  an  abdominal  operation  or  injury.  In  sapremia 
there  always  exist  a  considerable  absorbing  surface  and  a  large  amount  of 
dead  matter  which  has  become  putrid.  Roswell  Park  *  points  out  that 
sapremia  arises  from  putrefaction  of  a  blood-clot  or  wound  fluids  which  are 
retained  like  foreign  bodies  in  the  tissues,  and  does  not  arise  from  putrefaction 
of  the  tissues  themselves.  He  speaks  of  the  condition  as  due  to  the  absorption 
of  poison  from  a  "putrid  suppository."  Sapremia  will  not  occur  after  granu- 
lations form.  The  term  putrefaction  is  used  because  this  is  the  usual  change, 
but  any  fermentative  organism  may  cause  the  disorder.  Sapremia  is  a  malig- 
nant form  of  surgical  fever,  and  its  existence  means  an  ill-drained  wound,  and 
a  fermenting  and  probably  putrid  collection  of  blood-clot  or  wound  fluid. 

In  sapremia  there  is  congestion  of  the  stomach,  intestines,  and  other 
abdominal  viscera,  particularly  the  kidneys,  and  also  of  the  brain,  and  numbers 
of  red  blood-cells  disintegrate. 

*  "  Treatise  on  Surgery  by  American  Authors." 


1 62  Septicemia  and  Pyemia 

Symptoms. — The  patient  often  seems  to  react  incompletely  from  the 
injury;  he  feels  miserable,  complains  of  headache,  nausea,  and  pain  in  the 
back  and  limbs;  or,  he  may  react  and  in  a  day  or  two  develop  this  condition 
of  malaise.  In  some  cases  an  aseptic  fever  is  directly  succeeded  by  sapremia. 
In  most  cases  of  sapremia,  between  twenty-four  hours  and  two  or  three  days 
after  labor,  after  an  injury,  or  after  an  operation,  there  is  a  chill,  or  at  least  a 
chilly  sensation,  though  in  some  cases  this  is  wanting.  The  temperature 
rapidly  rises  to  103°  F.  or  even  more.  There  are  severe  headache,  dry  and 
coated  tongue,  rapid  and  weak  pulse,  nausea,  and  often  vomiting,  diarrhea, 
great  prostration,  restlessness,  muscular  twitching,  and  active  delirium.  The 
wound  is  found  to  be  foul,  and  commonly  there  is  drying  up  of  wound  discharge. 
There  is  diminution  or  suppression  of  urine,  and  a  strong  tendency  to  conges- 
tion of  various  organs.  Jaundice  is  not  unusual.  Petechial  spots  are  frequently 
noticed  upon  the  skin.  They  occur  also  upon  mucous  membranes  and  serous 
surfaces,  and  result  from  the  plugging  of  small  vessels  with  detritus  of  broken- 
down  red  corpuscles  and  consequent  vascular  rupture.  Great  elevation  of 
temperature  often  precedes  death.  In  some  cases  the  dose  of  poison  is 
so  large  that  the  patient  passes  into  rapid  collapse  without  preliminary 
fever.  Some  cases  recover  if  the  initial  dose  is  not  overwhelming  and  if 
additional  doses  are  not  absorbed.  Many  cases  die  of  exhaustion.  Some 
become  linked  with  fatal  pyemia  or  septicemia.  Hemoglobin  and  red  blood- 
corpuscles  are  rapidly  and  notably  diminished.  Distinct  leukocytosis  exists, 
except  in  those  cases  in  which  the  organism  is  overwhelmed  with  the  poison 
and  is  unable  to  react.  Cover-glass  preparations  do  not  show  organisms, 
and  cultures  from  the  blood  are  sterile. 

Treatment. —  The  treatment  consists  in  at  once  draining  and  asepticizing 
the  putrid  area  and  administering  very  large  doses  of  alcohol  and  large  me- 
dicinal doses  of  strychnin  and  digitahs.  The  patient  should  be  purged  and 
diaphoresis  favored.  The  hot  bath  is  valuable  to  cause  sweating.  The 
action  of  the  kidneys  must  be  maintained  if  possible.  Purgatives,  diuretics, 
and  diaphoretics  are  given  to  aid  in  removing  the  toxin,  and  stimulants  are 
used  to  sustain  the  strength  of  the  patient  during  the  elimination  of  the  poison. 
Vomiting  is  allayed  by  champagne,  cracked  ice,  calomel,  cocain,  or  carbolic 
acid  with  bismuth.  Food  should  be  administered  every  three  hours.  The 
patient  is  fed  on  milk,  milk  and  lime-water,  liquid  beef-peptonoids,  beef- 
juice,  and  other  concentrated  foods.  Quinin  in  stimulant  doses  is  of  value. 
Antipyretics  are  useless.  The  use  of  saline  fluid  by  hypodermoclysis  or  intra- 
venous infusion  dilutes  the  poison  and  stimulates  the  heart,  skin,  and  kidneys 
to  activity.  Visceral  compHcations  must  be  watched  for  and  should  be 
promptly  treated  if  discovered.  Among  the  possible  visceral  complications 
are  nephritis,  cholecystitis,  enteritis,  hepatitis,  peritonitis,  pleuritis,  empyema, 
bronchopneumonia,  pericarditis,  and  endocarditis.  Antistreptococcic  serum 
is  usele.ss  in  sapremia. 

Septic  Infection,  or  True  Septicemia. — This  condition  is  a  true  infective 
process.  In  .sapremia  the  blood  contains  toxins  of  putrefactive  bacteria, 
but  not  the  bacteria  themselves.  In  septic  infection  the  blood  contains 
both  pyogenic  toxins  and  multiplying  ])yogenic  bacteria.  In  sapremia  the 
causative  condition  is  putrid  material  lodged  like  a  foreign  body  in  the  tissues. 
In  septic  infection  the  tissues  themselves  are  suppurating,  and  both  bacteria 


Septic  Infection,  or  True  Septicemia  163 

and  toxins  are  being  absorbed  by  the  lymphatics.  Of  course,  septic  infection 
may  be  associated  with  septic  intoxication  or  may  follow  it.  In  suppurative 
fever  the  tissues  suppurate,  but  only  the  pyogenic  toxins  are  absorbed,  and 
not  the  pyogenic  bacteria.  In  septic  infection  both  the  pyogenic  bacteria 
and  toxins  enter  the  blood,  and  the  bacteria  multiply  in  the  blood  and  pro- 
duce continually  increasing  amounts  of  poison.  The  symptoms  of  sapremia 
depend  on  the  dose.  In  septic  infection  only  a  small  number  of  organisms 
may  get  into  the  blood,  but  they  multiply  enormously.  The  pus  microbes 
cause  true  septicemia,  and  reach  the  blood  chiefly  through  the  lymphatics, 
but  to  some  degree  by  penetrating  the  walls  of  vessels.  A  drop  of  blood  from 
a  man  with  septic  infection  will  reproduse  the  disease  when  injected  into  the 
blood  of  an  animal;  hence  the  disease  is  truly  infective.  The  wound  in  such 
cases  is  often  small,  but  may  be  large,  and  is  commonly  punctured  or  lacer- 
ated, and  the  disease  begins  later  after  the  infliction  of  a  wound  than  does 
sapremia.  No  wound  may  be  discoverable,  the  infection  having  arisen  from 
an  unrecognized  focus  of  suppuration — for  instance,  gonorrhea,  middle-ear 
disease,  dental  caries,  tonsillar  suppuration,  appendicitis,  etc.  Septicemia 
in  which  the  initial  atrium  of  infection  is  not  discovered  is  called  cryptogenetic 
septicemia. 

The  bacteria  which  exist  in  the  blood  and  organs  are  usually  staphylococci 
or  streptococci,  often  both.  Pneumococci  or  colon  bacilli  in  some  cases  are 
causative.  The  blood  is  found  to  have  lost  much  of  its  coagulating  power; 
it  remains  fluid  for  some  time  after  death,  quantities  of  red  corpuscles  are 
destroyed,  and  minute  hemorrhages  take  place  in  the  brain,  mucous  mem- 
branes, skin,  serous  membranes,  muscles,  and  various  viscera.  There  may 
be  inflammation  of  synovial  and  serous  membranes.  There  is  congestion  of 
the  gastro-intestinal  tube  and  of  the  abdominal  viscera.  The  lymph-glands 
are  larger  than  normal  and  the  spleen  is  notably  enlarged.  The  wound  con- 
tains numbers  of  bacteria. 

Symptoms. — The  type  of  this  condition  is  met  with  in  puerperal  septicemia 
or  in  an  infected  wound.  When  septicemia  arises  from  an  infected  wound, 
red  lines  due  to  lymphangitis  are  usually  seen  about  it,  and  there  is  enlarge- 
ment of  related  lymphatic  glands.  In  some  cases,  however,  the  wound  and 
the  parts  about  it  look  normal.  The  post-operative  rise  may  continue  for  an 
undue  time  and  septicemia  develop.  Septicemia  may  arise  during  the  exis- 
tence or  after  the  abatement  of  sapremia,  or  may  arise  when  the  aseptic  fever 
has  passed  away  and  when  there  has  been  no  putrid  intoxication.  It  begins 
in  from  four  to  seven  days  after  labor  or  an  injury,  usually  with  a  chill,  which 
is  followed  by  fever,  at  first  moderate,  but  soon  becoming  high.  In  some 
cases  there  is  a  chilly  sensation,  but  no  distinct  chill.  There  is  always  great 
prostration  even  before  the  chill.  The  fever  presents  morning  remissions  and 
evening  exacerbations,  and  may  occasionally  show  an  intermission.  When 
the  remission  begins  there  is  a  copious  sweat.  As  the  case  progresses  the 
temperature  may  fluctuate,  and  it  often  rises  very  high  before  death.  The 
pulse  is  small,  weak,  very  frequent,  and  compressible.  The  tongue  is  dry 
and  brown,  with  a  red  tip.  Sordes  gather  on  the  teeth  and  gums.  Vomiting 
is  frequent,  and,  as  a  rule,  there  is  diarrhea.  Low  delirium  alternates  with 
stupor,  and  coma  is  usual  before  death.  The  great  prostration  is  a  noticeable 
and  characteristic  feature  of  the  sufferer  from  septicemia.     There  are  sub- 


164  Septicemia  and  Pyemia 

sulius  tendinum  and  carphologia.  Toward  the  end  the  face  often  becomes 
Hippocratic.  Visceral  congestions  occur.  The  spleen  is  enlarged,  ecchy- 
moses  and  petechiae  are  noted,  urinary  secretion  becomes  scanty  or  is  sup- 
pressed, and  the  wound  becomes  dry  and  brown.  Blood-examination  detects 
a  rapid  and  great  diminution  in  red  corpuscles  and  hemoglobin.  The  anemia 
is  in  many  cases  profound.  There  is  marked  leukocytosis  except  when  the 
system  is  overwhelmed  by  the  poison.  Cover-glass  preparations  made  from 
blood  may  show  bacteria,  but  often  fail  to  do  so.  Cultures  from  the  blood 
are  sterile  in  most  cases,  but  not  in  all.  A  negative  finding  does  not  disprove 
the  existence  of  septic  infection;  a  positive  finding  is  of  conclusive  diagnostic 
value. 

The  prognosis  is  bad,  and  in  some  malignant  cases  death  occurs  within 
twenty-four  hours,  but  mild  cases  often  recover.  Welch  points  out  that 
finding  the  staphylococcus  pyogenes  albus  in  the  blood  is  not  particularly 
ominous,  but  the  presence  of  other  pyogenic  cocci  is  exceedingly  threatening 
(Dennis's  "System  of  Surgery").  Endocarditis,  pericarditis,  peritonitis, 
pleuritis,  bronchopneumonia,  empyema,  nephritis,  arthritis,  cholecystitis, 
hepatitis,  meningitis,  and  pyelitis  are  among  the  complications  which  may 
arise. 

Treatment. — The  treatment  is  the  same  as  for  septic  intoxication.  Anti- 
streptococcic serum  is  employed  by  some  surgeons,  but  the  value  of  this 
method  is  as  yet  doubtful.  It  does  not  do  any  harm.  It  may  do  good.  It 
is  proper  to  use  it,  but  not  to  the  exclusion  of  other  remedies.  The  usual  dose 
is  10  c.c.  injected  into  the  abdominal  wall.  It  can  be  repeated  two,  three, 
or  even  six  times  a  day,  and  can  be  used  for  a  number  of  days.  Washing  the 
blood  by  the  intravenous  infusion  of  salt  solution  often  produces  distinct 
improvement,  which,  unfortunately,  is  usually  temporary.  Dr.  C.  C.  Bar- 
rows commends  formalin  used  intravenously.  The  strength  of  the  solution 
is  I  part  of  formalin  to  5000  parts  of  salt  solution.  The  dose  is  500  c.c. 
I  have  had  no  experience  with  formalin  in  septicemia. 

Pyemia. — Pyemia  is  a  condition  in  which  metastatic  abscesses  arise  as 
a  result  of  the  existence  of  septic  thrombophlebitis,  the  disease  being  char- 
acterized by  fever  of  an  intermittent  type  and  by  recurring  chills.  It  is  not 
actually  due  to  free  pus  in  the  blood,  but  to  the  passage  into  the  blood  of 
clots  filled  with  toxins  or  infected  by  streptococci  or  staphylococci,  or  both. 
After  a  wound  is  inflicted  blood  clots  in  the  divided  veins.  If  suppuration  oc- 
curs, the  clots  may  become  filled  with  the  toxins  of  pyogenic  bacteria  or  be 
invaded  by  the  bacteria  themselves.  Thus  it  becomes  evident  that  pyemia 
may  develop  with  septicemia.  It  may  also  develop  when  there  is  suppura- 
tion in  a  wound,  but  not  septicemia,  no  lymphatic  absorption  of  bacteria  or 
toxins  having  occurred.  A  suppurating  focus  about  a  vein  may  cause  throm- 
bophlebitis and  clot-formation  even  when  no  wound  exists.  This  is  seen  in 
thrombophlebitis  of  the  lateral  sinus  secondary  to  suppuration  of  the  middle 
ear. 

A  vessel  thrombus  runs  uj)  in  the  lumen  of  a  vein,  and  the  apex  of  the 
clot  softens,  a  portion  of  it  is  broken  off  by  the  blood-stream  and  carried  as 
an  embolus  into  the  circulation.  Many  of  these  poisonous  emboli  enter  into 
the  blood  and  lodge  in  some  vessels  which  are  too  small  to  transmit  them,  and 
at  their  points  of  lodgment  form  embolic,  secondary,  or  metastatic  abscesses. 


Pyemia  165 

If  the  embolus  contains  only  pyogenic  toxins  the  danger  is  infinitely  less  than 
if  it  contains  bacteria.  The  secondary  abscess  if  caused  by  a  clot  containing 
only  toxins  may  not  lead  to  further  dissemination  of  disease.  If  the  embolus 
contains  bacteria,  thrombophlebitis  occurs  about  it,  and  new  infected  emboli 
form  and  are  sent  throughout  the  system.  Wounds  of  the  superficial  parts 
and  bones  produce  pyemic  infarctions  and  metastatic  abscesses  of  the  lungs. 
When  these  infarctions  break  into  fragments  particles  may  return  to  the  heart 
and  lodge,  or  may  be  sent  out  through  the  arterial  system  to  form  other  foci 
in  distant  organs.  Infected  areas  connected  with  the  portal  circulation 
(intestinal  injuries  or  suppurating  piles)  may  produce  abscess  of  the  liver. 
Wounds  of  bones  which  open  the  medullary  cavity  or  diploic  structure  are 
particularly  apt  to  be  followed  by  pyemia,  and  the  disease  may  follow  labor, 
phlegmonous  erysipelas,  and  other  conditions.  Malignant  endocarditis  is 
called  "  arterial  pyemia,"  and  is  due  to  endocardial  embolic  infection.  In  this 
disorder  infected  emboli  lodge  in  the  kidneys,  the  spleen,  the  alimentary  tract, 
the  brain,  or  the  skin  (Osier).  Idiopathic  pyemia  is  a  misnomer.  Some 
primary  focus  of  infection  must  exist,  as  was  pointed  out  when  discussing 
septicemia. 

Symptoms. — The  wound  often  becomes  dry  and  brown,  and  sometimes 
also  offensive.  A  severe  and  prolonged  chill  or  a  succession  of  chills  ushers 
in  the  disease;  high  fever  follows,  and  drenching  sweats  occur.  The  chills 
recur  every  other  day,  every  day,  or  oftener.  During  the  sweat  the  tempera- 
ture falls  and  may  become  nearly  normal,  normal,  or  actually  subnormal. 
The  temperature  often  oscillates  violently.  The  general  symptoms  of  vomit- 
ing, wasting,  etc.,  resemble  those  of  septicemia.  In  some  cases  the  mind  re- 
mains clear,  in  many  the  delirium  is  purely  nocturnal.  The  skin  frequently 
becomes  jaundiced,  and  a  profound  adynamic  state  is  rapidly  established. 
The  blood  changes  are  like  those  of  septicemia.  The  spleen  is  enlarged. 
The  lodgment  of  emboli  produces  symptoms  whose  nature  depends  upon  the 
organ  involved.  Lodgment  in  the  lungs  causes  shortness  of  breath  and  cough, 
with  slight  physical  signs.  Lodgment  in  the  pleura  or  pericardium  gives 
pronounced  physical  evidence.  Lodgment  in  the  spleen  produces  severe  pain 
and  great  enlargement.     The  parotid  gland  not  unusually  suppurates. 

In  a  suspected  case  of  pyemia  always  examine  an  existing  wound,  and  if 
there  is  no  wound,  remember  that  the  infection  may  arise  from  gonorrhea, 
osteomyelitis,  suppuration  in  the  middle  ear,  appendicitis,  dental  caries,  ton- 
sillar suppuration,  abscess  of  the  prostate,  etc.  Chronic  pyemia  may  last 
for  months;  acute  pyemia  may  prove  fatal  in  three  days.  The  chief  com- 
plications are  joint-suppuration,  bronchopneumonia,  pleuritis,  empyema, 
endocarditis,  pericarditis,  peritonitis,  nephritis,  cholecystitis,  pyehtis,  venous 
thrombosis,  and  abscesses. 

Treatment. — The  treatment  is  the  same  as  for  septicemia.  Open,  drain, 
and  asepticize  any  wound  and  any  accessible  secondary  abscess. 


1 66  Erysipelas 


XI.   ERYSIPELAS   (ST.  ANTHONY'S  FIRE). 

Erysipelas  is  an  acute,  contagious,  spreading  capillary  l\mphangitis 
due  to  the  streptococci  of  erysipelas,  which  grow  and  multiply  in  the  smaller 
lymph-channels  of  the  skin  and  its  subcutaneous  cellular  layers  and  also  in 
the  Ivmph-channels  of  serous  and  mucous  membranes.  Cutaneous  erysipelas 
is  characterized  bv  a  rapidly  spreading  dermatitis,  by  a  remittent  fever  due 
to  absorption  of  toxins,  and  by  a  tendency  to  recurrence.  It  is  always  pre- 
ceded bv  a  wound,  a  scratch,  or  an  abrasion,  which  may  have  been  trivial  and 
may  never  have  been  noticed.  The  so-called  idiopathic  erysipelas  is  pre- 
ceded bv  a  breach  of  surface  continuity  so  small  as  to  escape  notice.  The 
initial  point  of  infection  may  be  in  the  mouth,  the  nostril,  the  pharynx,  the 
auditorv  meatus,  between  the  fingers  or  toes,  at  the  margin  of  a  nail,  cr  in  a 
cutaneous  furrow.  The  involved  area  may  or  may  not  suppurate.  Sup- 
puration does  not  require  a  mixed  infection,  as  the  streptococcus  is  identical 
with  the  streptococcus  pyogenes.  Erysipelas  is  most  common  in  the  spring 
and  fall,  and  is  most  usually  met  with  among  those  who  are  crowded  into  dark, 
dirtv,  and  ill-ventilated  quarters;  it  attacks  by  preference  the  debilitated  and 
broken-down  (as  alcoholics  and  sufferers  from  Bright's  disease).  The  dis- 
ease may  become  endemic  in  special  places  or  localities.  The  poison  of 
erysipelas  will  produce  puerperal  fever  in  a  lying-in  woman.  The  strepto- 
coccus was  first  obtained  in  pure  cultures  by  Fehleisen.  This  organism  is 
widely  diffused.  The  question  of  identity  with  the  streptococcus  pyogenes 
is  discussed  on  page  t,'&. 

Forms  of  Erysipelas. — Ambulant,  erratic,  migratory,  or  wandering  erysipe- 
las  is  a  form  which  tends  to  spread  widely  over  the  body,  leaving  one  part  and 
going  to  another.  Bullous  erysipelas  is  attended  by  the  formation  of  bullae. 
In  diffused  erysipelas  the  borders  of  the  inflammation  gradually  merge 
into  healthv  skin.  Erythematous  erysipelas  involves  the  skin  superficially. 
Metastatic  erysipelas  appears  successively  in  various  parts  of  the  body.  Puer- 
peral erysipelas  begins  in  the  genitals  of  lying-in  women,  producing  puerperal 
fever.  Erysipelas  simplex  is  the  ordinary  cutaneous  form.  Erysipelas 
neonatorum  begins  in  the  unhealed  navel  of  a  newborn  child  and  spreads 
from  this  point.  Typhoid  erysipelas  occurs  with  profound  adynamia.  Uni- 
versal ervsipelas  involves  the  entire  body.  Cellulitis  is  often  erysipelas  of  the 
subcutaneous  layers.  Phlegmonous  erysipelas  involves  the  skin  and  the 
cellular  tissues,  and  causes  suppuration,  and  often  gangrene.  Edematous 
erysipelas  is  a  variety  of  phlegmonous  erysipelas  with  enormous  subcutaneous 
edema.  Lymphatic  erysipelas  is  characterized  by  rose-red  lines  due  to 
lymphangitis.  Venous  erysipelas  is  marked  by  the  dark  color  of  venous 
congestion.  Mucous  erysipelas  involves  a  mucous  membrane.  Erysipelas 
may  attack  the  fauces,  producing  the  very  gra\'e  condition  known  as  jaucial 
erysipelas. 

Clinical  Forms. — The  clinical  forms  are  cutaneous  erysipelas;  cellulo- 
cutaneous  or  phlegmcjnous  erysipelas;  cellulitis,  and  mucous  erysipelas. 

Cutaneous  erysipelas  most  frequently  attacks  the  face.  A  fever  sud- 
denly appears,  rises  rapidly,  reaches  a  considerable  height,  is  remittent  in 
type,  and  usually  terminates  in  four  or  five  days  by  crisis.     At  the  time  of 


Cutaneous  Erysipelas  167 

febrile  onset  spots  of  redness  appear  on  the  skin.  These  spots  run  together, 
and  soon  a  large  extent  of  surface  is  found  to  be  red  and  a  little  elevated.  Any 
wound,  ulcer,  or  abrasion  which  exists  becomes  dry  and  unhealthy,  and  its 
edges  redden  and  swell.  The  erysipelatous  area  of  redness  and  swelling 
extends,  its  margin  is  usually  sharply  defined  from  the  healthy  skin,  and  the 
color  fades  at  the  original  focus  as  the  disease  advances  at  the  periphery  of  the 
red  area.  The  color  fades  at  once  on  pressure  and  returns  at  once  when 
pressure  is  removed.  There  is  slight  burning  pain,  which  is  increased  by 
pressure.  In  the  hyperemic  area  vesicles  or  bullae  form,  containing  first 
serum  and  later  it  may  be  sero-pus,  but  there  is  rarely  genuine  suppuration 
in  cutaneous  erysipelas.  Edema  affects  the  subcutaneous  tissues,  producing 
great  swelling  in  regions  where  there  is  much  loose  cellular  tissue  (as  in  the 
eyelids).  The  anatomically  related  lymphatic  glands  may  become  large  and 
tender.  In  an  ordinarily  strong  person  the  color  is  bright  red  or  more  rarely 
dark  red.  A  dusky  color  precedes  suppuration.  A  blue  color  precedes 
gangrene  or  indicates  profound  cardiac  and  pulmonary  involvement.  Ery- 
sipelas spreads  now  in  one  direction,  now  in  another,  influenced,  according 
to  Pfleger,  by  the  furrows  of  the  skin.  When  the  disease  ceases  to  spread, 
the  swelling  and  redness  gradually  abate,  and  after  they  disappear  desquama- 
tion takes  place,  and  the  blebs  become  dry  and  crusted. 

In  strong  subjects  the  symptoms  of  cutaneous  erysipelas  are  usually  slight. 
In  the  old  and  debilitated  the  symptoms  are  typhoidal,  dehrium  comes  on, 
and  death  is  usual.  Possible  complications  are  meningitis,  pneumonia, 
septicemia,  pleuritis,  pyemia,  endocarditis,  arthritis,  and  albuminuria.  Ery- 
sipelas neonatorum  is  generally  fatal.  In  some  instances  an  attack  of  ery- 
sipelas will  cure  an  old  skin  eruption,  a  new  growth,  an  ulcer,  or  an  area  of 
lupus.     This  is  the  erysipele  salutaire  of  our  French  confreres. 

Treatment. — Isolate  the  patient,  asepticize  the  wound,  if  there  be  a  wound, 
and  administer  a  purge.  Cases  of  cutaneous  erysipelas  occurring  in  a  fairly 
healthy,  young,  or  middle-aged  subject,  tend  to  get  well  without  treatment. 
If  a  person  is  debiHtated,  free  stimulation  is  necessary.  Tincture  of  chlorid 
of  iron  is  usually  administered  in  doses  of  from  20  to  40  n\^  three  limes  a 
day.  Tonic  doses  of  quinin  are  also  given.  Nutritious  food  is  given  at 
intervals  of  three  or  four  hours.  For  sleeplessness  or  delirium  use  chloral 
or  the  bromids;  for  high  temperature,  cold  sponging  is  required.  To  prevent 
spreading  some  have  advised  injection  of  the  healthy  skin  near  the  blush  with 
a  2  per  cent,  carbolic  solution  or  with  fluid  containing  gr.  -j^  of  corrosive 
subhmate.  A  band  of  iodin  painted  on  the  skin  may  arrest  the  progress  of 
the  disease,  and  so  may  a  ring  streaked  around  a  limb  or  about  an  erysipelatous 
area  by  lunar  caustic.  Kraske  has  suggested  a  method  of  preventing  the 
spread  of  cutaneous  erysipelas  which  is  often  effective.  The  patient  is  anes- 
thetized. At  about  two  inches  from  the  margin  of  the  redness  a  series  of 
cuts  are  made  into  the  skin,  to  a  sufficient  depth  to  cause  free  oozing.  Each 
cut  is  crossed  by  another  cut  and  a  ring  of  scarifications  is  made  to  surround 
the  region  of  the  erysipelas.  After  the  oozing  ceases  the  scarified  area  is 
soaked  for  one  hour  with  a  solution  of  carbolic  acid  (i  :  20)  or  corrosive 
sublimate  (r  :  2000).  The  part  is  dressed  with  pads  wet  with  carbolic  acid 
(i  140)  or  corrosive  sublimate  (i  :  2000).  This  operation  causes  the  forma- 
tion of  a  protective  barrier  of  leukocytes.     Locally,  paint  the  inflamed  area 


1 68  Erysipelas 

with  equal  parts  of  iodin  and  alcohol  and  apply  lead-water  and  laudanum. 
The  iodin  is  germicidal  and  quickly  enters  the  lymph-spaces.  The  lead- 
water  and  laudanum  allays  the  burning  pain.  If  an  extremity  be  involved, 
bandage  it.  Some  advocate  a  daily  inunction  of  Crede's  soluble  silver.  A 
good  application  is  a  50  per  cent,  ichthyol  ointment  with  lanolin.  A  very 
useful  method  is  von  Nussbaum's.  The  author  applies  it  somewhat  modi- 
fied, as  follows:  wash  the  part  with  ethereal  soap,  irrigate  with  a  solution  of 
corrosive  subhmate  (i  :  1000),  dry  with  a  sterile  towel,  apply  an  ointment  of 
ichthyol  and  lanohn  (50  per  cent.),  and  dress  with  antiseptic  gauze.  Some 
use  iced-water  cloths.  Hot  fomentations  are  distinctly  harmful.  Some 
apply  borated  talc  or  salicylated  starch.  Ringer  advised  painting  every  three 
hours  with  a  mixture  composed  of  gr.  xxx  of  tannic  acid,  gr.  xxx  of  camphor, 
and  3iv  of  ether.  J.  M.  DaCosta  recommends  pilocarpin  internally  in  the 
beginning  of  a  case.  Antistreptococcic  serum  has  been  used  in  erysipelas, 
and  great  results  have  been  claimed  for  it.  It  is  asserted  that  under  its  influ- 
ence the  temperature  soon  becomes  normal.  My  personal  experience  with 
the  serum  treatment  has  not  convinced  me  of  its  value,  although  some  cases 
seem  to  be  benefited. 

Cellulocutaneous  or  phlegmonous  erysipelas  is  characterized  by  high 
temperature  (104°- 106°  F.),  the  rapid  onset  of  grave  prostration,  irregular 
chills,  sweats,  and  a  strong  tendency  to  delirium.  The  constitutional  con- 
dition may  be  one  of  suppurative  fever,  sapremia,  septicemia,  or  pyemia. 
The  parts  are  red,  as  in  cutaneous  erysipelas,  and  the  tumefaction  is  vastly 
greater.  The  swelling  is  brawny,  comes  on  early,  increases  with  exceeding 
rapidity,  induces  a  high  degree  of  tension,  and  frequently  produces  sloughing 
or  even  cutaneous  gangrene.  The  lymphatic  glands  are  swollen,  but  the  in- 
flamed lymphatic  vessels  are  hidden  by  the  tumefaction.  In  most  cases 
suppuration  occurs,  and  when  this  happens  the  parts  become  boggy  and  the 
pus  is  widely  disseminated  in  the  subcutaneous  and  intramuscular  tissues, 
and  even  into  muscular  sheaths  and  tendon-sheaths  (purulent  infiltration). 
When  the  disease  abates  sloughs  form,  which  leave  ulcers  upon  being  cast  off. 
In  bad  cases  muscles,  vessels,  tendons,  and  fascia  may  slough  away.  The 
commone.st  comphcations  are  suppression  of  urine,  bronchopneumonia,  con- 
gestion and  edema  of  the  lungs,  meningitis,  congestion  of  the  kidneys,  and 
acute  pleurisy.  Septicemia  or  pyemia  may  occur.  We  sometimes  meet  with 
this  form  of  erysipelas  after  extravasation  of  urine.  It  is  not  a  pure  strepto- 
coccus infection.  There  is  a  mixed  infection  with  other  pyogenic  cocci,  and 
often  with  organisms  of  putrefaction. 

Treatment. — At  once  asepticize  and  drain  any  existing  wound,  and  dress 
such  a  wound  with  hot  antiseptic  fomentations.  If  there  are  inilamed  lymph- 
vessels  or  glands  above  the  area  of  cellulocutaneous  infection,  paint  the  skin 
above  them  with  iodin  and  smear  it  with  blue  ointment  or  rub  in  Crede's 
ointment  of  soluble  silver.  Make  numerous  incisions  into  the  inflamed 
tissues.  The.se  incisions  should  be  near  together,  and  each  cut  should  be 
two  or  three  inches  long.  Spray  the  wounds  by  means  of  hydrogen  peroxid 
in  an  atomizer,  wash  with  corrosive  sublimate  solution  (i  :  1000),  and  pack 
each  wound  with  iodoform  gauze.  Dress  with  many  layers  of  gauze  wet  with 
a  hot  solution  of  corrosive  sublimate  and  covered  with  a  rubber  dam,  a  hot- 
water  bag  being  laid  upon  the  dressing.     If  sloughs  form,  cut  them  away 


Cellulitis  169 

and  employ  hot  antiseptic  fomentations.  Change  the  dressings  often.  In 
some  cases  it  may  be  necessary  to  employ  continuous  irrigation  with  warm 
antiseptic  fluid,  or  continuous  immersion  in  a  hot  aseptic  or  antiseptic  bath. 
It  is  not  unusually  necessary  to  operate  for  the  removal  of  enlarged  lymphatic 
glands.  In  rare  cases  amputation  is  demanded.  When  granulations  begin 
to  form,  treat  as  a  healing  wound.  The  constitutional  treatment  is  that  pre- 
viously set  forth  as  applicable  to  septicemia,  viz.,  purgation,  the  use  of  diuretics 
and  diaphoretics,  the  administration  of  strychnin,  quinin,  digitahs,  alcoholic 
stimulants,  and  nourishing  food.  Antistreptococcic  serum  may  be  employed. 
In  severe  cases  employ  hypodermoclysis  or  saline  infusion  into  a  vein. 

Cellulitis. — Cellulitis  is  a  microbic  inflammation  of  the  cellular  tissue. 
It  may  be  due  to  staphylococci,  to  streptococci,  to  other  pyogenic  bacteria,  or 
to  mixed  infection  with  two  varieties  of  pyogenic  organisms.  The  com- 
monest form  is  streptococcus  infection,  and  this  is  a  variety  of  erysipelas. 
Infection  with  the  bacillus  aerogenes  capsiilatiis  causes  gangrenous  cellulitis. 
In  cellulitis  of  the  subcutaneous  tissue  the  micro-organisms  find  entrance  by 
means  of  a  wound.  Swelling  precedes  redness.  The  swelling  is  not  so  marked 
as  in  phlegmonous  erysipelas,  and  the  redness  is  darker  and  is  less  distinct  than 
in  cutaneous  erysipelas.  The  redness  of  cellulitis  is  about  the  wound;  it 
spreads  but  does  not  fade  at  the  center  as  does  ordinary  erysipelas;  red  lines 
due  to  lymphangitis  ascend  the  Hmb  from  the  infected  wound,  and  the  ana- 
tomically associated  lymphatic  glands  enlarge.  In  the  wound  and  its  neigh- 
borhood there  is  severe  throbbing  pain.  The  constitutional  symptoms  of 
infection  develop  rapidly.  In  trivial  cases  the  lymphatics  dispose  of  the 
poison  and  suppuration  does  not  occur.  In  severe  cases  pus  forms  about 
the  wound  and  lymphatic  glands  may  suppurate.  Phlegmonous  erysipelas 
may  develop,  and  septicemia  or  pyemia  may  arise. 

Treatment. — Open,  disinfect,  and  drain  the  wound.  Paint  iodin  upon 
the  skin  over  inflamed  lymphatic  vessels  and  glands  and  cover  with  ichthyol 
ointment  or  rub  Crede's  soluble  silver  ointment  into  the  skin  over  the  inflamed 
lymph-glands  and  vessels.  Dress  the  wound  and  the  adjacent  inflamed  area 
with  hot  antiseptic  fomentations.  It  may  be  necessary  to  make  incisions  as 
in  phlegmonous  erysipelas.  In  some  cases  it  is  necessary  to  remove  breaking- 
down  glands.     The  constitutional  treatment  is  that  employed  for  septicemia. 


I/O  Tetanus,  or  Lockjaw 


XII.  TETANUS,  OR  LOCKJAW. 

Tetanus  is  a  microbic  disease  invariably  preceded  by  some  injury  and 
characterized  by  spasm  of  the  voluntary  muscles.  The  wound  may  have  been 
severe,  it  may  have  been  so  slight  as  to  have  attracted  no  attention,  it  may 
have  been  inflicted  upon  the  alimentary  canal  by  a  fish-bone  or  other  foreign 
body,  or  may  have  been  situated  in  the  nose,  urethra,  vagina,  or  ear.  It  is 
possible  that  infection  can  occur  through  a  mere  abrasion  of  a  mucous 
membrane.  The  so-called  idiopathic  tetanus  is  either  not  tetanus  at  all,  or 
the  term  expresses  the  fact  that  we  have  not  found  the  traces  of  an  injury 
which  did  exist.  Tetanus  arises  most  frequently  after  punctured  or  lacerated 
wounds  of  the  hands  or  feet,  and  before  it  appears  a  wound  is  apt  to  suppurate 
or  slough;  but  in  some  instances  the  wound  is  found  soundly  healed.  The 
toy  pistol  produces  a  peculiarly  dangerous  wound.  The  fact  that  the  bacillus 
of  tetanus  is  anaerobic  explains  the  comparative  frequency  with  which  punc- 
tured and  lacerated  wounds  are  attacked,  for  in  such  wounds  the  bacilli 
are  deeply  lodged  in  recesses  or  cavities  into  which  air  does  not  penetrate 
or  are  covered  with  discharges  which  exclude  air.  Suppuration  favors  the 
growth  of  tetanus  bacilli,  because  the  pyogenic  organisms  consume  oxygen. 
Occasionally,  though  fortunately  very  rarely,  tetanus  follows  vaccination. 
It  is  essential  that  vaccine  virus  should  be  carefully  selected  and  prepared. 
When  care  is  taken,  the  operation  is  absolutely  safe.  When  tetanus  follows 
vaccination,  it  arises  from  infection  of  the  wound  either  at  the  time  of  vac- 
cination or,  as  is  common,  at  a  later  period  from  scratching  or  some  other 
fouling.  Tetanus  may  appear  within  twenty-four  hours  after  an  accident, 
but  it  may  not  arise  until  many  days  or  even  several  weeks  have  elapsed. 
Samuel  D.  Gross,  in  his  "  System  of  Surgery,"  speaks  of  one  case  occurring  in 
a  man  five  weeks  after  injury,  and  another  in  a  girl  four  weeks  after  injury.  It 
prevails  more  in  certain  locaHties  than  in  others.  Colored  people  are  very  sus- 
ceptible, and  the  disease  may  exist  endemically.  Tetanus  is  due  to  the  growth 
in  a  wound  of  a  bacillus  which  was  first  described  by  Nicolaier  and  was  first 
cultivated  by  Kitasato.  It  is  the  most  widely  distributed  of  all  the  pathogenic 
bacteria.  It  is  very  difficult  to  cultivate  and  cannot  be  cultivated  at  all  unless 
air  is  absolutely  excluded.  Tetanus  bacilU  or  their  spores  are  found  particu- 
larly in  garden  soil,  in  the  dust  of  walls,  walks,  and  cellars,  in  street  dirt,  and 
in  the  refuse  of  stables.  There  is  much  suggestive  evidence  that  virulent  teta- 
nus baciUi  come  from  the  intestinal  canal  of  animals;  that  organisms  lose  their 
virulence  when  long  outside  of  the  intestinal  canal;  and  that  the  highest  degree 
of  virulence  is  obtained  by  organisms  which  have  passed  frequently  through 
intestinal  canals.  The  above  view  is  known  as  the  fecal  theory  and  is  strongly 
advocated  by  Somani.* 

In  tetanus  the  bacilli  do  not  enter  into  the  blood,  but  toxic  products 
produced  by  them  pass  into  the  circulation,  become  fixed  in  the  nerve- 
cells  of  the  brain  and  cord,  and  produce  the  symptoms  of  the  disease.  Hence 
tetanus  is  an  intoxication  and  not  an  infection,  and  a  drop  of  blood  of  an 
animal  with  tetanus,  if  injected  into  another  animal,  will  not  produce  the 
disease.     Tetanus  toxin  poisons  the  nervous  system  as  would  strychnia  or 

*  "  Verhandl.  d.  lo.  internat.  med.  Cong,,"  Berlin,  1890,  Bd.  v,  Abth.  15,  p.  152. 


Symptoms  1 7 1 

some  other  vegetable  alkaloid.  It  is  probably  the  most  powerful  of  known 
poisons.  It  has  been  estimated  that  ^ts"  ^^  ^  grain  is  sufficient  to  kill  an 
adult  weighing  165  pounds  ("American  Medicine,"  Nov.  30,  1901).  The 
great  power  of  the  poison  is  shown  by  the  report  of  Dr.  Nicholas's  case 
("Comptes  rendu  de  la  Societe  de  Biologic,"  1893).  Dr.  Nicholas  had  been 
using  a  syringe  to  inject  filtered  cultures  of  the  baciUi  of  tetanus  and  he  acci- 
dentally pricked  his  finger  with  the  needle.  In  four  days  tetanus  began,  and 
the  Doctor  barely  escaped  with  his  life  in  spite  of  the  fact  that  the  fluid  was 
free  of  bacteria  and  the  dose  of  toxin  was  extremely  minute.  The  nature  of 
the  virulent  poison  which  is  produced  at  the  seat  of  inoculation  is  uncertain : 
Some  believe  it  to  be  alkaloidal,  like  the  vegetable  alkaloids;  others  maintain 
that  it  is  an  enzyme  or  ferment  (Nocard,  Courmont,  and  others). 

Symptoms. — Acute  tetanus  begins  within  ten  days  of  an  accident. 
The  usual  period  of  incubation  is  from  three  to  five  days.  In  most  cases  the 
first  symptom  is  stiffness  of  the  jaw  on  opening  the  mouth.  In  some  cases 
the  first  symptom  is  stiffness  of  the  neck,  and  the  patient  believes  he  has 
''caught  cold."  In  any  case  the  neck  soon  becomes  stiff,  and  finally  both 
the  neck  and  jaw  are  as  rigid  almost  as  iron.  The  fixation  of  the  jaw  is  called 
trismus.  The  muscles  of  deglutition  become  rigid  on  attempts  at  swallowing. 
The  muscles  of  the  back,  legs,  and  .abdomen  are  thrown  into  tonic  spasm, 
but  the  arms  rarely  suffer.  If  the  infected  injury  is  on  the  hand  or  foot,  that 
extremity  usually  is  found  to  be  rigid.  Spasm  of  the  face  muscles  causes 
the  risus  sardonicus,  or  sardonic  smile  (contraction  particularly  of  the  miis- 
cidiis  sardonicus  of  Santorini).  The  contraction  of  the  muscles  of  the  back 
is  often  so  powerful  as  to  bend  the  patient  into  a  curve  like  a  bow  and  allow 
him  to  rest  only  on  his  occiput  and  heels.  This  condition  is  known  as  opisthot- 
onos. If  he  is  bent  forward,  so  that  the  face  is  drawn  to  the  legs,  it  is  called  em- 
prosthotonos.  If  his  body  is  curved  sideways,  it  is  designated  pleurosthotonos. 
An  upright  position  is  orthotonos.  The  spasm  may  be  so  violent  as  to  cause 
muscular  rupture. 

The  characteristic  condition  in  tetanus  is  one  of  widely  diffused  tonic 
spasm,  aggravated  frequently  by  clonic  spasms  arising  from  peripheral  irri- 
tations. These  irritations  may  be  draughts,  sounds,  lights,  shaking  of  the 
bed,  attempts  at  swallowing,  contact  of  the  bed-clothing,  the  presence  of  urine 
in  the  bladder  or  of  feces  in  the  rectum,  or  various  visceral  actions.  The  clonic 
spasms  begin  early  in  the  case  and  become  more  frequent  and  more  violent 
as  the  disease  progresses.  The  muscles  become  more  rigid  and  the  attitude 
produced  by  the  tonic  contraction  of  the  muscles  is  temporarily  exaggerated. 
The  forcible  contraction  of  the  jaw  may  loosen  or  break  teeth.  The  spasms 
of  the  diaphragm,  of  the  glottis,  and  of  the  muscles  of  respiration  mav  produce 
death  and  always  produce  great  dyspnea.  The  man  laboring  under  a  tetanic 
convulsion  presents  a  dreadful  picture;  he  is  bent  into  some  unnatural  atti- 
tude, the  face  is  cyanotic  and  covered  with  drops  of  sweat,  the  lips  are  covered 
with  froth  which  is  often  bloody,  the  eyes  bulge  and  are  suffused,  and  the 
countenance  expresses  deadly  terror  and  suffering.  The  agonizing  "girdle 
pain"  so  often  met  with  is  due  to  spasm  of  the  diaphragm.  Each  clonic  spasm 
causes  a  hideous  scream  by  the  constriction  of  the  chest  forcing  air  through 
a  contracted  glottis.  During  the  progress  of  the  disease  constipation  is 
persistent,  and  retention  of  urine  is  the  rule  (because  of  sphincter  spasm). 


172 


Tetanus,  or  Lockjaw 


The  mind  is  entirely  clear  until  near  the  end — one  of  the  worst  elements  of 
the  disease.  Swallowing  in  many  cases  is  impossible.  Talking  is  very 
difficult  and  it  is  impossible  to  project  the  tongue.  The  muscles  throughout 
the  body  feel  very  sore.  The  temperature  may  be  normal,  but  it  is  usually 
a  little  elevated,  and  always  rises  just  before  death.  Hyperpyrexia  sometimes 
occurs  (io8°-iio°  F.),  and  the  temperature  may  even  ascend  for  a  time  after 
death.  Insomnia  is  obstinate.  In  80-90  per  cent,  of  cases  of  acute  tetanus 
death  occurs  in  the  course  of  two  or  three  days.  If  a  patient  Hves  a  week, 
his  chance  of  recovery  is  good.  Death  may  be  due  to  exhaustion  or  to  car- 
bonic-acid narcosis  from  spasm  of  the  glottis  or  fixation  of  the  respiratory 
muscles. 

Chronic  tetanus  comes  on  late  after  a  wound  (from  ten  days  to  several 
weeks).  The  symptoms  are  not  so  severe  as  in  acute  tetanus.  The  muscular 
spasm  is  widespread,  but  it  may  not  be  persistent,  intervals  of  relaxation 
permitting  sleep  and  the  taking  of  food.  Chronic  tetanus  may  last  some 
weeks,  and  in  about  40  per  cent,  of  the  cases  the  disease  can  be  cured.  Tris- 
mus neonatorum  or  trismus  nascentiiim,  the  lockjaw  of  the  newborn,  is  due  to 
infection  of  the  stump  of  the  umbilical  cord,  and  is  practically  invariably 
fatal.  Hydrophobic  tetanus,  head  tetanus,  or  cephalic  tetanus,  is  a  condition 
in  which  the  spasms  are  confined  chiefly  to  the  face,  pharynx,  and  neck, 
although  the  abdominal  muscles  are  usually  also  rigid.  It  follows  head- 
injuries,  and  gives  a  better  prognosis  than  does  general  tetanus. 

Diagnosis. — Tetanus  may  be  confounded  with  strychnin-poisoning, 
with  hysteria,  with  tetany,  or  with  hydrophobia.  Wood's  table  makes  the 
diagnosis  clear  between  tetanus,  strychnin-poisoning,  and  hysteria.* 


Hysterical  Tetanus. 


Strychnin-poisoning. 


Muscular  symptoms 
usually  commence  with 
pain  and  stiffness  in  the 
back  of  the  neck,  some- 
times with  slight  muscu- 
lar twitching ;  comes  on 
gradually.  Jaw  one  of 
the  earliest  parts  affected; 
rigidly  and  persistently 
set. 

Persi  sten  t  m  u  s  c  u  1  a  r 
rigidity  very  generally, 
with  a  greater  or  le.ss 
degree  of  permanent 
opisthotonos,  emprostho- 
tonos,  pleurosthotonos, 
or  orthotonos. 


Commences    with  blind- 
ness and  weakness. 


Muscular  symptoms  com- 
mence with  rigidity  of  the 
neck,  which  creeps  over 
the  body,  affecting  the  ex- 
tremities last.  Jaws  rigidly 
set  before  a  convulsion,  and 
remain  so  between  the 
paroxysms. 


Persistent  opisthotonos 
and  intense  rigidity  between 
the  convulsions  and  after 
the  convulsions  have  ceased, 
the  opisthotonos  and  intense 
rigidity  lasting  for  hours. 


Begins  with  exhilaration  and  rest- 
lessness, the  special  senses  being 
usually  much  sharpened.  Dimness 
of  vision  may  in  some  cases  be 
manifested  later,  after  the  develop- 
ment of  other  symptoms,  but  even 
then  it  is  rare. 

Muscular  symptoms  develop  very 
rapidly,  commencing  in  the  extremi- 
ties, or  the  convulsion  when  the  dose 
is  large  seizes  the  whole  body  simul- 
taneously. Jaw  the  last  part  of  the 
body  to  be  affected  ;  its  muscles  re- 
lax first,  and  even  when,  during  a 
severe  convulsion,  it  is  set,  it  drops 
as  soon  as  the  latter  ceases. 

Muscular  relaxation  (rarely  a 
slight  rigidity)  between  the  convul- 
sions, the  patient  being  exhausted 
and  sweating.  If  recovery  occurs, 
the  convulsions  gradually  cease,  leav- 
ing merely  muscular  soreness,  and 
sometimes  stiffness  like  that  felt  after 
violent  exercise. 


*  "  Nervous  Diseases,"  by  Prof.  U.  C".  Wood. 


Treatment 


173 


Tetanus. 


Hysterical  Tetanus. 


Consciousness  pre-  1  Consciousness  lost  as  the 
served  until  near  death,  i  second  convulsion  comes 
as  in  strychnin-poison-  on,  and  lost  with  every 
ing.  other    convulsion,    the    dis- 

turbance of  consciousness 
and  motility  being  simul- 
taneous. 


Draughts,  loud  noises, 
etc.,  produce  convul- 
sions, .  as  in  strychnin- 
poisoning  ;  may  com- 
plain bitterly  of  pain. 

Eyes  open  and  rigidly 
fixed  during  the  convul- 


Strvchnin-poisoning. 


Crying  spells  alternating 
with  convulsions. 


Eyes  closed. 


Partial  spasm  in  the  leg, 
producing  in  Wood's  cases 
crossing  of  the  feet  and 
inversion  of  the  toes.  If 
all  the  muscles  were  in- 
volved, eversion  would  oc- 
cur, as  the  muscles  of  ever- 
sion are  the  stronger. 


Consciousness  always  preserved 
during  convulsions,  except  when  the 
latter  become  so  intense  that  death 
is  imminent  from  suffocation,  in 
which  case  .sometimes  the  patient 
becomes  insensible  from  asphyxia, 
which  comes  on  during  the  latter 
part  of  a  convulsion  and  is  almost  a 
certain  precursor  of  death. 

The  "slightest  breath  of  air" 
produces  convulsion.  Patient  may 
scream  with  pain  or  may  express 
great  apprehension,  but  "crying 
spells"  would  appear  to  be  impos- 
sible. 

Eyes  stretched  wide  open. 


Legs  stiffly  extended  with  feet 
everted,  as  the  spasms  affect  all  the 
muscles  of  the  leg. 


Tetany  is  distinguished  from  tetanus  by  the  milder  nature  of  the  spasms, 
by  the  greater  hmitation  of  the  rigidity,  by  the  fact  that  spasms  begin  in  the 
hands  or  feet,  not  in  the  jaw  and  neck,  and  in  most  cases  by  periods  of  dis- 
tinct intermittence. 

In  hydrophobia  tonic  spasm  does  not  exist,  and  if  clonic  spasms  occur 
thev  are  secondary  to  suffocative  attacks. 

Treatment. — Far  better  even  than  to  treat  tetanus  well  is  to  prevent  it. 
Careful  antisepsis  will  banish  it  as  a  sequence  of  surgical  operations  as  thor- 
oughly as  it  has  banished  septicemia.  Every  wound  must  be  disinfected 
with  the  most  scrupulous  care.  Every  punctured  wound  is  to  be  incised  to 
its  depth  and  thoroughly  cleaned  and  drained.  Puerperal  tetanus  is  prevented 
by  antiseptic  midwifery,  and  tetanus  neonatorum  is  obviated  by  the  antiseptic 
treatment  of  the  stump  of  the  cord.  In  order  to  obviate  all  danger  of  the 
development  of  tetanus  during  vaccinia,  perform  the  little  operation  with 
cleanliness  and  care  properly  for  the  wound  and  for  the  pustule.  The  skin 
should  be  cleansed  with  soap  and  water,  rubbed  with  alcohol,  and  washed 
with  boiled  water.  It  should  be  gently  scraped  with  a  knife  (which  has  been 
boiled)  until  serum  exudes.  The  virus,  taken  from  a  hermetically  sealed 
tube,  is  apphed  to  the  raw  surface,  and  allowed  to  remain  exposed  to  the  air 
until  dry.  A  piece  of  sterile  gauze  is  laid  over  the  part  and  is  held  in  place 
by  a  bandage.  This  dressing  is  changed  once  or  twice  a  day  as  may  be  neces- 
sary, and  is  used  until  granulation  begins,  at  which  time  the  use  of  any  simple 
ointment  is  admissible.  Do  not  apply  a  shield.  The  evil  of  shields  is  pointed 
out  by  Robert  N.  Willson  ("American  Medicine,"  Dec.  7,  1901). 

When  tetanus  exists,  always  look  for  a  wound,  and  if  one  is  found,  open 


174  Tetanus,  or  Lockjaw 

it;  if  there  are  sloughs,  cut  them  away,  wash  the  wound  with  peroxid  of 
hydrogen  and  then  with  a  hot  solution  of  corrosive  sublimate  (i  :  500).  dry 
the  wound  with  gauze,  paint  the  surfaces  cf  the  wound  with  bromin,  and  secure 
drainage  by  packing  with  iodoform  gauze.  Dennis  disinfects  the  wound 
with  a  solution  of  trichlorid  of  iodin  (0.5  per  cent.). 

Surgeons  of  a  former  day  were  accustomed  to  amputate  for  tetanus  if  the 
wound  was  upon  an  extremity  When  we  reflect  that  the  poison-producers 
are  in  the  wound  and  not  in  the  circulation,  it  seems  a  reasonable  treatment. 
As  a  matter  of  fact,  it  never  does  any  good,  because,  when  the  symptoms 
begin,  the  toxin  has  already  entered  into  the  nerve-cells  anjj  become  fixed. 
Kitasato  has  shown  that  if  a  mouse  is  inoculated  with  tetanus  near  the  root  of 
the  tail,  excision  of  the  tail  and  cauterization  of  the  stump  will  not  prevent 
tetanus  unless  it  is  performed  within  one  hour  of  the  inoculation;  and  Nocard 
inoculated  sheep  near  the  root  of  the  tail  with  tetanus  spores,  and  althcugh 
the  moment  symptoms  appeared  he  amputated  well  above  the  point  of  inocu- 
lation, the  animals  died  of  the  disease.  We  must  regard  amputation  as  a 
useless  method  of  treatment.  It  is  maintained  by  several  surgeons  that  in 
certain  wounds,  like  those  inflicted  by  the  toy  pistol  and  those  contaminated 
with  earth  or  with  fecal  matter,  antitetanus  serum  should  be  injected  as  a 
preventative.  Obviously,  this  cannot  be  done  for  every  wound,  and  it  is 
doubtful  if  the  procedure  is  really  useful.  Reynier  injected  antitoxin  into  a 
patient  on  whom  he  was  about  to  operate  because  there  was  a  case  of  tetanus 
in  the  wards  and  yet  this  man  developed  tetanus  ("  Gaz.  des  Hopitaux,"  July 
16,  1901).  Nevertheless  it  is  sure  that  animals  can  be  rendered  immune  to 
tetanus,  and  the  prophylactic  power  of  antitoxin  is  warmly  advocated  by  many 
eminent  men.     (See  F.  L.  Taylor,  in  "N.  Y.  Med.  Journal,"  July  20,   1901.) 

Keep  the  sufferer  from  tetanus  in  a  darkened,  well-ventilated,  and  quiet 
apartment,  so  as  to  exclude  as  far  as  possible  peripheral  irritation.  Watch  for 
the  occurrence  of  retention  of  urine,  and  use  the  catheter  if  necessary.  Secure 
movements  of  the  bowels  by  administering  salines,  castor  oil,  croton  oil,  or 
enemas.  Give  plenty  of  concentrated  liquid  food,  and  stimulate  freely  with 
alcohol.  If  swallowing  causes  convulsions,  give  an  inhalation  of  nitrite  of 
amyl  before  an  attempt  is  made  to  swallow.  If  this  treatment  does  not  make 
swallowing  possible,  partially  anesthetize  the  patient  and  feed  him  by  means 
of  a  pharyngeal  tube  passed  through  the  nose.  Large  doses  of  the  bromid 
of  potassium,  or  of  this  drug  with  chloral,  give  the  best  results,  as  far  as  drug 
treatment  is  capable  of  giving  results.  If  bromid  is  used,  give  about  ?>]  every 
four  to  six  hours.  Other  drugs  that  have  been  used  with  some  success  are 
gelsemium,  morphin,  curare,  injections  and  fomentations  of  tobacco,  physo- 
stigmin,  anesthetics,  cocain,  and  cannabis  indica.  An  ice-bag  to  the  spine 
somewhat  relieves  the  girdle  pain.  Hot  baths  have  been  advised.  It  is  said 
that  venesection  followed  by  the  intravenous  infusion  of  saline  fluid  does  good. 
This  procedure  is  followed  by  a  free  flow  of  urine  and  by  lessening  of  the 
number  of  the  paroxysms.  It  may  be  repeated  several  times  during  a  few 
days  (E.  J.  McOscar,  in  "American  Medicine,"  Sept.  14,  1901;  A.  V.  Mosch- 
cowitz,  in  "Med.  News,"  Oct.  13,  igoo).  Baccelli's  method  of  treatment  is 
the  admini.stration  of  carbolic  acid  hypodermatically. 

Yandell  says,  in  summing  up  Cowling's  report  on  tetanus:  *  "Recoveries 
*  American  Practitioner,  Sept.,   1S70. 


Treatment  175 

from  traumatic  tetanus  have  been  usually  in  cases  in  which  the  disease  occurs 
subsequent  to  nine  days  after  the  injury.  When  the  symptoms  last  fourteen 
days,  recovery  is  the  rule,  apparently  independent  of  treatment.  The  true 
test  of  a  remedy  is  its  influence  on  the  history  of  the  disease.  Does  it  cure 
cases  in  which  the  disease  has  set  in  previous  to  the  ninth  day?  Does  it  fail 
in  cases  whose  duration  exceeds  fourteen  days  ?  No  agent  tried  by  these 
tests  has  yet  established  its  claims  as  a  true  remedy  for  tetanus."  * 

It  is  now  claimed  by  some  observers  that  we  have  a  remedy  which  fulfils 
the  requirements  of  Yandell  in  the  tetanus  antitoxin  serum.  Behring's 
serum  is  said  to  be  six  times  as  strong  as  Tizzoni's,  but  it  is  difficult  or  impos- 
sible to  estimate  the  e.xact  power  of  either.  Serum  is  usually  prepared  as 
follows:  A  horse  is  injected  repeatedly  with  the  toxins  obtained  from  cultures 
of  tetanus  bacilli,  the  strength  of  the  injections  being  gradually  increased. 
Eventually  the  animal  becomes  immune  to  tetanus.  Some  davs  after  the 
final  injection  a  cannula  is  placed  in  the  jugular  vein  of  the  immunized  animal, 
blood  is  drawn  into  a  sterile  vessel  and  is  permitted  to  coagulate  during 
twenty-four  hours,  and  at  the  end  of  this  period  the  serum  is  separated  from 
the  clot,  is  evaporated  to  dryness  in  a  vacuum  over  sulphuric  acid,  and  the 
powder  is  placed  in  hermetically  sealed  glass  tubes.  In  order  to  use  the 
serum,  dissolve  the  powder  in  sterile  water,  in  the  proportion  of  i  gm.  to  10  c.c. 
The  fluid  serum  sold  in  the  shops  bears  this  proportion  to  the  powder.  The 
serum  can  be  given  subcutaneously  or  intravenously,  or  can  be  injected  into 
the  brain  or  under  the  cerebral  dura  or  the  spinal  arachnoid.  If  used  sub- 
cutaneously, from  20  to  30  c.c.  of  the  fluid  serum  should  be  injected  into  the 
abdominal  wall,  and  this  dose  should  be  given  every  six  or  eight  hours  until 
there  is  improvement.  Then  from  5  to  10  c.c.  should  be  given  every  six  or 
eight  hours.  As  the  symptoms  abate  the  dose  is  lessened  and  the  intervals 
between  the  doses  are  increased.  In  a  violent  case  of  tetanus  the  first  dose 
should  consist  of  40-50  c.c,  and  this  can  be  repeated  in  four  or  five  hours. 
In  a  case  of  tetanus  which  recovered,  reported  by  Mixter,  enormous  doses 
were  given.  This  patient  received  in  the  aggregate  3400  c.c.  of  serum,  or 
285  c.c.  a  day.f  Roux  and  Borrel  maintain  that  the  toxins  of  tetanus  pass 
from  the  blood  into  nervous  tissue  and  are  fixed  in  the  nerve-cells.  As  the 
antitoxin  when  given  hypodermatically  or  intravenously  remains  in  the  blood, 
it  can  only  antidote  the  poison  in  the  blood  and  not  that  in  the  nerve-cells. 
These  observers  advise  that  the  antitoxin  be  placed  where  the  toxins  are  active 
— that  is,  that  it  be  thrown  into  the  cerebrum.  The  skull  is  trephined  or 
opened  with  a  small  drill,  a  blunt  needle  is  passed  to  the  depth  of  one  and  a 
half  inches  into  the  frontal  lobe,  and  the  serum  is  slowly  injected.  Abbe 
follows  Kocher;  uses  a  local  anesthetic  and  bores  a  very  small  hole  through 
the  skull  midway  between  the  outer  angle  of  the  orbit  and  the  middle  of  a  line 
running  across  the  head  from  one  external  auditory  meatus  to  the  other. 
The  serum  should  be  concentrated.  One  gram  of  dry  antitoxin  is  dissolved 
in  5  c.c.  of  water,  and  this  amount  is  the  proper  dose.  The  opposite  frontal 
lobe  should  also  be  injected  either  at  once  or  the  next  day.  Even  when  serum 
has  been  injected  into  the  cerebrum  it  should  also  be  given  subcutaneously. 
Abbe  employed  intracerebral  injection  in  5  .severe  cases  and  3  of  them  recov- 

*  Quoted  by  Hammond,  in  his  "  Diseases  of  tlie  Nervous  System." 
t  Boston  Med.  and  Surg.  Jour.,  Oct.  6,  189S. 


176  Tetanus,  or  Lockjaw 

ered.  He  is  a  strong  believer  in  the  method  ("  Annals  of  Surgery,"  March, 
1900).  Moschcowitz  has  collected  38  cases  so  treated  and  claims  that  one- 
half  of  them  recovered.  Cerebral  abscess  followed  in  i  case  ("Med.  News," 
Oct.  13,  1900).  TulSer  has  reported  a  successful  case  in  which  he  injected 
10  c.c.  of  serum  into  each  frontal  lobe  ("  Gaz.  heb.  de  Med.  et  Chir.,"  July  4, 
1901). 

The  value  of  the  tetanus  antitoxin  is  doubtful.  It  seems  to  distinctly 
benefit  chronic  tetanus,  but  to  have  only  a  trivial  effect  on  the  acute  disease. 
Nancrede  estimates  that  antitoxin  treatment  has  lessened  the  mortahty  of 
acute  tetanus  about  5  per  cent.  Other  writers  give  much  better  figures.  In 
290  cases  so  treated,  collected  by  Moschcowitz,  117  died.  The  intracerebral 
injection  is  still  an  experiment,  but  appears  to  be  more  successful  than  other 
methods.  Kitasato  has  shown  that  injections  of  iodoform  render  animals 
immune,  and  Sonnani  has  maintained  that  this  drug  in  a  wound  prevents 
the  disease.  If  antitoxin  is  not  obtainable,  give  hypodermatic  injections  of 
iodoform,  3  to  5  grs.  t.  i.  d. 


Tubercle 


177 


XIII.  TUBERCULOSIS. 

Tuberculosis  is  an  infective  disease  due  to  the  deposition  and  multipli- 
cation of  tubercle  bacilli  in  the  tissues  of  the  body.  It  is  characterized  either 
by  the  formation  of  tubercles  or  by  a  widespread  infiltration,  both  of  these 
conditions  tending  to  caseation,  sclerosis,  or  ulceration. 

A  tubercle  is  a  non-vascular  infective  focus,  appearing  to  the  unaided 
vision  as  a  semi-transparent  gray  mass  the  size  of  a  mustard-seed.  The 
microscope  shows  that  a  gray  tubercle  consists  of  a  number  of  cell-clusters, 
each  cluster  constituting  a  primitive  tubercle.  A  typical  primitive  tubercle 
shows  a  center  consisting  of  one  or  of  several  polynucleated  giant-cells  sur- 
rounded by  a  zone  of  epithehoid  cells  which  are  surrounded  by  an  area  of 
leukocytes.  When  the  bacillus  obtains  a  lodgment  the  fixed  connective- 
tissue  cells  multiply  by  karyokinesis,  forming  a 
mass  of  nucleated  polygonal  or  round  cells, 
called  epithelioid  from  their  resemblance  to  epi- 
thelial cells,  and  at  the  same  time  the  blood- 
supply  of  the  growth  is  limited  by  occlusion  of 
surrounding  vessels  through  multiplication  of  the 
cells  of  their  endothelial  coats,  and  also  because 
of  the  pressure  of  proliferating  perivascular  cells. 
Some  of  the  epithelioid  cells  prohferate,  and 
others  attempt  to,  but  fail  for  want  of  blood-  _  -.^  ,v 
supply.  Those  which  fail  to  multiply  succeed  ^^!|i''\^''''s4  *■ 
only  in  dividing  their  nuclei  and  enormously  in-  '-'^--^•-'^^  -« 
creasing  their  bulk  (giant-cells).  Giant-cells, 
which  may  also  form  by  a  coalescence  of  epi- 
thelioid cells,  are  not  always  present.  The 
presence  of  irritant  bacterial  products  induces 
surrounding  inflammation  and  numbers  of  leuko- 
cytes gather  about  the  epithelioid  cells  (Fig.  61). 

The  bacilli,  when  found,  exist  in  and  about  the  epithehoid  cells,  and  some- 
times in  the  giant-cells.  A  tubercle  may  caseate — a  process  that  is  destruc- 
tive and  dangerous  to  the  organism,  and  which  resembles  and  yet  differs  from 
fatty  degeneration.  Deprivation  of  blood-supply  may  result  in  fatty  degen- 
eration. Caseation  is  due  to  a  coagulation-necrosis  arising  from  direct  mi- 
crobic  action  upon  a  cellular  area  which  contains  no  blood-vessels,  the  nutri- 
tion of  the  area  being  cut  off  by  obliteration  of  surrounding  vessels.  This 
process  starts  at  the  center,  and  the  entire  tubercle  becomes  converted  into  a 
soft  yellowish-gray  mass.  Caseation  forms  cheesy  masses,  which  may  soften 
into  tuberculous  pus,  may  calcify,  may  become  encapsuled  by  fibrous  tissue, 
or  may  be  replaced  by  an  area  of  sclerosis. 

A  tubercle  may  undergo  sclerosis,  which  is  an  attempt  on  the  part  of 
Nature  to  heal  and  repair  the  part.  Coagulation-necrosis  occurs  in  the  center 
of  the  tubercle;  " hyaHne  transformation  proceeds,  together  with  a  great  in- 
crease in  the  fibroid  elements,  so  that  the  tubercle  is  converted  into  a  firm, 
hard  structure"  (Osier).     Infiltrated  tubercle  is  due  to  the  running  together 


Fig.    5i.  —  Synovial    membrane, 
showing-  giant-cells  (Bowlby). 


1/8  Tuberculosis 

of  many  minute  infective  foci,  or  to  widespread  infiltration  without  any  for- 
mation of  foci.     Infiltrated  tubercle  tends  strongly  to  caseate. 

The  bad //us  oj  tuber  c/e,  discovered  by  Koch  in  1882,  is  a  httle  rod  with  a 
length  equal  to  about  half  the  diameter  of  a  red  blood-corpuscle.  It  can  be 
stained  with  anihn,  and  this  stain  is  not  removable  by  acids  (it  being  the  only 
bacillus  except  that  of  leprosy  which  acts  in  this  way).  In  its  growth  the 
tubercle  bacillus  causes  the  formation  of  toxins,  and  the  absorption  of  toxins 
induces  constitutional  symptoms.  The  bacilli  exist  in  all  active  lesions:  the 
mere  active  the  process,  the  greater  is  their  number.  They  may  be  widely 
distributed,  and  are  occasionally,  though  rarely,  identified  in  the  blood. 
They  may  not  be  found,  having  once  existed,  but  having  been  subsequently 
destroyed.  Bacilli,  when  present,  can  easily  be  overlooked.  In  an  active 
tuberculous  lesion,  even  if  the  bacilh  be  not  found,  injection  of  the  tuberculous 
matter  into  a  guinea-pig  wdll  produce  lesions  in  which  they  can  be  demon- 
strated. Bacilh  exist  in  enormous  numbers  in  phthisical  sputum,  but  are  not 
found  in  the  breath  of  consumptives.  Their  great  medium  of  distribution 
is  dried  sputum  mixed  with  dust.  They  are  found  in  the  milk  of  tuberculous 
cows,  and  sometimes  in  the  meat  of  diseased  animals. 

Hereditary  Transmission. — Infection  may  be  due  to  hereditary 
transmission.  Congenital  tuberculosis  is  occasionally,  though  rarely,  seen. 
Tuberculosis  is  apt  to  appear  in  young  children.  Some  think  this  is  due  to 
infection  from  without  upon  tissues  whose  resistance  is  lowered  by  hereditary 
predisposition;  others  think  it  is  due  to  a  tardy  development  of  the  germs 
transmitted  by  heredity.  That  the  disease  may  be  present  in  a  latent  form 
is  shown  by  the  experiment  in  which  the  viscera  of  the  fetus  of  a  consumptive 
mother  showed  no  tubercles,  but  produced  the  disease  in  guinea-pigs  when 
inoculated.* 

Inoculation=tuberculosis. — Tuberculosis  may  arise  by  inoculation, 
inoculation-tuberculosis  being  seen  in  leather-workers  and  in  those  who  dis- 
sect tuberculous  bodies  (butchers  and  doctors  are  liable  to  anatomical  tu- 
bercle). Osier  mentions  as  other  causes  of  inoculation  the  bite  of  a  tuberculous 
patient,  the  washing  of  infected  garments,  and  circumcision  in  which  suction  is 
employed  by  an  individual  with  phthisis.  Granulation  tissue,  chronic  abscess, 
and  areas  of  dermatitis  may  be  infected  from  without  (G.  R.  Fowler). 

Infection  through  the  Air  and  Food. — Infection  through  the  air  is 
very  common.  The  bacteria  of  the  dried  sputum  adhere  to  particles  of  dust 
and  are  carried  into  the  lungs.  Infection  by  meat,  milk,  and  other  foods  may 
arise  by  this  dust  setthng  upon  them  in  quantity,  but  it  may  also  be  due  to 
disease  of  the  animals  from  which  the  materials  were  obtained.  Milk  is  a 
vehicle  of  contagion.  It  is  dangerous  if  the  udder  contains  tuberculous  lesions. 
Tuberculosis  of  the  udder  may  arise  early  even  in  a  mild  case.  Some  ob- 
servers maintain  that  the  milk  from  a  tuberculous  cow  is  dangerous  even  when 
an  ulcerated  udder  does  not  exi.st.  Of  late,  doubt  has  been  expressed  as  to 
the  possibility  of  infecting  a  human  being  with  bovine  tuberculosis,  and  the 
doubters  maintain  that  bovine  tuberculosis  and  human  tuberculosis  are  two 
different  diseases.  Koch  questions  whether  men  are  really  susceptible  to  bovine 
tuberculosis,  and  says  if  they  are  susceptible,  infection  from  this  source  is 
extremely  rare.     He  does  not  consider  it  necessary  to  take  any  precautions 

*  Quoted  by  (Jsler  from  Ijirch-I  lirschfeld. 


Scrofula  179 

to  protect  human  beings  from  bovine  tuberculosis.  Ravenel  strongly  opposes 
the  views  of  Koch,  and  maintains  that  the  bacillus  of  bovine  tuberculosis  is 
highly  pathogenic  for  man  ("University  of  Penna.  Med.  Bull.,"  xiv,  238, 
1901).  Ravenel,  in  support  of  his  contention,  reports  3  cases  of  tuberculosis 
of  the  human  skin  due  to  bovine  inoculation  ("Phila.  Med.  Jour.,"  July  21, 
1900).  Nocard  reports  2  cases  of  individuals  who  wounded  themselves  while 
cutting  the  meat  of  tuberculous  cattle.  Each  patient  developed  generalized 
lesions  and  died. 

Elements  Favoring  Infection. — Infection  is  favored  by  hereditary 
predisposition — that  is  to  say,  by  hereditary  tissue-weakness,  which,  by 
maintaining  a  lowered  momentum  of  nutritive  processes,  lessens  the  normal 
resistance  to  infection.  Hutley  studied  432  cases  of  tuberculosis.  In  23.8 
per  cent,  one  or  both  parents  had  the  disease  (the  father  alone  in  11.5  per  cent., 
the  mother  alone  in  9.9  per  cent.,  and  both  in  2.4  per  cent.). 

Tubercle  tends  to  arise  at  points  where  the  normal  resistance  of  the  tissue 
is  lessened  by  disease  or  injury,  the  process  of  phagocytosis  being  in  such  a 
spot  limited  in  activity,  and  the  germicidal  power  of  the  body-fluids  being  at 
a  low  ebb.  The  organisms,  which  are  destroyed  by  healthy  cell-activities, 
are  victorious  when  those  activities  are  diminished.  Catarrhal  inflammations 
of  the  air-passages  favor  phthisis,  and  slight  traumatism  is  not  unusually 
followed  by  a  development  of  tubercle.  Severe  traumatism  is  rarely  followed 
bv  tuberculous  trouble.  It  is  probable  that  in  a  sUght  traumatism  a  sufficient 
number  of  leukocytes  do  not  gather,  and  a  sufficient  amount  of  serum  is  not 
effused  to  kill  the  bacteria.  Lowered  health,  impure  air,  and  improper  or 
insufficient  food  all  favor  the  development  of  tubercle.  When  an  area  be- 
comes tuberculous,  it  is  not  unusual  for  indican  to  appear  in  the  urine.  Any 
tuberculous  process  tends  to  spread  locally  and  to  produce  inflammation.  A 
tuberculous  area  is  always  a  danger  to  the  system;  from  this  as  a  focus  dissemi- 
nation may  occur,  tuberculous  lesions  appearing  in  a  distant  part  or  general 
tuberculosis  setting  in. 

Scrofula  is  not  a  disease.  It  is  a  condition  of  the  tissues  in  which  low 
resisting  power  makes  them  hospitable  hosts  to  invading  bacilli  of  tubercle. 
It  is  met  with  particularly,  but  not  exclusively,  in  children.  Some  observers 
teach  that  scrofula  is  tuberculosis  of  bones,  glands,  and  joints;  others  teach 
that  it  is  latent  tuberculosis  until  some  cause  lights  it  into  activity;  while  still 
others  say  that  it  is  a  tendency  rather  than  a  disease.  It  is  certain  that  some 
lesions  of  scrofula  are  not  tuberculous  (eczema  capitis,  facial  eczema,  corneal 
ulcers,  granular  lids,  and  chronic  catarrhal  inflammations),  and  that  they  re- 
sult from  ill  health,  poor  nutrition,  bad  air,  and  improper  diet.  A  person  who 
is  recognized  as  of  a  scrofulous  type  may  never  develop  tuberculous  lesions. 
It  is  unquestionable,  however,  that  strumous  subjects  are  peculiarly  apt  to 
develop  true  tuberculous  lesions.  These  lesions  often  appear  after  a  tissue 
or  an  organ  has  become  the  seat  of  a  primary  non-tuberculous  inflammation; 
the  bacilli,  which  could  not  live  in  the  healthy  tissue,  thrive  in  the  tissue  weak- 
ened by  disease.  Scrofula  is  generally  of  congenital  origin,  one  or  both 
parents  being  tuberculous,  scrofulous,  or  in  ill  health;  it  may,  however,  be 
acquired  as  a  result  of  poor  food,  bad  air,  crowding,  and  general  lack  of  sanita- 
tion. The  scrofulous  are  very  prone  to  develop  tuberculous  lesions  of  the 
bones,  the  joints,  the  lungs,  and  the  lymphatic  glands.     There  are  two  types 


I  So  Tuberculosis 

of  scrofula — the  sanguine  and  the  lymphatic.  The  Sanguine  or  Angelic 
Type  :  Those  with  oval  faces,  clear  skins,  large  blue  eyes,  long  lashes,  long 
and  slender  bones,  a  small  amount  of  fat,  precocious  minds,  and  a  nervous 
manner.  Such  children  are  often  graceful  or  even  beautiful.  The  Phleg- 
matic Type  (the  classical  scrofula) :  Those  with  stolid  countenances,  thick 
Hps,  thick  noses,  thict  and  muddy  skin,  dark  and  coarse  hair,  swollen  necks, 
heavv  bones,  clumsy  movements,  ungainly  figures,  dulness  of  apprehension, 
and  feeble  emotions. 

Tuberculous  Abscess. — For  description  of  this,  see  page  122. 

Tuberculosis  of  the  Skin. — Tuberculosis  of  the  skin  may  arise  from 
inoculation  with  material  derived  from  a  bovine  or  human  source.  It  is  fre- 
quently found  that  some  other  member  of  the  family  labors  under  tuberculous 
disease  or  that  some  family  predecessor,  direct  or  collateral,  suffered  from  it. 
Stelwagon  ("Diseases  of  the  Skin")  includes  all  cases  under  five  heads:  (i) 
tuberculosis  ulcerosa;  (2)  tuberculosis  disseminata;  (3)  tuberculosis  verru- 
cosa; (4)  scrofuloderma;  (5)  lupus  vulgaris. 

Tuberculosis  Ulcerosa. — The  disease  arises  by  a  mucous  outlet  and  is 
usually  secondary  to  internal  tuberculous  disease.  Small  miliary  tubercles 
form  which  caseate  and  are  converted  into  ulcers.  The  ulcers  are  shallow, 
round  or  oval  in  outline,  with  soft  edges,  the  floor  being  composed  of  sluggish  or 
edematous  granulations  covered  with  a  crust.  The  discharge  is  scanty  and 
seropurulent.  In  some  cases  there  is  but  one  ulcer;  in  others  there  are  two 
or  several,  and  the  fusion  of  ulcers  produces  a  serpiginous  outline.  The  ulcers 
do  not  heal,  but  gradually  and  steadily  advance.  Such  ulcers  are  met  with 
about  the  mouth,  the  genital  organs,  and  the  anus. 

Tuberculosis  Disseminata. — This  occurs  only  in  children;  it  is  acute  in 
onset  and  widespread.  One  type  is  polymorphic:  spots,  papules,  pustules, 
and  crusted  ulcers  existing,  and  lymphatic  glands  being  enlarged.  Another  type 
follows  one  of  the  exanthemata  and  presents  "  a  rough  resemblance  to  flat  lupus 
tubercles,  to  sluggish  acne  papules,  and  to  lichen  scrofulosum"  (Stelwagon). 
Lupus  begins  usually  before  the  age  of  twenty-five,  but  is  met  with  often  in 
individuals  in  middle  life.  It  is  most  usual  upon  the  face,  especially  the  nose. 
It  is  a  very  chronic  and  extremely  destructive  disease.  Three  forms  are 
recognized:  (i)  lupus  vulgaris,  in  which  pink  nodules  appear  that  after  a  time 
ulcerate  and  then  cicatrize  partly  or  completely.  These  nodules  resemble 
jelly  in  appearance;  (2)  lupus  exedens,  in  which  ulceration  is  very  great;  and 
(3)  lupus  hypertrophicus,  in  which  large  nodules  or  tubercles  arise.  Lupus 
may  appear  as  a  pimple,  as  a  group  of  pimples,  or  as  nodules  of  a  larger  size. 
The  ulcer  arises  from  desquamation,  and  is  surrounded  by  inflammatory 
products  which,  by  progressively  breaking  down,  add  to  the  size  of  the  raw 
surface.  The  ulcer  is  usually  superficial,  is  irregular  in  outhne,  the  edges 
are  soft  and  neither  sharp  nor  undermined,  the  sore  gives  origin  to  a  small 
amount  of  thin  discharge,  the  parts  about  are  of  a  yellow-red  color,  the  edges 
are  solid  and  puckered  and  scar-like,  and  there  is  no  pain.  The  sore  is  often 
crusted,  the  cru.sts  being  thin  and  of  a  brown  or  black  color;  it  may  be  pro- 
gressing at  one  point  and  healing  at  another;  it  is  slow  in  advancing,  but  often 
proves  hideously  destructive.  The  scars  left  by  its  healing  are  firm  and 
corrugated,  but  are  apt  to  break  down.  Clinically  it  is  separated  from  a  rodent 
ulcer  by  several  points.     The  rodent  ulcer  is  deep,  its  edges  are  everted,  and 


Intestinal  Tuberculosis  '  i8i 

the  parts  about  filled  with  visible  vessels.  It  is  not  crusted,  has  not  a  puckered 
edge,  its  edges  and  base  are  hard  and  rarely  show  any  tendency  to  heahng. 

Tuberculosis  Verrucosa. — Anatomical  tubercle,  the  verruca  necro- 
genica  of  Wilks,  is  due  to  local  inoculation  with  tuberculous  matter.  It  is  met 
with  in  surgeons,  the  makers  of  post-mortems,  leather-workers,  and  butchers, 
usually  upon  the  backs  of  the  hands  and  fingers.  It  consists  of  a  red  mass  of 
granulation  tissue  having  the  appearance  of  a  group  of  inflamed  warts.  Pus- 
tules often  form. 

Scrofulodermata  or  tuberculous  gummata  are  chronic  inflammations 
of  the  skin,  the  granulation-tissue  product  of  which  caseates,  mixed  infection 
occurs,  and  small  abscesses,  sinuses,  or  ulcers  form.  A  tuberculous  ulcer  has  a 
floor  of  a  pale  color,  and  has  no  granulations  at  all,  or  is  covered  with  large, 
pale,  edematous  granulations.  The  discharge  is  thin  and  scanty.  It  is 
surrounded  by  a  considerable  zone  of  purple,  tender,  and  undermined  skin, 
which  is  apt  to  slough.  When  healing  occurs,  the  skin  puckers  and  usually 
inverts. 

Tuberculosis  of  Subcutaneous  Connective  Tissue.— In  this  form 
of  tuberculosis  tuberculous  nodules  form  and  break  down  (tuberculous  ab- 
scesses). In  the  deeper  tissues  these  abscesses  are  usually  associated  with 
bone,  joint,  or  lymphatic  gland  disease  (see  Cold  Abscess,  page  122). 

Tuberculosis  of  the  Mammary  Gland. — (Seepage  125.) 

Tuberculosis  of  Blood=vessels. — It  is  certain  that  bacilli  in  the  blood 
or  in  tuberculous  emboli  may  establish  intravascular  tuberculosis. 

Tuberculosis  of  nerve  is  excessively  rare.  Tuberculous  neuritis  may 
arise  in  the  course  of  general  tuberculosis.  A  nerve  lying  in  a  tuberculous  area 
may  itself  become  tuberculous.  It  rarely  does  so,  however.  In  fact,  nerves 
resist  infections  though  in  the  midst  of  them,  and  for  this  reason  have  been 
called  the  "aristocrats  of  the  body." 

Pulmonary  Tuberculosis. — In  adults  the  lungs  are  more  commonly 
aft'ected  than  any  other  structure.  The  lung  aft'ection  may  be  primary  or 
may  be  secondary  to  some  distant  tuberculous  process.  Pulmonary  tubercu- 
losis belongs  to  the  province  of  the  physician  and  requires  no  description  here. 

Tuberculosis  of  the  Alimentary  Canal. — A  tuberculous  ulcer  of  the 
lip  occasionally  occurs,  and  may  be  mistaken  for  a  cancer  or  a  chancre.  A 
tuberculous  ulcer  of  the  tongue  is  commonly  associated  with  other  foci  of  dis- 
ease. Such  ulcers  are  separated  from  cancer  by  their  soft  bases  and  edges 
and  by  the  rarity  of  glandular  enlargements,  and  from  syphilitic  processes 
by  the  therapeutic  test.  Confirmation  of  the  diagnosis  is  obtained  by  culti- 
vations and  inoculations.  Tubercle  may  affect  the  pharynx,  palate,  tonsils 
and  very  rarely  the  stomach.  It  is  thought  that  the  acid  gastric  juice  must 
protect  the  stomach  from  tubercle,  because  tubercle  bacilli  are  frequently 
introduced  into  the  stomach,  but  the  organisms  very  rarely  lodge  and  multiply 
in  the  stomach- wall. 

Intestinal  tuberculosis  may  follow  pulmonary  tuberculosis,  but  it  may 
arise  primarily  in  the  mucous  membrane  of  the  bowel  or  result  from  tubercu- 
lous peritonitis.  Intestinal  tuberculosis  causes  diarrhea  and  fever,  may  resemble 
appendicitis,  and  may  cause  abscess  and  perforation.  True  tuberculous  dis- 
ease of  the  appendix  occasionally  occurs.  Tuberculosis  of  the  cecum  is  by 
no  means  as  rare  as  we  used  to  believe  (page  736).     Fistula  in  ano  is  frequently 


1 82  Tuberculosis 

tuberculous,  and  when  it  is  the  lungs  are  very  often  involved,  the  pulmonary 
lesion  being  usually  primary  (page  855). 

Tuberculosis  of  the  Liver. — Tuberculous  disease  of  the  liver  causes 
cold  abscess  or  cirrhosis. 

Peritoneal  tuberculosis  may  be  primary,  infection  having  been  by  way 
of  the  blood,  may  be  part  of  a  diffused  process,  or  may  follow  intestinal  tuber- 
culosis, the  serous  and  muscular  coats  of  the  bowel  having  been  at  some  point 
in  contact  or  a  follicular  ulcer  having  perforated  (Abbe).  The  germ  may  have 
entered  by  the  Fallopian  tube.  It  may  be  due  to  ovarian  or  Fallopian  tuber- 
culosis, or  to  ulceration  of  a  tuberculous  appendix.  It  usually  causes  ascites, 
tympany,  and  tumor-like  formations  composed  of  adherent  bunches  of  bowel 
or  omentum  or  distended  mesenteric  glands  (page  743). 

The  heart  muscle  is  rarely  attacked  by  tuberculosis.  In  fact,  valvular 
lesions  of  the  left  side  of  the  heart  actually  protect  the  individual  from  pul- 
monary tuberculosis.  Non-tuberculous  endocarditis  may  arise  in  the  course  of 
a  tuberculous  process  elsewhere.  Tuberculous  endocarditis  does  very  rarely 
occur. 

The  pericardium  may  be  attacked  with  primary  tuberculosis,  or  the 
process  may  be  secondary  to  pleural  tuberculosis. 

Tuberculosis  of  the  pleura  is  not  uncommon.  Tuberculous  pleurisy 
may  be  acute  or  chronic.  In  some  instances  mixed  infection  takes  place  and 
suppuration  occurs.  The  tuberculosis  may  be  primary,  but  is  usually  secon- 
dary to  pulmonary  tuberculosis,  and  may  be  due  to  direct  extension  or  to 
rupture  of  an  area  of  pulmonary  softening.  A  primary  pleurisy  not  due  to 
traumatism  is  very  apt  to  be  tuberculous. 

Tuberculosis  of  the  brain  induces  meningitis  and  hydrocephalus  (page 
617). 

Tuberculosis  of  the  membranes  of  the  spinal  cord  is  seen  alone 
or  in  association  with  tuberculous  inflammation  of  the  brain. 

Tuberculous  disease  of  fascia  is  common;  in  fact,  fascia  is  peculiarly 
prone  to  infection.  Fascia  may  be  attacked  primarily,  and  when  it  is  the 
disease  is  apt  to  spread  rapidly  and  widely  and  to  produce  most  disastrous 
results.  The  elder  Senn  regards  tuberculosis  of  the  intermuscular  septa  of  the 
thigh  as  a  very  grave  condition,  which,  if  extensive,  demands  amputation  of 
the  limb.  Secondary  tuberculosis  of  fascia  is  far  more  common  than  the 
primary  form,  the  original  focus  of  disease  being  in  bone,  joint,  tendon-sheath, 
or  lymph-gland. 

Tuberculosis  of  muscle  is  rare.  Instances  of  primary  tuberculosis 
have  been  reported.  Secondary  tuberculosis  is  more  common,  but  e\'en  this 
condition  is  rare,  muscle  seeming  to  have  a  high  degree  of  resistance. 

Tuberculous  disease  of  bone  is  very  common  in  youth,  and  is  usually 
preceded  by  a  sprain  or  a  contusion,  which  is  oftener  slight  than  severe.  The 
injury  establishes  a  point  of  least  resistance,  and  in  the  damaged  area  the 
bacilli  are  deposited  and  multiply.  The  organisms  may  be  deposited  directly 
from  the  blood,  or  may  arrive  in  an  embolism  from  a  distant  tuberculous  focus 
(lung  or  lymph-gland),  which  embolus  is  caught  in  a  terminal  artery  in  the  end 
of  a  long  bone  and  causes  a  wedge-shaped  infarction  (Warren). ' 

Tuberculous  osteitis,  as  a  rule,  begins  just  beneath  the  articular  cartilage 
or  in  theepi[)hysis  (Warren).     The  j^nxlucts  of  the  tuberculous  inflammation 


Tuberculosis  of  the  Testicle  183 

may  be  absorbed,  may  be  encapsuled  by  fibrous  tissue,  or  may  caseate  (page 

177)- 

Tuberculous  disease  of  the  joints  is  called  "white  swelling"  and  also 
pulpy  degeneration  of  the  synovial  membrane.  Joints  are  especially  liable 
to  tuberculosis  in  youth,  although  the  wrist  and  shoulder  not  infrequently 
suffer  in  adult  life.  Joint-tuberculosis  is  often  preceded  by  an  injury.  The 
tuberculous  process  may  begin  in  the  synovial  membrane.  Primary  synovial 
tuberculosis  is  most  often  met  with  in  the  knee-joint.  Usually  the  disease 
begins  in  the  head  of  a  bone,  dry  caries  resulting,  necrosis  ensuing,  or  an 
abscess  forming  which  may  break  into  the  joint. 

Tuberculosis  of  lymphatic  glands  is  known  as  "  tuberculous  adenitis." 
It  is  the  most  typical  lesion  of  scrofula.  The  common  antecedent  of  tuberculous 
adenitis  of  the  neck  is  shght  glandular  enlargement  as  a  result  of  catarrhal 
inflammation  of  the  mucous  membrane  of  the  mouth.  Tuberculous  adenitis 
is  most  frequent  between  the  third  and  fifteenth  years.  A  person  not  of  the 
tuberculous  type  may  acquire  tuberculosis  of  the  glands,  but  the  disease  is 
unquestionably  of  much  greater  frequency  in  those  who  are  recognized  as 
predisposed  to  tuberculosis.  Tuberculous  glands  may  get  well,  may  even 
calcify,  but  usually  caseate  if  left  alone.  Long  after  healing  they  may  break 
down  and  soften  (residual  abscess  of  Paget).  Tuberculous  glands  very  fre- 
quently suppurate  because  of  mixed  infection.  Though  at  first  a  local  dis- 
ease, tuberculous  glands  may  prove  to  be  a  dangerous  focus  of  infection,  fur- 
nishing bacteria  which  are  carried  by  blood  or  lymph  to  distant  organs  or 
throughout  the  entire  system.  Glandular,  enlargement  is  in  rare  instances 
widely  diffused,  but  it  is  far  more  commonly  localized.  Enlargement  of  the 
cervical  glands  is  most  common.  Tuberculous  disease  of  the  mesenteric 
gland  is  known  as  tabes  mesenterica. 

Cervical  lymphadenitis  may  be  confused  with  lymphadenoma.  The 
former,  as  a  rule,  first  appears  in  the  submaxillary  triangle;  the  latter,  in  the 
occipital  or  sternomastoid  glands.  Tuberculous  glands  weld  together,  they 
are  apt  to  remain  localized  for  a  considerable  time,  and  they  tend  to  soften. 
They  may  be  accompanied  by  other  tuberculous  manifestations.  Lymph- 
adenoma  from  the  start  affects  many  glands;  it  may  arise  simultaneously  in 
several  regions,  although  in  some  cases  there  is  a  distinct  beginning  in  one 
region.  Lymphadenoma  shows  very  little  tendency  to  suppurate,  and  does 
not  break  down  except  late  in  the  course  of  the  disease,  and  is  accompanied 
by  great  debility  and  anemia.  Mahgnant  gland-tumors  infiltrate  adjacent 
glands  and  other  structures,  binding  skin,  muscles,  and  glands  into  one  hard, 
firm  mass. 

Tuberculosis  of  tendon=sheaths  (tuberculous  tenosynovitis)  is  dis- 
cussed on  page  559. 

Tuberculosis  of  the  Kidney. — (See  page  944.) 

Tuberculosis  may  attack  the  Fallopian  tubes,  ovaries,  or  uterus. 

Tuberculosis  of  the  urethra,  prostate  gland,  seminal  vesicles, 

and  bladder  is  considered  in  the  section  on  Regional  Surgery. 

Tuberculosis  of  the  Testicle. — ^This  disease  is  not  rare.  It  is  some- 
times primary,  but  is  usually  preceded  by  tuberculosis  of  the  kidney,  bladder, 
or  prostate.     But  one  testicle  is  affected  in  the  beginning,  but  the  other  gland 


184.  Tuberculosis 

is  apt  to  be  attacked  later.  The  tuberculous  mass  softens,  becomes  ad- 
herent to  the  scrotum,  and  breaks  or  bursts,  exposing  the  damaged  testicle 
{fungus  of  the  testicle).  The  cord  is  apt  to  be  involved  in  tuberculosis  of 
the  testicle. 

Diagnosis  of  Surgical  Tuberculosis. — The  diagnosis  may  be  deter- 
mined by  purely  chnical  facts.  It  may  require  the  use  of  the  microscope, 
cultivation  experiments,  or  inoculations.  In  a  suspected  tuberculous  lesion 
remove  a  portion  of  the  tissue  if  it  be  accessible  (by  Mixter's  cannula),  and 
make  sections,  stains,  and  cultivations.  If  no  bacilli  are  found,  inoculate  a 
guinea-pig  with  the  suspected  material.  If  it  be  tuberculous,  the  animal  will 
develop  miliary  tuberculosis  in  a  few  weeks.  The  tuberculin  test  is  occasion- 
ally employed. 

Tuberculin  in  Diagnosis. — Tuberculin  is  used  extensively  for  diagnosti- 
cating tuberculosis  in  cattle.  It  is  said  that  in  a  tuberculous  animal  an  injec- 
tion of  tubercuhn  produces  a  marked  and  characteristic  reaction.  Many 
observers  maintain  that  the  same  is  true  of  tuberculous  human  beings.  Czerny 
has  shown  that  in  renal  tuberculosis  bacilli  are  often  absent  from  the  urine, 
but  an  injection  of  tuberculin  will  cause  them  to  appear  plentifully. 

The  reported  results  of  the  serum  test  in  human  beings  are  variable.  The 
value  of  the  test  is  not  certain;  its  results  are  irregular;  a  negative  result 
certainly  does  not  positively  rule  out  the  existence  of  tuberculosis;  it  is  not 
certain  that  the  procedure  is  absolutely  innocuous,  and  it  is  certain  that  the 
method  is  entirely  useless  and  possibly  dangerous  unless  employed  by  a 
trained  and  skilful  man. 

Prognosis. — The  prognosis  varies  with  the  age,  sex,  duration,  extent, 
and  situation  of  the  lesion.  The  prognosis  is  best  in  children,  and  is  better 
in  males  than  in  females.  Tuberculosis  of  the  skin  gives  a  fair  prognosis. 
Tuberculous  adenitis  is  often  cured.  Any  tuberculous  lesion  is,  however,  a 
menace  to  the  organism,  and  tends  strongly  to  recurrence.  When  phthisis 
exists,  the  performance  of  any  surgical  operation  on  any  part  of  the  body 
may  cause  the  awakening  and  rapid  spread  of  the  pulmonary  lesions.  In 
such  subjects  only  operations  of  necessity  are  to  be  advised  and  that  method 
must  be  selected  which  requires  the  least  period  of  confinement  to  bed  and 
to  the  house. 

Treatment. — Destroy  the  bacilli  present  and  radically  remove  infected 
areas  which  are  accessible.  Never  be  satisfied  with  the  removal  of  part  of 
a  diseased  focus.  Incomplete  operations  are  apt  to  be  followed  by  diffuse 
tuberculosis,  because  many  pathways,  vascular  and  lymphatic,  are  opened 
to  infection.  Among  the  many  drugs  which  have  been  recommended  for 
local  use  we  mention  the  following:  iodin,  carbolic  acid,  guaiacol,  arsenious 
acid,  corrosive  sublimate,  chlorid  of  zinc  (Lannelongue),  phosphate  of  iron, 
balsam  of  Peru  (Landerer),  camphorated  naphtol,  oil  of  cinnamon,  cinnamic 
acid  (Landerer),  and  iodoform.*  Iodoform  used  locally  upon  or  in  tuberculous 
areas  is  of  great  value,  and  there  is  no  drug  which  takes  its  place.  Lupus 
may  be  treated  by  the  application  of  blue  ointment;  by  curetting,  cauterizing 
with  carbolic  acid,  and  dressing  with  iodoform;  by  excision,  followed  in  some 

*  See  article  upon  "Tuljerculosis,"  by  George  Ryersoii   Fowler,  Brooklyn   Med.  Jour., 
Nos.  8  and  9,  1894. 


Treatment 


185 


instances  by  sliding  in  of  a  flap  of  sound  tissue  or  immediate  skin-grafting. 
If  treating  a  nodular  and  non-ulcerated  area,  wash  it  with  a  2  per  cent,  solu- 
tion of  corrosive  sublimate  and  inject  several  nodules  with  camphorated 
naphtol,  one  drop  for  each  nodule.  In  seven  or  eight  days  inject  other  nodules, 
and  so  on.  Koch's  lymph  has  cured  some  cases  of  lupus.  The  .T-rays  are 
undoubtedly  curative  in  many  cases  of  lupus.  Enlarged  glands  of  uncertain 
character  and  very  recent  tuberculous  enlargements  should  be  treated  by  rub- 
bing ichthyol  into  the  skin  over  the  glands  and  treating  the  patient  hygienically, 
and  by  the  internal  administration  of  antituberculous  drugs.  If  this  plan  fails 
to  cure,  the  glands  should  be  removed.  When  glands  break  down  they  should 
be  removed,  or  should  be  opened,  curetted,  and  packed.  The  rule  must  be 
to  completely  dissect  out  enlarged  lymphatic  glands  which  fail  to  quickly 
respond  to  treatment,  removing  capsules  and  glands.  In  any  tuberculous 
trouble  climate  is  of  very  great  importance.  Osier  sums  up  climatic  neces- 
sities as  "pure  atmosphere,  equable  temperature,  and  maximum  amount  of 
sunshine."  Open-air  life  is  imperative.  The  patient  must  have  a  well- 
ventilated  sleeping-room,  and  his  house  should  be  free  from  dampness. 
Nourishing  diet  is  essential.  To  secure  a  gain  in  weight  is  a  constant  aim. 
Give  meat,  milk,  cream,  butter,  and  cod-Hver  oil.  The  oil  is  poorly  borne 
in  hot  weather,  during  which  period  it  should  be  discontinued.  Advancing 
doses  of  arsenic,  quinin,  and  stimulants  have  their  uses.  Beechwood  creasote 
is  a  valuable  remedy.  It  should  be  mixed  with  an  equal  amount  of  alcohol 
and  be  given  in  milk  one  hour  after  each  meal.  The  initial  dose  is  10  drops 
of  the  mi.xture,  and  the  dose  is  advanced  day  by  day  until  50  or  60  drops  are 
being  taken  at  one  time,  at  which  point  the  dose  is  lowered  or  the  adminis- 
tration is  suspended  for  a  time.  While  giving  creasote  be  watchful  for  symp- 
toms of  its  toxic  action.  Guaiacol  in  5-drop  doses  is  distinctly  valuable. 
(For  treatment  of  tuberculosis  of  bones,  joints,  peritoneum,  pleura,  etc.,  look 
under  special  regional  headings.) 

Bier\s  Method. — A  few  years  ago  Bier  set  forth  a  new  plan  for  treating 
tuberculous  lesions.  It  consists  in  causing  venous  obstruction  and  passive 
congestion.  In  the  area  of  passive  congestion  the  tissue-cells  form  antitoxins 
which  kill  the  bacteria  or  attenuate  their  virulence.  The  treatment  is  founded 
upon  the  principle  announced  by  Laennec,  that  "  cyanosis  is  antagonistic  to 
tubercle."  The  plan  is  applied  particularly  in  joint-tuberculosis.  An  elastic 
band  three  inches  broad  is  placed  around  the  Hmb,  above  the  seat  of  disease, 
and  it  is  apphed  sufficiently  tight  to  cause  congestion.  Several  pieces  of  lint 
ought  to  be  interposed  between  the  skin  and  the  band.  By  applying  a  flannel 
bandage  from  the  periphery  to  the  lower  border  of  the  disease  the  congestion 
is  limited  to  the  area  of  trouble.  The  patient  should  wear  the  band  con- 
tinually and  move  about  with  it  on.  Some  people  wear  it  without  any  incon- 
venience, but  others  complain  greatly  after  wearing  it  but  a  short  time.  Bier 
and  others  have  reported  cures. 

Finsen's  Treatment  with  Concentrated  Light. — Finsen  has  proved  that 
concentrated  chemical  rays  from  sunlight  and  also  from  electric  light  have 
germicidal  power.  He  applies  these  rays  using  an  apparatus  which  concen- 
trates actinic  rays  and  intercepts  heat-rays.  Local  areas  of  tuberculosis  are 
often  benefited  or  cured  by  this  method,  but  it  must  be  used  for  months. 

Koch's  Tuberculin. — The  specific  treatment  by  Koch's  tuberculin  or  parato- 


1 86  Tuberculosis 

loid  has  excited  widespread  interest.  It  has  not  fulfilled  the  expectations 
which  many  entertained,  but  does  benefit  some  cases,  notably  lupus.  A 
serious  drawback  to  the  value  of  Koch's  tuberculin  is  that  it  often  causes  fever 
and  inflammation  to  a  dangerous  degree.  In  some  cases,  as  Virchow  showed, 
it  produces  acute  mihary  tuberculosis.  Koch's  lymph  is  a  glycerin  extract 
of  a  culture  of  tubercle  bacilh,  and  the  usual  dose  is  i  milligram,  given  hypo- 
dermatically  into  the  back  by  Koch's  pistonless  syringe.  After  it  has  been 
used  for  a  time  the  dose  may  be  increased  to  lo  milligrams,  or  even  much 
more.  Bergmann  gave  i  gram.  Koch's  lymph  causes  inflammation  and 
necrosis  of  tuberculous  tissue  by  the  action  of  certain  antitoxins.  Many  cases 
it  improves.  Some  cases  it  apparently  cures,  but  the  disease  is  apt  to  re- 
turn. In  pulmonary  tubercle  it  must  not  be  given  if  there  be  much  fever  or 
extensive  consolidation.  Chiene  used  tuberculin  largely  in  joint  cases  by  giv- 
ing two  or  three  doses  a  day  and  increasing  the  dose.  It  is  best  to  associate 
other  treatment  with  the  lymph.  Koch  has  recently  modified  his  tuberculin. 
He  makes  it  as  follows:  dried  cultures  of  bacilh  are  mixed  with  distilled 
water,  and  the  mixture  is  agitated  in  a  centrifuge.  Two  layers  separate. 
The  upper  layer  is  the  old  tuberculin.  The  lower  layer  is  the  new  tuber- 
cuUn.  The  new  tuberculin  is  given  hypodermatically,  at  first  in  very  small 
doses,  but  finally  in  doses  as  large  as  20  milligrams.  It  is  not  to  be  given  in 
far  advanced  cases  or  cases  with  much  fever. 

Hunter,  of  London,  declares  that  Koch's  old  lymph  contains  one  principle 
which  causes  fever,  another  with  causes  inflammation,  and  a  third  which  pro- 
duces atrophy  of  tuberculous  foci  without  either  fever  or  inflammation.  This 
third  desirable  element  he  believes  he  has  isolated  in  what  is  called  a  "  deriva- 
tive of  tubercuhn,"  a  modified  lymph.  Some  remarkable  results  have  fol- 
lowed the  use  of  this  material;  its  administration  seems  entirely  safe,  and  it 
should  thoroughly  and  carefully  be  tried  to  ascertain  its  true  rank  as  a  remedy. 
The  injection  of  serum  obtained  from  animals  refractory  to  tubercle  has  been 
employed,  but  Richet  and  Hericourt  have  seen  no  benefit  from  the  plan. 
Maragliano,  of  Genoa,  uses  a  serum  which  he  believes  can  cure  tuberculosis. 
He  immunizes  animals  not  by  injection  of  living  cultures,  but  by  employing 
the  toxic  principles  extracted  from  them.  Progressive  vaccinations  immunize 
a  dog.  The  serum  of  the  animal  is  injected  for  the  cure  of  tuberculosis  in 
man  or  other  animals.  If  injected  along  with  tuberculin,  it  neutralizes  the 
general  and  local  reaction  of  the  latter  agent.  The  serum  has  apparently 
benefited  some  cases,  but  is  certainly  useless  against  mixed  infections.* 
*  Brit.  Med.  Jour.,  1895,  ■'>  444- 


Rickets  187 

XIV.  RACHITIS,  OR  RICKETS. 

Rickets  is  a  chronic  disorder  of  nutrition  arising  during  the  early  years 
of  Ufe  (the  first  two  or  three)  as  a  result  of  insufi&cient  or  of  improper  diet, 
aided  and  abetted  in  many  cases  by  bad  hygienic  surroundings.  A  deficiency 
of  fat  and  phosphate  in  the  food  or  the  use  of  a  diet  which,  by  inducing  gastro- 
intestinal catarrh,  prevents  assimilation,  causes  rickets.  The  disease  is  not 
common  in  nursing  children  unless  breast-feeding  has  been  unduly  prolonged, 
and  children  fed  upon  artificial  food  are  particularly  apt  to  develop  it.  Holt 
says  such  diet  is  very  deficient  in  fat  and  often  in  proteids,  and  contains  an 
excess  of  carbohydrates  ("Diseases  of  Infancy  and  Childhood").  The  dis- 
ease is  essentially  a  city  malady,  "  being  principally  seen  in  children  living  m 
crowded  tenements  where  the  effects  of  improper  food  are  most  strikingly 
shown;  yet  even  here  the  disease  is  rare  in  those  who  get  a  plentiful  supply 
of  good  breast-milk"  (Holt).  Rickets  must  not  be  regarded  as  a  bone  dis- 
ease. It  is  true  the  bones  are  affected,  but  so  are  various  structures  and  organs, 
all  of  the  disorders  being  due  to  an  underlying  nutritive  defect.  Some  main- 
tain that  lactic  acid,  produced  in  the  intestinal  canal,  causes  bone  inflamma- 
tion, but  most  observers  do  not  believe  the  bone-changes  are  inflammatorv. 
Children  are  rarely  born  with  rickets,  but  develop  it  later,  the  period  of  greatest 
liability  being  between  the  seventh  month  and  the  fifteenth  month.  So-called 
congenital  rickets  is  usually  sporadic  cretinism. 

Evidences  of  Rickets. — The  condition  is  one  of  general  ill-health;  the 
child  is  ill-nourished,  pallid,  flabby;  it  has  a  tumid  belly  and  suffers  from 
attacks  of  diarrhea  and  sick  stomach;  it  is  disinclined  for  exertion  and  has  a 
capricious  appetite;  it  is  liable  to  night-sweats;  enlarged  glands  are  often 
noted,  the  teeth  appear  behind  time,  and  the  fontanels  close  late.  In  health 
the  posterior  fontanel  closes  in  the  second  month  and  the  anterior  fontanel  in 
the  eighteenth  month.  In  rickets  the  anterior  fontanel  is  often  open  when 
the  child  is  3  years  of  age.  The  sutures  are  often  open  at  the  end  of  the  first 
year.  The  head  is  square  in  shape,  the  cranial  bones  are  thick,  and  areas  of 
thickening  known  as  bosses  appear  over  the  parietal  bones.  The  head  is  large 
and  the  forehead  bulges.  The  long  bones  become  much  curved,. the  upper  part 
of  the  chest  sinks  in,  curvature  of  the  spine  appears,  and  the  pelvis  is  distorted. 
The  ligaments  are  relaxed  and  lengthened  and  the  joints  are  wobbly.  The 
muscles  are  feeble  and  ill  developed.  Infantile  convulsions  are  common. 
Nocturnal  restlessness  and  night  terrors  are  the  rule.  Laryngismus  stridulus 
and  tetany  may  occur.  Swelling  appears  in  the  articular  heads  of  long  bones, 
by  the  side  of  the  epiphyseal  cartilages,  and  in  the  sternal  ends  of  the  ribs, 
forming  in  the  latter  case  rachitic  beads.  The  lesions  of  rickets  are  due  to 
imperfect  ossification  of  the  animal  matter  which  is  prepared  for  bone-forma- 
tion, and  the  soft  bones  gradually  bend.  The  swellings  at  the  articular 
heads  are  due  to  pressure  forcing  out  the  soft  bone  into  rings.  Rachitic 
children  rarely  grow  to  full  size,  and  the  disease  is  responsible  for  many  dwarfs. 
Most  cases  recover  without  distinct  deformity,  but  the  time  lost  during  the 
period  when  active  development  should  have  gone  on  cannot  be  made  up,  and 
some  slight  deficiency  is  sure  to  remain.  Bowlegs,  knock-knees,  and  spinal 
curvatures  are  usually  rachitic  in  origin.     The  disease  mav  be  associated  with 


1 88  Rachitis,  or  Rickets 

scurvy,  inherited  syphiHs,  or  tuberculosis.  In  appearance  the  rickety  child  is 
pot-beUied,  pale  and  anemic,  and  usually  fat  and  flabby,  though  occasionally 
thin.  There  is  great  liabihty  to  enlargement  of  the  tonsils,  gastro-intestinal 
catarrh,  and  bronchial  catarrh.  The  blood  is  deficient  in  red  corpuscles 
and  hemoglobin,  and  sometimes  there  is  leukocytosis.  The  disease  lasts  for 
many  months  and  is  usually  recovered  from.  It  does  not  directly  produce 
death,  but  is  a  powerful  indirect  cause  of  infant  mortality  because  it  lessens 
resistance  and  predisposes  to  many  diseases.  It  is  almost  always  afebrile; 
rarely  congenital;  and  in  unusual  cases  known  as  late  rickets  develops  be- 
tween the  fifth  and  tenth  year.  The  so-called  acute  rickets  is  practically 
always  scurvy  (Holt).  The  victims  of  rachitis  are  very  liable  to  fracture  the 
bones  from  slight  force  and  green-stick  fractures  are  particularly  prone  to 
occur.     After  fracture  of  a  rickety  bone  union  is  usually  delayed. 

Treatment. — The  treatment  consists  in  having  the  child  live  as  much  as 
possible  in  the  open  air  and  sunshine.  Salt-water  baths  are  useful.  Sea-air 
is  very  beneficial.  Fresh  food  (milk,  cream,  and  meat-juice)  should  be 
ordered.  Cod-liver  oil,  syrup  of  the  iodid  of  iron,  arsenic,  and  some  form 
of  phosphorus  are  to  be  administered.  It  is  absolutely  necessary  to  improve 
the  primary  assimilation.  Slight  deformities  of  the  extremities  require  no 
special  treatment  unless  they  increase.  If  the  deformity  is  marked  or  is  in- 
creasing, use  braces;  employ  massage,  manipulation  and  faradism.  Holt 
points  out  that  by  the  time  the  child  is  two  years  of  age  the  bones  are  so  firm 
that  the  pressure  of  a  brace  cannot  cure  the  deformity.  Hence  after  this  age 
braces  are  useless.  Severe  established  deformities  of  the  extremities  are 
usually  treated  surgically.  Kyphosis  is  treated  by  making  the  patient  lie  upon 
a  hard  bed  without  a  pillow.  The  child  sits  up  a  few  hours  each  day,  the 
shoulders  being  held  back  and  support  applied  to  the  body.  In  bad  cases, 
during  the  time  the  child  is  erect  it  should  wear  a  brace  or  plaster-of-Paris 
jacket.  Daily  manipulation,  the  child  lying  prone,  is  helpful.  Friction  and 
electricity  to  the  spinal  muscles  do  good. 

Scorbutus  (Scurvy). — This  disease  is  rare  to-day  in  adults,  but  was  at 
one  time  very  common  among  those  who  took  long  voyages,  or  who  engaged 
in  campaigns,  or  were  the  victims  of  sieges.  Of  recent  years  it  is  very  uncom- 
mon, and  has  occurred  chiefly  among  voyagers  in  the  Arctic  regions  or  those 
who  were  beleaguered.  Some  years  ago  I  saw  several  cases  in  a  large  alms- 
house. It  is  important  to  remember  that  though  scurvy  is  rare  in  adults,  it  is 
by  no  means  uncommon  in  ill-nourished  infants.  (A  most  graphic  picture  of 
scurvy  as  it  used  to  occur  will  be  found  in  "A  Voyage  Around  the  World," 
by  Lord  Anson.     Compiled   by  the    Rev.  R.  Walter.) 

Scurvy  is  a  constitutional  malady  due  to  the  consumption  of  improper  diet, 
and  especially  to  the  employment  of  a  diet  characterized  by  the  absence  of 
vegetables. 

The  use  of  .salt  meat  as  a  staple  article  seems  to  favor  the  production  of 
the  di.sease.  Garrod  considered  ab.sence  of  potas.sium.  salts  to  be  the  real 
cause.  Absence  of  variety  in  diet,  bad  water,  poorly  ventilated  quarters,  and 
insufficient  exerci.se  fav(jr  the  development  of  the  disease. 

Scurvy  begins  with  weakness,  drowsiness,  muscular  pains,  and  great 
susceptibility  to  cold.  The  skin  is  pallid  or  dirty  white,  and  is  occasionally 
mottled  and  often  peels  off.     The  patient  is  breathless  on  the  slightest  exer- 


Infantile  Scurvy  189 

tion.  The  pulse  is  excessively  weak  and  slow.  There  is  no  fever.  After 
two  or  three  weeks  the  gums  become  tender,  painful,  and  swollen,  and  bleed 
at  frequent  intervals;  the  breath  becomes  offensive,  the  teeth  loosen  and  even 
drop  out;  subcutaneous  hemorrhages  take  place,  giving  rise  to  petechise  or 
extensive  extravasations;  the  vision  becomes  dim;  the  urine  becomes  scanty 
and  of  low  specific  gravity;  cutaneous  vesicles  form,  rupture,  and  give  rise 
to  bleeding  ulcers,  and  ulcers  likewise  arise  from  breaking  down  of  blood 
extravasations;  hemorrhages  take  place  into  and  between  the  muscles,  and 
in  severe  cases  beneath  the  periosteum  and  into  joints,  and  blood  may  flow 
from  the  nose,  lungs,  kidneys,  stomach,  and  intestines.  Deep  hemorrhages 
are  felt  as  hard  lumps.  Bleeding  at  an  epiphyseal  line  may  separate  the 
epiphysis  from  the  shaft.  If  an  inflammation  or  ulceration  arises  at  any 
point,  fever  is  observed.  It  was  observed  by  DeHaven,  who  commanded 
the  Grinell  expedition  in  search  of  Sir  John  Franklin,  that  scurvy  causes  old 
and  soundly  healed  wounds  to  ulcerate.  The  same  observation  was  made 
years  before  in  Lord  Anson's  voyage.  A  sailor  of  the  "  Centurion"  had  been 
wounded  fifty  years  before  at  the  battle  of  the  Boyne.  He  developed  scurvy 
and  the  old  wound  opened.  Most  cases  of  scurvy  get  well  under  proper  treat- 
ment, but  complete  recovery  is  not  attained  for  a  long  time.  Sudden  death 
is  liable  to  occur  if  any  exertion  is  made. 

Captain  Cook  succeeded  in  preventing  scurvy  among  his  sailors  by  pro- 
viding plenty  of  fresh  water;  guarding  them  against  fatigue,  wet,  and  ex- 
tremes of  heat  and  cold;  attending  to  cleanliness  and  ventilation,  and  stimu- 
lating cheerfulness.  This  great  navigator  lost  no  men  from  scurvy.  After 
the  time  of  Captain  Cook,  the  British  Admiralty,  acting  on  the  suggestions 
of  Lind  and  Blane,  provided  ships  with  lime-juice  or  lemon-juice  with  the 
most  beneficial  results  in  preventing  the  disease.  Scurvy  is  prevented  at  the 
present  time  by  employing  a  proper  diet  and  by  maintaining  cleanliness  and 
hygienic  conditions. 

The  following  agents  are  believed  to  be  especially  useful  as  preventatives: 
fresh  meat,  lemon-juice,  cider,  vinegar,  milk,  eggs,  onions,  cranberries,  cab- 
bages, pickles,  potatoes,  and  lime-juice.  When  the  disease  develops,  give 
vinegar,  lemon-juice,  onions,  scraped  apples,  cider,  nitrate  of  potassium, 
whiskey  or  brandy,  and  plenty  of  nourishing  food.  Antiseptic  mouth-washes 
are  necessary  and  strychnin  is  a  valuable  stimulant  to  the  circulation.  Sleep 
must  be  secured  and  ulcers  are  treated  by  antiseptic  dressings  and  compres- 
sion. 

Infantile  scurvy  may  exist  alone  or  with  rickets  (scurvy  rickets).  It 
occurs  most  often  in  the  children  of  the  well-to-do,  those  who  have  been 
brought  up  on  artificial  foods.  It  occurs  between  the  eighth  and  eighteenth 
months.  The  child  is  anemic,  suffers  from  gastro-intestinal  disorders,  spongy 
and  bleeding  gums,  weakness  of  the  legs,  general  muscular  tenderness,  night- 
sweats,  and  often  febrile  attacks  (Rotch),  bleeding  from  the  nose,  bleeding 
beneath  the  skin  (blue  spots),  bloody  urine  and  stools,  bleeding  beneath  the 
periosteum,  into  joints,  viscera,  or  muscles  A  subperiosteal  hemorrhage  is 
very  dense,  is  tender,  is  fusiform  in  outhne,  and  does  not  fluctuate.  It  is 
sometimes  mistaken  for  sarcoma.  In  one  case  seen  by  the  author  a  hemor- 
rhage beneath  the  periosteum  of  the  femur  was  mistaken  for  a  sarcoma.  The 
limb  attacked  is  flexed,  and  the  child  will  not  move  it.      Separation  of  an 


igo  Rachitis,  or  Rickets 

epiphysis  may  result  from  hemorrhage  between  it  and  the  bone.  Infantile 
scurvy  is  often  unrecognized.  If  promptly  treated,  recovery  is  the  rule,  other- 
wise death  may  occur  from  exhaustion. 

Treatment. — Keep  the  child  quiet  in  bed  and  give  liberal  amounts  of  cow's 
milk  and  beef-juice.  Administer  orange-juice,  grape-juice,  scraped  apples, 
and  tonics.  To  children  over  one  year  of  age  give  potatoes.  Antiseptic 
mouth-washes  are  necessary. 


Contusions  191 


XV.  CONTUSIONS  AND  WOUNDS. 

Contusions. — A  contusion  or  bruise  is  a  subcutaneous  laceration,  due  to 
the  application  of  blunt  force,  the  skin  above  it  being  uninjured  or  damaged 
without  a  surface-breach  and  blood  being  effused.  Punches,  kicks,  blows 
from  a  blackjack,  etc.,  cause  contusions.  In  intra-abdominal  contusions 
the  skin  of  the  abdomen  is  frequently  not  damaged.  In  contusions  of  struc- 
tures overlying  a  bone  the  skin  suffers  with  the  deeper  structures.  If  a  large 
vessel  is  ruptured,  hemorrhage  is  profuse  and  much  blood  gathers  in  the 
tissue.  If  only  small  vessels  suffer,  hemorrhage  is  moderate.  An  ecchymosis 
is  diffuse  hemorrhage  over  a  large  area,  the  blood  lying  in  the  spaces  of  the 
subcutaneous  or  submucous  areolar  tissue.  A  very  small  ecchymosis  is 
known  as  a  petechia;  a  very  large  ecchymosis  is  called  a  suffusion  or  extrav- 
asation. A  hematoma  is  a  blood-tumor  or  a  circumscribed  hemorrhage, 
the  blood  lying  in  a  distinct  cavity  in  the  tissue.  In  extremely  severe  con- 
tusions tissue  vitahty  may  be  destroyed  or  so  seriously  impaired  that  gangrene 
follows.  Suppuration  rarely  occurs,  but  occasionally  does  so,  and  is  most  apt 
to  in  a  drunkard  or  a  person  of  dilapidated  constitution.  When  hemorrhage 
arises  in  the  tissues  after  a  contusing  force  it  soon  ceases  unless  a  verv  consid- 
erable vessel  is  ruptured.  The  arrest  of  hemorrhage  is  brought  about  by  the 
resistance  of  the  tissues,  the  contraction  and  retraction  of  the  vessels,  by  coagu- 
lation of  blood,  and  in  some  cases  of  severe  injury  coagulation  is  favored 
by  syncope.  Blood  in  the  tissues,  as  a  rule,  soon  coagulates,  the  fluid 
elements  being  absorbed  and  the  red  corpuscles  breaking  up  and  setting  free 
pigment,  which  pigment  may  be  carried  away  from  the  seat  of  injury  or  may 
crystallize  and  remain  there  as  hematoidin.  In  some  cases  inflammation 
occurs  about  the  extravasated  blood,  a  capsule  of  fibrous  tissue  being  formed, 
and  the  blood  being  slowly  absorbed,  or  the  fluid  elements  remaining  un- 
absorbed  (blood-cyst),  or  the  blood  becoming  thicker  and  thicker,  finally 
calcifying.  Blood  in  serous  sacs  (joints,  pleura,  pericardium)  coagulates 
very  slowly.  As  blood  is  being  absorbed  it  undergoes  chemical  changes  and 
color-changes  ensue,  the  part  being  at  first  red  and  then  becoming  purple, 
black,  green,  lemon,  and  citron.  The  stain  following  a  contusion  is  most 
marked  in  the  most  dependent  area.  After  a  bruise  of  the  periosteum  a 
blood-clot  forms,  much  tissue-induration  occurs,  and  a  hard  edge  can  be 
detected  by  palpation. 

Symptoms. — The  symptoms  are  tenderness,  swelling,  and  numbness, 
followed  by  some  aching  pain  or  a  feeling  of  soreness.  The  pain  rarely  per- 
sists beyond  the  first  twenty-four  hours.  Cutaneous  discoloration  appears 
quickly  in  superficial  contusions,  but  only  after  days  in  deep  ones.  In  some 
regions — the  scalp,  for  instance — it  can  scarcely  be  detected;  in  others,  as  in 
the  eyelid  and  vulva,  discoloration  is  early,  widespread,  and  marked.  Dis- 
coloration and  swelling  are  very  marked  in  regions  where  loose  cellular  tissue 
abounds  (eyelids,  prepuce,  scrotum).  The  discoloration  is  at  first  red,  and 
becomes  successively  purple,  black,  green,  lemon,  and  citron.  The  swelling  is 
primarily  due  to  blood,  and  is  added  to  by  inflammatory  exudation.  In  a  more 
severe  contusion  a  hematoma  may  form.  A  recent  hematoma  fluctuates,  but 
gradually,  because  of  cell-proliferation,  the  edge  becomes  hard  and  the  center 


192  Contusions  and  Wounds 

continues  to  fluctuate.  The  mass  gradually  grows  smaller  and  finally  dis- 
appears. A  hematoma  of  the  scalp  may  be  mistaken  for  depressed  fracture 
of  the  skull.  It  may  also  be  mistaken  for  an  abscess,  but  ditl'ers  from 
it  in  the  absence  of  inflammatory  signs.  It  occasionally,  though  rarely, 
suppurates.  In  a  case  in  which  suppuration  occurs  an  abrasion,  which  may 
be  very  minute,  often  exists  on  the  skin.  In  any  severe  contusion  there  is 
considerable  and  possibly  grave,  or  even  fatal,  shock. 

Treatment. — In  a  severe  injury  bring  about  reaction  from  the  shock. 
Local  treatment  consists  in  rest,  elevation,  and  compression  to  arrest  bleeding, 
antagonize  inflammation,  and  control  swelling.  Cold  is  useful  early  in  most 
cases,  but  it  is  not  suited  to  very  severe  contusions  nor  to  contusions  in  the 
debilitated  or  aged,  as  in  such  cases  it  may  cause  gangrene.  In  very  severe 
contusions  employ  heat  and  stimulation.  When  inflammation  is  subsiding 
after  a  contusion,  compression  and  inunctions  of  ichthyol  should  be  em- 
ployed. Massage  and  passive  motion  are  imperatively  needed  after  con- 
tusion of  a  joint.  A  contusion  should  never  be  incised  unless  the  amount  of 
blood  is  large  and  a  distinct  cavity  exists,  or  hemorrhage  continues,  or  infec- 
tion takes  place,  or  a  lump  remains  for  some  weeks,  or  gangrene  is  threatened. 
If  the  amount  of  blood  is  very  large,  massage  must  not  be  used  because  it  may 
cause  embolism  or  fat-embolism.  If  a  distinct  cavity  exists,  aspiration  or 
incision  lessens  the  danger  of  fat-embolism.  For  persistent  bleeding  freely 
lay  open  the  contused  area,  turn  out  clots,  ligate  vessels,  insert  drainage- 
strands  or  a  tube,  and  close  the  wound.  If  gangrene  is  feared,  make  incisions 
and  apply  heat  to  the  part.  If  a  slough  forms,  employ  antiseptic  fomentations. 
The  constitutional  treatment  for  contusion,  after  the  patient  has  reacted  from 
shock,  is  the  same  as  that  for  inflammation.     (See  Abdomen,  etc.) 

Wounds. — A  wound  is  a  breach  of  surface  continuity  effected  by  a  sudden 
mechanical  force.  Wounds  are  divided  into  open  and  subcutaneous,  septic 
and  aseptic,  incised,  contused,  lacerated,  punctured,  gunshot,  stab,  and 
poisoned  wounds. 

The  local  phenomena  of  wounds  are  pain,  hemorrhage,  loss  of  func- 
tion, and  gaping  or  retraction  of  edges. 

Pain  is  due  to  the  injury  of  nerves,  and  it  varies  according  to  the  situation 
and  the  nature  of  the  injury.  It  is  influenced  by  temperament,  excitement, 
and  preoccupation.  It  may  not  be  felt  at  all  at  the  time  of  the  injury.  At 
first  it  is  usually  acute,  becoming  later  dull  and  aching.  In  an  aseptic  wound 
the  pain  is  usually  slight,  but  in  an  infected  wound  it  is  always  severe. 

The  nature  and  amount  of  hemorrhage  vary  with  the  state  of  the  system, 
the  vascularity  of  the  part,  and  the  variety  of  injury. 

Loss  oj  junction  depends  on  the  situation  and  extent  of  the  injury. 

Gaping  or  retrartion  oj  edges  is  due  to  tissue-elasticity,  and  varies  according 
to  the  tissues  injured  anrl  the  direction,  nature,  and  extent  of  the  wound. 

The  constitutional  condition  after  a  severe  injury  is  a  state  known  as 
shock. 

Shock  is  a  suflden  depression  of  the  vital  powers  arising  from  an  injury 
or  a  profound  emotion  acting  on  the  nerve-centers  and  inducing  exhaustion 
or  inhibition  of  the  vasomotor  mechanism.  By  overstimulation  of  sensory 
nerves  the  vasomotor  center  is  exhausted  or  inhibited,  vaso-constrictor 
power  is   lost,  the  arteries   and    capillaries    are  depleted  or  nearly  emptied 


Symptoms  of  Shock  193 

of  blood,  and  the  blood  is  largely  transferred  to  the  veins.  The  blood- 
pressure  is  lowered,  the  cardiac  action  is  impaired,  the  respiratory  action 
is  impeded,  and  quantities  of  dark-colored  blood  gather  in  the  somatic 
veins,  but  especially  in  the  veins  of  the  splanchnic  area.  (See  the  masterly 
study  of  "Surgical  Shock"  by  Crile.)  In  shock  the  abdominal  veins  are 
greatlv  distended  and  the  other  veins  of  the  body  may  also  be  overfull,  the 
arteries  contain  less  blood  than  normal,  and  an  insufficient  amount  of  blood 
is  sent  to  the  heart  and  to  the  vital  centers  in  the  brain.  In  other  words,  in 
shock  there  is  a  deficiency  in  the  circulating  blood.  The  term  collapse  is  used 
by  some  to  designate  a  severe  condition  of  shock,  and  is  employed  by  others 
as  a  name  for  a  condition  of  shock  produced  by  mental  disturbance  rather 
than  by  physical  injury.  Crile  regards  collapse  as  inhibition  of  the  vaso- 
motor center,  in  contrast  to  shock,  which  is  exhaustion  of  the  center.  As 
a  matter  of  fact,  shock  and  collapse  are  often  both  present.  Shock  may 
be  slight  and  transient,  it  may  be  severe  and  prolonged,  and  it  may  even 
produce  almost  instant  death.  Sudden  death  from  shock  is  due  to  re- 
flex .stimulation  of  the  pneumogastric  nuclei  and  arrest  of  cardiac  action. 
It  is  known  as  death  by  inhibition.  Shock  is  more  severe  in  women 
than  in  men,  in  the  nervous  and  sanguine  than  in  the  lymphatic,  in  those 
weakened  by  suffering  than  in  those  who  are  strangers  to  illness.  It  is  pre- 
disposed to  by  fear,  by  disease  of  the  kidneys,  diabetes,  chronic  cardiac 
disease,  and  alcoholism.  Injuries  of  nerves,  of  the  brain,  of  the  intrathoracic 
viscera,  of  the  intra-abdominal  viscera,  of  the  urethra,  or  of  the  testicle  pro- 
duce extreme  shock.  Anything  which  extracts  the  body-heat  favors  the  de- 
velopment of  shock  (exposure  to  cold  air,  insufficient  covering,  chilling  the 
bodv  by  solutions  or  wet  towels).  Cerebral  concussion  is  shock  plus  other 
conditions.  Sudden  and  profuse  hemorrhage  causes  shock;  so  does  prolonged 
anesthetization.  Great  shock  may  occur  after  the  removal  of  a  large  tumor 
or  a  quantity  of  fluid  from  the  abdomen.  In  such  a  case  shock  is  brought 
about  by  the  sudden  removal  of  pressure  and  the  consequent  rapid  distention 
of  intra-abdominal  veins.  Exposure  of  tissue  and  vital  parts  to  air  aggra- 
vates .shock. 

Symptoms. — The  symptoms  of  ordinary  shock  (torpid  or  apathetic  shock) 
are  subnormal  temperature;  irregular,  weak,  rapid,  and  compressible  pulse; 
cold,  paUid,  clammv,  or  profusely  perspiring  skin;  and  shallow  and  irregular 
respiration.  Consciousness  is  usually  maintained,  but  there  is  an  absence 
of  mental  originating  power,  the  injured  person  answering  when  spoken  to, 
init  v(^lunteering  no  statements  and  lying  with  partly  closed  hds  and  expres- 
sionless countenance  in  any  position  in  which  he  may  be  placed.  The  pupils 
are  dilated  and  react  but  slowly  to  light.  The  sphincters  are  relaxed. 
Pain  is  slightly  or  not  at  all  appreciated.  Nau.sea  is  absent  and  vomiting 
may,  as  in  concussion,  presage  reaction.  Gastric  regurgitation,  after  a  con- 
siderable duration  of  shock,  is  not  unusual,  and  is  a  bad  omen.  Shock  is  not 
rarely  followed  by  suppression  of  urine.  Whereas  the  victim  of  shock  is 
usuallv  stupid  and  indifferent,  he  may  become  delirious.  If  dehrium  arises, 
the  condition  is  \ery  graxc.  Travers  called  shock  with  delirium  erethistic  or 
delirious  sliorl^.  .\s  a  matter  of  fact,  such  a  state  is  not  genuine  shock, 
but  is  either  a' traumatic  or  a  toxic  delirium.  It  is  usually  due  to  uremia  or 
sepsis.     Delirious  shock  is  seen  after  a  y)er.son  has  been  bitten  by  a  poisonous 


194 


Contusions  and  Wounds 


snake.  Many  years  ago  Travers  described  a  secondary  or  delayed  form  of 
shock,  which  comes  on  several  hours  after  an  injury  or  violent  emotional 
disturbance.  This  form  of  shock  is  seen  not  unusually  in  those  who  have 
passed  through  a  railroad  accident.  It  may  be  a  sign  of  hemorrhage,  and  is 
sometimes  met  with  after  the  administration  of  ether  or  chloroform. 

Diagnosis. — Concealed  hemorrhage  is  difficult  to  differentiate  from  shock. 
It  produces  impairment  of  vision  (retinal  anemia),  irregular  tossing,  frequent 
yawning,  great  thirst,  nausea,  and  sometimes  convulsions.  In  shock  the 
hemoglobin  is  unaltered;  in  hemorrhage  it  is  enormously  reduced  (Hare  and 


Fig.  62, — Subcutaneous  saline  infusion  (Senn) 


Martin).  In  hemorrhage  recurrent  attacks  of  syncope  are  met  with.  In 
pure  shock  such  attacks  do  not  occur.  In  concealed  hemorrhage  the  abdomen 
may  exhibit  physical  signs  of  a  rapidly  increasing  collection  of  fluid.  Shock 
and  hemorrhage  are  often  associated.  The  essential  characteristic  of  shock 
is  sudden  onset,  which  separates  it  distinctly  from  exhaustion.  It  arises  at  a 
much  earlier  period  after  an  injury  than  does  fat-embolism. 

The  Prevention  of  Shock  in  Operations. — Examine  the  patient  with 
care  before  operating,  giving  sj)ecial  attention  to  the  condition  of  the  kidneys. 
The  amount  of  urine  passed  and  the  amount  of  urea  it  contains  should  always 
be  determined  when  j)ossible.     The  amount  of  urea  should  be  estimated  from 


Treatment  of  Shock 


195 


the  twenty-four  hours"  urine.  The  normal  amount  of  urine  in  the  twenty- 
four  hours  is  about  fifty  ounces  and  the  normal  amount  of  urea  2  per  cent. 
Less  urea  is  significant  of  danger  from-shock  and  subsequent  kidney  complica- 
tions. If  the  "condition  of  the  patient  leads  us  to  fear  that  there  will  be  dan- 
gerous shock,  do  not  purge  him  severely  before  operation,  and  just  previous 
to  operation  give  a  rectal  injection  of  hot  saline  fluid.  It  is  a  good  plan  in 
such  cases  to  give  a  hypodermatic  injection  of  gr.  ^  of  morphin  twenty  minutes 
before  operation.  Give  as  httle  ether  as  possible.  Cover  every  part  but  the 
field  of  operation  with  hot  blankets  and  put  cans  of  hot  water  about  the 
patient,  or  put  him  on  a  bed  composed  of  hot-water  pipes  covered  with 
blankets.  Prevent  bleeding  with  the  greatest  possible  care.  Operate  as 
rapidly  as  is  consistent  with  safety  and  thoroughness.  Crile  has  shown  that 
when  the  nerve-trunks  from  a  part  have  been  anesthetized  with  cocain  there 
is  a  complete  physiological  block  to  peripheral  impressions  productive  of 
shock.  Operations  such  as  amputations  can  thus  be  done  without  depression 
of  the  vital  powers.  Such  a  method  should  be  used  in  certain  cases  in  which 
shock  exists  or  in  which  we  greatly  fear  its  development. 

Treatment. — In  treating  ordinary  apathetic  shock  raise  the  feet  and  lower 
the  head,  unless  this  position  causes  cyanosis.  At  least  place  the  head  flat 
and  the  body  recumbent. 
Wrap  the  patient  in  hot 
blankets  and  surround 
him  with  hot  bottles,  hot 
bricks,  hot-water  bags, 
or  cans  of  hot  water. 
Always  wrap  a  can,  a 
bottle,  or  a  bag  in  flan- 
nel, to  avoid  burning 
the  patient.  Ordinary 
stimulants  seem  of  but 
little  value.  The  infu- 
sion of  salt  solution  into 
a  vein  (Fig.  63)  does 
good,  but,  unfortunately, 
the  benefit  is  temporary 
except  in  cases  associ- 
ated with  hemorrhage. 
Salt  solution  may  be 
given  by  the  rectum  or 


Fig.  63. — Intravenous  saline  infusion.     Manner  of  incising  vein 
and  inserting  glass  tube  (Senn). 


subcutaneously.        Hy- 

podennoclysis  is  given  as  follows:  Insert  an  aspirator  tube  into  cellular 
tissue  of  the  loin,  scapular  region,  or  under  the  mamma,  cleansing  the 
part  first.  The  tube  is  attached  to  a  fountain  syringe,  which  is  filled 
with  normal  salt  solution,  and  is  hung  at  a  height  of  two  or  three 
feet  above  the  bed  (Fig.  62).  In  an  hour's  time  a  pint  or  more  of 
fluid  will  enter  the  tissue  and  be  absorbed.  It  is  the  custom  to  give 
hypodermatic  injections  of  ether,  brandy,  strychnin,  digitalis,  or  atropin,  or 
inhalations  of  amyl  nitrite.  Crile  has  demonstrated  experimentally  that 
strychnin  is  perfectly  futile  in  pure  shock  and   may  actually  aggravate  the 


196  Contusions  and  \\'ouiids 

condition.  In  collapse  it  is  of  some  value.  We  believe  this  statement  is 
true  clinically.  The  same  experimenter  points  out  that  the  only  way  "  to 
increase  and  sustain  the  blood-pressure  when  the  vasomotor  center  is  ex- 
hausted "  is  to  "  create  a  peripheral  resistance  either  by  a  drug  acting  on  the 
blood-vessels  themselves  or  by  mechanical  pressure.'"*  The  proper  drug 
to  use  is  adrenalin  chlorid.  Because  of  the  rapidity  with  which  this  drug  is 
oxidized,  Crile  gives  it  intravenously  and  continuously,  using  a  solution  of  a 
strength  of  from  i  in  50,000  to  i  in  100,000  in  salt  solution.  It  is  given 
slowly  from  a  buret. ''  the  rate  of  flow  being  controlled  by  a  screw-cock  attached 
to  the  rubber  tube."  Since  the  publication  of  Crile's  paper  I  have  used  adre- 
nalin chlorid  in  shock  in  preference  to  strychnin,  and  am  satisfied  that  it  is 
greatly  superior  to  the  latter  drug.  A  preparation  of  a  solution  of  adrenalin 
chlorid  is  on  the  market  which  can  be  readily  added  to  salt  solution  until 
the  proper  degree  of  dilution  is  obtained.  A  teaspoonful  of  this  solution 
contains  the  drug  m  the  proportion  of  i  part  to  1000,  and  this  amount 
should  be  added  to  i  liter  of  salt  solution.  If  the  skin  is  very  moist,  atropin 
is  indicated.  Senn  recommends  the  hypodermatic  injection  of  sterile  cam- 
phorated oil,  a  syringeful  every  fifteen  minutes  until  reaction  begins.  In- 
halation of  oxygen  is  often  of  much  service,  and  artificial  respiration  may 
be  necessary.  Opiates  are  contraindicated  in  shock.  Mustard  plasters 
should  be  placed  over  the  heart,  spine,  and  shins.  The  use  of  hot  and  stimu- 
lating rectal  enemata  is  important.  The  rectum  may  absorb  fluids  when 
the  stomach  refuses  to  do  so.  Enemata  of  hot  normal  salt  solution  are 
beneficial  (enteroclysis) .  The  tube  is  carried  into  the  sigmoid  flexure  and  the 
injection  is  introduced  so  as  to  distend  the  colon.  A  turpentine  enema  is 
useful.  An  enema  of  hot  coffee  and  whiskey  is  valuable.  In  severe 
cases  of  shock,  bandage  the  extremities.  Bandaging  for  the  relief  of  shock  is 
called  autotrans fusion.  This  procedure  enables  the  body  to  utilize  to  the  best 
advantage  the  small  amount  of  circulating  blood,  and  sends  most  of  it  to  the 
brain,  where  it  will  maintain  the  activity  of  the  vital  centers  and  keep  up 
circulation  and  respiration.  For  this  purpose  ordinary  muslin  bandages 
may  be  used,  or  gauze  bandages,  or  the  bandages  of  Esmarch.  Abdominal 
massage  helps  drive  out  the  imprisoned  blood,  and  after  massage  sets  free 
the  abdominal  blood  apply  a  compress  and  binder.  In  serious  cases 
artificial  respiration  and  stimulation  of  the  diaphragm  with  a  galvanic 
current  may  be  used.  If  shock  comes  on  during  an  operation,  the  operation 
must  be  hurried  or  even  stopped,  and  proper  treatment  must  be  instituted 
at  once.  The  anesthetizer  should  give  very  little  ether  when  shock  becomes 
at  all  evident.  Should  we  operate  during  shock?  We  .should  only  do  so 
when  death  without  instant  operation  is  inevitable.  We  must  operate,  if  it  is 
necessary  to  do  so,  to  arrest  hemorrhage,  to  relieve  strangulated  hernia,  in- 
testinal obstruction,  obstruction  of  the  air-passages,  compound  fractures  of 
the  skull,  extravasated  urine,  or  intraperitoneal  extravasations  from  ruptured 
viscera.  If  hemorrhage  can  be  temporarily  controlled  by  pressure  or  a  clamp, 
so  much  the  better,  and  the  permanent  arrest  can  be  effected  after  the  reaction 
from  shock.  It  is  not  wise,  in  the  author's  opinion,  to  amputate  during 
.shock  A  tourniquet  or  Esmarch  bandage  should  be  applied,  and  attempts 
be  made  to  bring  about  reaction,  and  when  reaction  is  obtained  the  amputa- 

*fjeorge  Crile,  in  Bo.ston  Med.  and  Surg.  Jour.,  March  5,  1903. 


Treatment  of  Wounds  197 

tion  should  be  performed.  It  is  only  just  to  say  that  some  eminent  surgeons 
oppose  this  rule.  Roswell  Park  says  that  "shock  is  often  alleviated  by  the 
prompt  removal  of  mutilated  Hmbs  which,  when  still  adherent  to  the  trunk,  seem 
to  perpetuate  the  condition."  The  same  teacher  believes  in  operating  at  once 
upon  severe  compound  fractures.*  After  every  operation  keep  careful  watch 
upon  the  amount  of  urine  passed,  see  to  it  that  the  patient  takes  sufficient 
fluid,  and  if  the  urine  becomes  scanty  put  a  hot-water  bag  over  the  kidneys, 
give  diuretics  and  hot  saline  enemata.  If  the  condition  is  not  soon  benefited, 
infuse  hot  saline  fluid  into  a  vein.  Post-operative  suppression  of  urine  is 
almost  invariably  fatal.  Delayed  shock  is  treated  in  the  same  manner  as 
apathetic  shock  if  hemorrhage  can  be  excluded.  If  hemorrhage  is  the  cause, 
the  bleeding  must  be  arrested.  If  delirious  shock  is  due  to  sepsis,  the  treat- 
ment is  that  of  sepsis.  If  it  is  a  nervous  delirium,  give  morphin  and  other 
sedatives.     If  due  to  uremia,  the  treatment  is  obvious. 

Fat=embolism.— (See  page  158.) 

Fever. — (See  Fevers,  page  105.) 

Treatment  of  Wounds. — All  wounds,  other  than  those  made  by  the 
.surgeon,  are  regarded  as  infected.  The  rules  for  treating  such  wounds  are: 
(i)  arrest  hemorrhage;  (2)  bring  about  reaction;  (3)  remove  foreign  bodies; 
(4)  asepticize;  (5)  drain,  coaptate  the  edges,  and  dress;  and  (6)  secure  rest 
to  the  part  and  combat  inflammation.  Constitutionally,  allay  pain,  secure 
sleep,  maintain  the  nutrition,  and  treat  inflammatory  conditions. 

Arrest  of  Hemorrhage. — To  arrest  hemorrhage  the  bleeding  point  must  be 
controlled  by  an  Esmarch  band  or  digital  pressure  until  ready  to  be  grasped 
with  forceps;  it  is  then  caught  up  and  tied  with  catgut  or  aseptic  silk.  Slight 
hemorrhage  ceases  spontaneously  on  exposure  of  the  bleeding  point  to  air, 
and  moderate  hemorrhage  ceases  permanently  after  the  temporary  applica- 
tion of  a  clamp.  An  injured  vessel  when  not  of  the  smallest  size  must  be 
ligated,  even  if  it  has  ceased  to  bleed.  Capillary  oozing  is  checked  by  hot 
water  and  compression.  If  a  large  artery  is  divided  in  a  limb,  apply  a  tourni- 
quet before  ligating  (see  Wounds  of  Vessels) 

Bringing  about  of  Reaction. — (See  Shock.) 

Removal  of  Foreign  Bodies. — Remove  all  foreign  bodies  A'isible  to  the  eye 
(spHnters,  bits  of  glass,  portions  of  clothing,  gun-wadding,  grains  of  dirt,  etc.) 
with  forceps  and  a  stream  of  corrosive  sublimate  solution,  sterile  water,  or 
normal  salt  solution.  In  a  lacerated  or  contused  wound  portions  of  tissue 
injured  beyond  repair  should  be  regarded  as  foreign  bodies  and  be  removed 
with  scissors. 

Cleatiing  the  Wound. — To  clean  the  wound  shave  the  surrounding  area, 
if  it  is  hairy;  scrub  the  surface  about  the  wound  with  ethereal  soap, 
green  soap,  or  castile  soap,  wash  with  water,  scrub  with  alcohol,  and 
then  with  corrosive  subHmate  solution  (i  :  1000).  An  accidental  wound 
is  infected,  and  must  be  well  washed  out  with  an  antiseptic  solution. 
A  clean  wound  made  by  the  surgeon  need  not  be  irrigated;  in  fact,  irrigation 
with  an  antiseptic  fluid  leads  to  necrosis  of  tissues,  causes  a  profuse  flow  of 
serum,  and  necessitates  drainage.  If  clots  have  gathered  in  a  wound,  they 
must  be  removed,  as  their  presence  will  prevent  accurate  coaptation  of  the 
edges.     In  an  infected  wound  they  are  washed  out  with  a  stream  of  corrosive 

*  Park's  ''  Surgery  by  American  Autlior.s." 


198  Contusions  and  Wounds 

solution.  In  a  clean  wound  they  are  washed  out  with  hot  salt  solution. 
If  dirt  is  ground  into  a  wound,  as  is  often  seen  in  crushes,  pour  sweet 
oil  into  the  wound,  rub  it  into  the  tissues,  and  scrub  the  wound  with 
ethereal  soap.  The  oil  entangles  the  dirt,  and  the  soap  and  water  remove 
both  oil  and  dirt.  After  the  rough  cleansing  irrigate  with  corrosive  sublimate 
solution.  In  some  cases,  especially  in  bone-injuries,  it  is  necessary  to  scrape 
the  wound  with  a  curet.  If  a  fissure  of  the  skull  is  infected,  enlarge  the 
fissure  with  a  chisel  in  order  to  clean  it.  In  a  badly  infected  wound  one  of 
the  most  valuable  agents  for  use  in  producing  disinfection  is  pure  carbolic 
acid.  After  cleaning  the  wound,  it  is  necessary  in  certain  regions  to  examine 
in  order  to  determine  if  tendons  or  considerable  nerves  have  been  cut.  If 
such  structures  have  been  divided,  they  must  be  sutured  with  fine  silk,  chromic 
gut,  or  kangaroo-tendon. 

Drainage,  Closure,  and  Dressing. — Superficial  wounds  require  no  special 
drainage,  as  some  wound  fluid  will  find  e.xit  between  the  stitches  and  the  rest 
will  be  absorbed.  A  large  or  deep  wound  requires  free  drainage  for  at  least 
twenty-four  hours  by  means  of  a  tube,  strands  of  horsehair,  silk,  or  catgut, 
or  bits  of  iodoform  gauze.  An  infected  wound  must  invariably  be  drained. 
Good  drainage  may,  to  a  considerable  extent,  compensate  for  imperfect  anti- 
sepsis. If  capillary  drains  be  employed,  apply  a  moist  dressing.  Approxi- 
mate the  edges  with  interrupted  sutures  of  silk  or  silkworm-gut  if  the  wound 
is  deep  and  considerable  tension  is  inevitable.  Catgut  is  used  for  superficial 
wounds  and  for  those  where  tension  is  slight.  If  there  is  decided  tension, 
silver  wire  may  be  used.  In  very  deep  wounds  buried  sutures  must  be  used. 
These  sutures  may  consist  of  absorbable  material  (kangaroo-tendon  or  cat- 
gut) or  unabsorbable  material  (silver  wire).  If  the  wound  is  infected,  dress 
with  warm,  moist  antiseptic  gauze.  If  it  is  not  infected,  dress  with  dry 
sterile  gauze.  The  custom  once  was  to  cover  even  dry  gauze  with  a  rubber 
dam  to  diffuse  the  fluids,  but  we  now  prefer  to  omit  the  rubber  dam  and  use 
plentiful  dressings.  A  dry  dressing  absorbs  wound  fluids  quickly  and  is  less 
likely  to  become  infected.  Change  the  dressings  in  twenty-four  hours,  or 
sooner  if  they  become  soaked  with  discharge.  Dressings  are  changed  for 
cause,  but  not  according  to  scheduled  time.  They  must,  of  course  be  changed 
when  they  become  soaked  with  wound  fluid,  and  soaking  may  occur  in  a  few 
hours,  but  may  not  occur  for  days.  As  long  as  the  temperature  remains 
normal,  the  wound  free  from  pain,  and  the  dressing  is  not  wet  with  discharge, 
it  can  be  left  in  place  unless  removal  is  necessary  to  take  out  a  drainage-tube. 
If  pus  forms,  open  the  wound  at  once.  Many  surgeons  sprinkle  wounds 
before  approximation  and  wound  surfaces  after  approximation  with  a  drying- 
powder.  These  powders  are  of  great  use  in  infected  wounds,  but  are  not 
necessary  in  clean  wounds.  Among  the  substances  employed  are  salicylic 
acid,  boracic  acid,  calomel,  acetanilid,  aristol,  iodoform,  subiodid  of  bismuth, 
and  glutol.  In  large  wounds  which  cannot  be  approximated  it  is  occasionally 
advisable  to  skin-graft  by  Thiersch's  method.  A  small  wound  which  cannot 
be  sutured  is  dusted  with  an  anti.septic  powder  and  dressed.  A  granulating 
wound  is  dre.ssed  as  is  a  healing  ulcer.  A  sloughing  wound  is  opened,  is 
dusted  with  iodoform  or  acetanilid,  and  is  dressed  with  hot  antiseptic  fomen- 
tations. 

Rest. — Severe   wounds   require   the   confinement   of  the  patient  to  bed. 


Incised  Wounds 


199 


Bandages,  splints,  etc.,  are  used  to  secure  rest.  The  metiiods  of  combating 
inflammation  have  previously  been  set  forth. 

Constitutional  Treatment. — Bring  about  reaction  from  depression,  but  pre- 
vent undue  reaction.  Feed  the  patient  well,  stimulate  him  if  necessary, 
attend  to  the  bowels  and  bladder,  secure  sleep,  and  allay  pain.  Watch  for 
complications,  namely,  inflammation,  suppuration,  gangrene,  tetanus,  ery- 
sipelas, suppression  of  urine,  and  pneumonia.  Observe  the  temperature 
closelv;  it  mav  be  a  danger-signal  of  urgent  importance. 

Incised  Wounds. — An  incised  wound  is  a  clean  cut  inflicted  by  an  edged 


Fig.  64. — Muscle  suture:   A,  Transverse  wound   of   biceps   muscle,  showing  marked  relraclioii  of 
muscle-ends  and  mattress  suture  in  place  ;  />',  muscle  suture  completed  (Senn). 


instrument.     Only  a  thin  film  of  tissue  is  so  devitalized  that  it  must  die. 
These  wounds  have  the  best  possible  chance  of  union  by  first  intention. 

The  pain  may  be  very  severe;  but  if  the  instrument  is  sharp  and  used 
quickly  it  may  be  trivial.  The  pain  is  less  severe  than  that  caused  by  some 
other  varieties  of  wounds.  The  acute  pain  does  not  last  long,  and  is  followed 
by  smarting.  The  hemorrhage  is  profuse,  varying,  of  course,  with  the  region 
cut.  Bleeding  from  the  scalp  is  violent,  because  there  are  numerous  vessels 
which  lie  in  fibrous  tissue  and  cannot  retract  nor  contract.  The  edges  of 
incised  wounds  retract  because  of  tissue-elasticity,  and  the  wound  "  gapes." 
If  the  skin  or  fascia?  are  divided  at  a  right  angle  to  the  muscle  beneath,  there 
is  wide  gaping.     If  the  cut  is  parallel  to  the  muscle-fibers,  the  gaping  is  slight. 


200 


Contusions  and  Wounds 


\Mien  the  skin  is  violently  pulled  upon,  it  tends  to  split  in  a  certain  line. 
Langer  and  Kocher  speak  of  this  as  the  line  of  cleavage,  and  point  out  the 
direction  of  these  lines  in  various  situations.     A  cut  across  the  Hne  of  cleavage 


Fig.  65. — Suturing  of  tendons  and  nerves   in   incised  wounds:  a.  Primary  tendon  suture;  d,  primary 

nerve  suture  (Senu). 

is  follovi^ed  by  wide  gaping.  A  cut  in  the  direction  of  the  line  of  cleavage  pro- 
duces slight  gaping,  and  is  followed  by  a  trivial  scar. 

When  a  muscle  is  cut  across,  the  wound  edges  widely  separate.  When  a 
tendon  is  completely  cut  across,  extensive  separation  occurs. 

An  incised  wound  can  be  thoroughly  inspected,  all  divided  structures  can 
be  identified,  foreign  bodies  can  be  easily  removed,  and  disinfection  can  be 
satisfactorily  carried  out. 


T/ir  1  isrht  way. 


Fig.  67.— Interrupted  suture. 


The  wrong  way. 


Fig.  66. — Tlie  itjterrupted  suture  (after  Bryant). 


\  \  'vP 


Fig.  68. — Continuous  suture. 


TrgaMen/.— According  to  general  principles  arrest  hemorrhage  3.nd 
asepticize. 

Examine  the  wound  carefully  to  see  if  a  nerve,  a  tendon,  or  a  muscle  is 
divided,  and  if  such  injury  is  discovered,   suture    at   once   (Figs.   64,    65). 


Incised  Wounds 


20 1 


If  the  wound  is  extensive  or  deep,  it  may  be  necessary  to  use  buried  sutures 
in  order  to  keep  the  sides  of  the  wound  in  contact.  If  the  surface  of  a  wound 
is  approximated,  but  the  depths  are  not,  the  dead  space  or  cavity  becomes 
filled  with  fluid,  and  infection  almost  certainly  occurs.  If  buried  sutures  have 
not  been  used,  such  a  cavity  must  be  obHterated  by  the  judicious  application 
of  pressure  upon  the  surface.  This  is  secured  by  the  adaptation  of  a  mass  of 
loose  or  fiuffed-up  gauze,  and  the  firm  application  of  a  bandage  or  binder.  An 
incised  wound  is  usually  closed  with  interrupted  sutures  (Figs.  66  and  67).  In 
adjusting  the  sutures,  see  that  the  edges  of  the  wound  are  not  inverted,  but 
are  neatly  adjusted,  and  that  the  knot  does  not  lie  upon  the  wound  line,  but 
rests  to  the  side  of  it.  Tie  the  stitches  firmly  but  not  tightly.  If  a  stitch  is  tied 
too  tightly  it  will  make  a  furrow,  as  shown  in  Fig.  66,  and  undue  tightness  is 


Fig.  6g. — Ford's  suture  :  a  square  knot,  a 
single  knot,  a  double  or  friction  knot,  and 
the  first  method  of  passing  the  needle  to  tie 
a  single  knot  immediately. 


Fig.  70  . — Ford's  suture  :  showing  two 
square  knots,  a  single  knot,  and  the  method 
of  completing  a  square  knot. 


sure  to  cause  necrosis,  and  is  often  productive  of  a  stitch-abscess.  A  silk  suture 
and  a  catgut  suture  should  be  tied  with  the  reef  knot;  a  suture  of  silkworm- 
gut  should  be  tied  with  a  surgeon's  knot.  If  a  wound  is  on  the  face,  particular 
care  must  be  employed  in  closing  it,  in  order  to  hmit  the  amount  of  disfigure- 
ment. In  a  clean  wound  stitches  can,  as  a  rule,  be  removed  in  from  six  to 
eight  days.  In  a  large  wound  one-half  the  stitches  are  removed  at  one  sitting, 
and  in  a  day  or  two  the  rest  are  removed.  Stitches  are  promptly  removed  if 
they  begin  to  cut  out  or  if  infection  occurs. 

The  old  continued  suture  (Fig.  68)  is  rarely  used  for  skin-wounds  at  the 
present  time.  This  suture  is  employed  to  suture  the  dura  after  division,  to 
suture  the  two  layers  of  pleura  together  before  an  abscess  of  the  lung  is  opened, 
to  suture  the  peritoneum  after  laparotomy,  and  to  suture  the  mucous  mem- 
brane after  certain  operations  upon  the  stomach.     The  continued  suture  is 


202 


Contusions  and  Wounds 


shown  in  Fig.  68.  A  continuous  suture  knotted  after  each  emergence  was 
devised  by  Ford.  It  is  very  useful  in  suturing  the  parietal  peritoneum 
(Figs.  69,  70). 

Halsted's  subcuticular  stitch  (Fig.  71)  makes  a  most  perfect  closure  of  the 

skin-wound,  and  is  followed  by 
the  smallest  possible  scar.  It  is 
only  used  in  wounds  which  are 
almost  certainly  clean,  as  those 
made  by  the  surgeon,  ^and  in 
wounds  which  do  not  require 
drainage.  The  suture  material 
should  be  of  silver  wire  caught 
upon  a  curved  Hagedorn  needle 
or  silkworm-gut  carried  by  a  long,  straight,  round  needle.  The  suture  is 
passed   through   the  corium  on  each  side  of  the  wound,  as  shown  in  Fig.  71. 


Fie 


71- — Halsted's  subcuticular  suture, 
true  skin. 


A  is  the 


Fig.  72. — The  quilled  suture. 


The  curved  needle  must  be  held  in  the  bite  of  a  needle-holder.    When  the  suture 
has  been  passed  the  ends  are  pulled  upon,  and  the  skin-wound  closes  neatly. 

Halsted's  suture  does  not  penetrate  the  cuticle;  hence,  in 

passing  it  the  white  .staphylococcus  is   not   carried  through 

stitch-holes  and  into  the  wound,  an  accident  which  might  be 

followed  by  infection  of  a  stitch-hole  or  even  of  the  wound. 

When   it   is  desired   to  withdraw  this  suture,  take  one  end  in 

the  bite  of  a  forceps,  cut  it  off  short  with  scissors,  and  pull 

steadily  upon   the  other  cn(\. 
In    very   deep    wounds   or 

wounds  in  which  there  is  much 

tension    after    approximation 

the   quilled     suture   (Fig.    72) 

or  the  button  .suture  (Fig.  73) 

ma}'    ])C  u.sed.       The  twisted 

suture,    or    harelip    suture,    is 

shown  in  Fig.  74. 

Problems  of  drainage,  dressing,  etc.,  arediscus.sed  on  page  198. 
If  infecti(m  occurs,  the  wound  becomes  .swollen,  tender,  ])ainful,  and  dis- 
colorefi,  and  the  tem])erature  of  the  patient  .soon  becomes  elevated.     In  such 
a  condition  cut  the  stitches,  di.sinfect,  and  drain. 


F'g-    73— Button 
suture. 


ImK-  74 


Contused  and   Lacerated  Wounds  203 

Wounds  of  Mucous  Membranes. — If  the  surgeon  intends  to  inflict  a 
wound  upon  a  mucous  surface,  he  should  see  to  it  that  the  patient's  general 
condition  is  good.  Thorough  asepsis  is  impossible,  and  a  good  result  depends 
largely  upon  the  vital  resistance  of  the  tissues.  Before  operating,  irrigate  the 
part  frequently  with  boric  acid,  peroxid  of  hydrogen,  or  normal  salt  solution. 
When  ready  to  sew  up  the  wound  be  sure  that  all  irritant  fluids  are  removed 
(saliva  in  the  mouth,  etc.).  Cleanse  the  wound  with  hot  normal  salt  solution. 
The  stitches  must  include  submucous  tissue  as  well  as  the  mucous  membrane, 
and  consist  of  silver  wire,  silk,  chromic  catgut,  or  silkworm-gut.  After 
sewing  up  a  wound  in  the  mouth,  wash  the  cavity  at  frequent  intervals  with 
salt  solution,  and  follow  each  washing  with  the  insufflation  of  iodoform. 

In  accidental  wounds  irrigate  with  salt  solution,  dust  with  iodoform,  and 
close  as  directed  above.  Corrosive  subhmate  is  so  irritant  that  it  does  harm 
when  appHed  to  a  mucous  membrane. 

Contused  and  Lacerated  Wounds. — A  contused  wound  results  from  a 
blow  or  a  squeeze  which  bruises  and  crushes  the  tissues  and  splits  or  ruptures 
the  skin.  It  is  a  common  injury  when  force  is  appHed  to  tissues  over  a  bone. 
The  blow  of  a  blackjack  may  cause  either  a  contusion  or  a  contused  wound 
of  the  scalp.  A  contused  wound  is  irregular  in  outline,  with  jagged  edges,  and 
is  surrounded  by  a  broad  zone  of  contusion.  The  worst  form  of  contused 
wound  is  a  crush  of  an  extremity  produced  by  being  run  over.  The  skin  is 
often  widely  separated  from  the  tissues  beneath. 

A  lacerated  wound  results  from  tearing  apart  of  the  tissues.  It  too  is 
irregular  and  jagged,  and  is  accompanied  by  more  or  less  contusion.  A 
brush-burn  is  a  contused-lacerated  wound  due  to  friction.  Both  lacerated 
and  contused  wounds  contain  masses  of  partly  detached  and  damaged  tissue, 
the  vitality  of  which  is  endangered.  Hence,  such  wounds  are  apt  to  slough, 
frequently  suppurate,  and  are  occasionally  followed  by  cellulitis  or  even  by 
gangrene.  There  is  more  danger  of  tetanus  than  in  incised  wounds.  A  wound 
especially  apt  to  be  followed  by  tetanus  is  made  by  the  toy  pistol.  Nerve 
trunks,  muscles,  and  great  vessels  may  be  torn  across.  In  contused  and 
lacerated  wounds  the  edges  are  discolored  and  cold  to  the  touch,  and  there 
is  little  primary  hemorrhage  unless  a  cerebral  sinus  is  opened.  There  is 
considerable  danger  of  secondary  hemorrhage  if  large  vessels  have  been 
bruised.  In  wounds  of  this  nature  the  pain  is  often  slight,  but  it  may  be 
violent.     Shock  is  very  severe. 

Avulsion  of  a  limb  is  a  dreadful  form  of  lacerated  wound.  The  thumb 
or  a  finger  may  be  torn  ofT  or  the  arm  may  be  wrenched  from  the  body  with 
or  without  the  scapula.  In  such  cases  the  wound  is  large,  jagged,  and  irreg- 
ular, long  strings  of  muscle  or  tendon  hang  from  the  gap,  the  wound  edges 
are  cold,  but  the  bleeding  is  trivial.     The  shock  is,  of  course,  profound. 

Avulsion  oj  the  scalp  may  be  produced  when  the  hair  is  caught  in  machin- 
ery. The  American  Indian  inflicts  this  injury  when  he  scalps  a  conquered 
foe.  In  some  cases  of  avulsion  of  the  scalp  the  periosteum  is  removed  with 
the  flap;  in  most  it  is  not.  The  flap  consists  of  skin  and  aponeurosis.  In  this 
form  of  laceration  there  is  severe  bleeding. 

Treatment. — The  surgeon  brings  about  reaction  and  endeavors  to  asepticize 
the  wound  and  skin  about  it  (page  197),  arrests  hemorrhage,  and  ligates  any 
visible  damaged  vessel  whether  it  bleeds  or  not.     Hopelessly  damaged  tissue 


204  Contusions  and  \\'ouncls 

should  be  cut  away,  doubtful  tissue  being  retained.  In  some  cases  amputation 
is  necessary.  Secure  thorough  drainage,  in  some  situations  making  counter- 
openings  if  necessary.  Tube-drainage  may  be  necessary  or  iodoform  gauze 
packing  may  be  used.  Contused  wounds  and  lacerated  wounds  are  rarely 
closed  by  sutures  except  when  on  the  face.  They  are  rarely  closed  because 
the  damage  is  so  great  and  the  blood-supply  so  interfered  with  that  primary 
union  will  not  occur.  In  the  face  the  blood-supply  is  so  good  that  primary 
union  may  be  obtained  in  part  or  entirely,  and  it  is  worth  while  to  try  to  obtain 
it.  Cold  must  not  be  applied  to  a  region  of  lowered  vitality,  because  it  might 
cause  gangrene.  Heat  is  useful.  Hence,  it  is  advisable,  even  from  the  start, 
to  dress  with  hot  antiseptic  fomentations,  and  this  mode  of  dressing  becomes 
imperative  if  sloughing  begins.     Of  course  the  part  must  be  kept  at  rest. 

If  suppuration  occurs,  the  surgeon  sees  to  it  that  the  pus  has  free  exit,  and 
if  necessary  secures  free  exit  by  making  incisions. 

Aiter  avulsion  of  a  limb  the  patient  is  reacted  from  shock,  large  vessels  are 
sought  for  and  tied,  damaged  tissue  is  cut  away,  the  wound  is  packed  with 
gauze  and  is  partly  approximated  by  sutures.  After  avulsion  of  the  scalp 
bleeding  vessels  are  carefully  hgated.  A  portion  of  the  scalp  may  be  torn 
away,  but  a  pedicle  may  connect  it  with  the  balance  of  this  structure.  In  such 
a  case  cleanse  it  thoroughly  and  suture  it  in  place  (W.  T.  Bivings,  "Phila. 
Med.  Jour.,"  June  7,  1902).  If  the  portion  of  scalp  is  entirely  separated, 
adopt  Gussenbauer's  suggestion  when  possible  and  graft  pieces  of  the  avulsed 
scalp.  In  any  case  the  ulcer  resulting  from  avulsion  must  be  repeatedly 
grafted.  Abbe  in  a  case  obtained  heahng  after  four  years  by  the  use  of  12,000 
grafts. 

Punctured  Wounds. — Punctured  wounds  are  made  with  pointed  in- 
struments, as  needles,  splinters,  etc.  The  depth  of  a  punctured  wound 
greatly  exceeds  its  surface  area.  After  the  withdrawal  of  the  instrument 
inflicting  the  injury  the  wound  partly  closes  at  points,  blood  and  wound  fluid 
cannot  find  exit,  and  if,  as  is  probably  the  case,  bacteria  were  deposited  in  the 
tissues,  infection  with  pus  organisms  is  very  likely  to  occur,  and  if  it  does  occur 
suppuration  spreads  widely.  There  is  also  danger  of  infection  with  tetanus 
bacilli.  Such  a  wound  may  involve  an  important  blood-vessel,  and  in  such  a 
case  profuse  hemorrhage  may  occur;  otherwise  hemorrhage  is  slight.  A  great 
cavity  of  the  body  may  be  penetrated  or  an  important  organ  may  be  wounded. 
Large-sized  foreign  bodies  may  be  driven  into  the  tissues  or  a  portion  of  the 
in.strument  may  break  off  and  lodge.  Pain  is  rarely  severe  unless  a  consid- 
erable nerve  has  been  damaged.  If  both  a  large  vein  and  artery  are  punctured, 
varicose  aneurysm  or  aneurysmal  varix  may  arise. 

Treatment. — When  possible,  inspect  the  instrument  which  did  the  dam- 
age, to  see  if  a  piece  has  been  broken  off.  If  there  is  severe  hemorrhage,  en- 
large the  wound  and  tie  the  bleeding  vessels.  In  a  puncture  not  made  by  the 
surgeon,  the  wound  must  be  regarded  as  infected.  If  a  wound  is  made  by  a 
dirty  instrument  through  skin  known  to  be  unclean,  it  is  proper  that  the  skin 
about  it  be  sterilized,  that  the  wound  be  enlarged,  that  foreign  bodies  be  re- 
moved, that  the  wound  be  irrigated  with  an  anti.scptic  solution,  or  be  painted 
with  pure  carbolic  acid,  and  be  drained  with  a  tube  or  a  strip  of  gauze.  Such 
treatment,  though  painful,  and  appearing  unneces.sarily  severe  or  even  cruel  to 
the  sufferer  from  a  trivial  puncture,  is  necessary,  and  may  save  the  patient  from 


Gunshot  Wounds  205 

serious  illness  or  from  death.  Every  deep  puncture  inflicted  by  an  instrument 
not  surgically  clean,  and  every  puncture  inflicted  b}-  a  nail,  a  splinter,  a  meat 
hook,  a  rusty  pin,  a  tooth  of  a  cat  or  dog,  etc.,  must  be  regarded  as  grossly  in- 
fected and  must  be  treated  by  incision,  sterihzation,  drainage,  hot  antiseptic 
fomentations,  and  rest.  If  the  puncture  is  superficial  and  is  made  with  a 
smooth  pointed  instrument  hke  a  needle,  when  the  instrument  was  not  grossly 
infected  the  parts  may  be  dressed  with  hot  antiseptic  fomentations,  but  they 
should  be  inspected  daily  for  evidence  of  infection  and  at  the  first  sign  of 
trouble  an  incision  must  be  made.  If  a  foreign  body  is  retained  in  the 
tissue,  it  must  be  removed. 

Pure  carbolic  acid  is  a  mo.st  efficient  agent  tQ.sterihze  a  punctured  wound. 

If  an  important  cavity  of  the  body  has  been  invaded  by  a  puncture,  ex- 
ploratory incision  is  necessary  (see  Brain,  Thorax,  Abdomen). 

Stab-wounds. — Stab-wounds  were  formerly  considered  with  punctured 
wounds,  but  Senn  wisely  places  them  in  a  class  by  themselves  ("  Practical 
Surgery,"  p.  150).  Stab-wounds  are  inflicted  by  penetrating  the  tissues 
with  a  pointed  or  narrow  instrument — for  instance,  a  dagger,  a  knife,  the 
blades  of  scissors,  a  bayonet,  or  a  sword.  Such  wounds  are  narrow  and  very 
deep.  A  stab  wound  may  cause  rapid  death  by  penetration  of  a  large  blood- 
vessel. Som„e  great  cavity  of  the  body  may  be  penetrated  and  internal 
hemorrhage  will  then  occur.  The  body  may  be  transfixed  by  a  sword  or 
bayonet.  Bone  is  rarely  injured  unless  the  skull  is  perforated  or  the  chest 
entered.     In  stab-wounds  there  is  usually  great  hemorrhage  and  shock. 

Treatment. — Whenever  possible,  look  at  the  instrument  which  did  the 
damage  and  see  if  a  piece  is  broken  off.  If  no  great  cavity  is  entered,  treat  by 
general  rules:  arrest  bleeding,  react  from  shock,  etc.  The  treatment  of 
penetrating  wounds  of  the  abdomen,  throat,  and  cranium  is  discussed  in  the 
special  sections 

Gunshot-wounds. — Gunshot-wounds  are  contused  or  contused-lacerated 
wounds  inflicted  b\-  materials  projected  by  explosives.  A  bit  of  rock  or  a 
crowbar  hurled  by  dynamite  inflicts  a  gunshot-wound,  as  does  a  shell-frag- 
ment, a  pistol-ball,  a  small  birdshot,  a  rifle-bullet,  a  flying  cap,  a  piece  of 
wadding,  grains  of  powder,  a  buckshot,  a  fragment  of  metal  broken  oft'  a 
sheU,  grape.shot  and  canister,  or  a  cannon-ball.  Injuries  by  shell-fragments, 
portions  of  a  bursted  boiler,  pieces  of  masonry  or  wood,  are  either  lacerated 
or  punctured  wounds,  and  need  no  special  consideration  here.  In  this  article 
we  treat  of  injuries  caused  by  bullets  and  shot. 

The  round  bullet  of  the  old-time  musket  being  large,  moving  with  com- 
parative slowness,  and  flattening  easily,  is  ^•ery  apt  to  lodge.  When  it  is  fired 
from  close  range  and  strikes  the  tissue  at  a  right  angle  it  produces  a  "punched- 
out"  entrance  wound.  If  the  velocity  is  low  or  the  impact  is  not  at  a  right 
angle  to  the  tissues,  the  entrance  wound  may  "be  formed  of  triangular  flaps," 
the  corners  of  which  are  inverted.*  The  entrance  wound  is  surrounded  by  a 
bruised  area.  The  track  of  the  bullet  is  larger  than  the  bullet,  is  so  badly 
contused  and  lacerated  that  much  tissue  is  devitahzed,  and  the  shaft  of  a  bone 
is  apt  to  be  sphntered  if  struck.  If  the  ball  emerges,  the  wound  of  exit  is 
larger  than  the  bullet  and  forms  triangular  and  everted  flaps  (Stevenson). 
Healing  by  first  intention  will  rarely  occur. 

'■■'  "Wounds  ill  War,"  bv  Svirg.-Ciilonel  W.  F.  Stevenson. 


2o6  Contusions  and  Wounds 

The  conical  or  cylindrico-conoidal  rifle-bullet  has  much  greater  velocity 
and  penetrating  power  than  the  round  bullet,  hence  it  is  more  apt  to  perforate. 
The  track  of  this  bullet  is  less  devitalized  than  is  the  track  of  the  round  ball 
and  the  surface  is  not  so  much  contused.  The  wound  of  entrance  is  smaller 
than  the  bullet  and  is  punched  out  or  inverted.  The  wound  of  exit  is  larger 
than  that  of  entrance,  and  is  often  everted.  The  bones  are  more  seriously 
comminuted  than  by  the  round  ball,  and  the  fragments  may  be  driven  widely 
into  the  tissues  (Stevenson) ;  in  fact,  an  explosive  effect  may  occur  at  close 
range.  Delorme  lays  it  down  as  a  rule  that  comminution  of  bone  makes  the 
wound  of  exit  larger,  and  he  asserts  that  a  wound  of  exit  larger  in  diameter 
than  the  thumb  means  that  there  is  comminution  of  bone. 

At  the  present  day  the  old  round  ball  is  very  rarely  used,  the  conical  pro- 
jectile having  taken  its  place.  For  the  firearms  of  civilians,  as  a  rule,  the 
bullets  are  made  of  lead,  hardened  and  shaped  by  compression,  or  hardened 
by  an  admixture  with  tin.  The  conical  shape  of  the  pistol-ball,  the  great 
velocity  with  which  it  is  propelled  and  with  which  it  rotates,  and  its  hardness 
make  it  unlikely  that  at  near  range  the  bullet  will  only  contuse  and  not  enter 
the  skin.  It  will  almost  always  enter;  it  will  often  lodge  and  will  not  unusu- 
ally perforate;  it  is  rarely  deflected,  and  is  not  nearly  so  much  flattened  by 
impact  as  is  the  softer  round  ball.  A  pistol-ball  or  a  spent  rifle-ball,  however, 
may  fail  to  enter  the  tissues,  grazing  the  surface  and  inflicting  a  brush-burn, 
or  simply  contusing  the  part.  A  bullet  may  enter  the  tissues,  a  cavity,  or  an 
organ,  and  lodge  there,  causing  a  penetrating  wound.  It  may  enter  and  emerge, 
causing  a  perforating  wound.  The  bullet  may  not  enter  alone,  but  may  carry 
with  it  bits  of  clothing  or  other  foreign  bodies.  This  comphcation  is  much 
more  rare  in  injury  by  the  conical  bullet  than  by  the  round  ball. 

The  military  surgeon  deals  with  wounds  inflicted  by  smaU,  densely  hard, 
conical  projectiles,  which  are  impelled  at  a  great  velocity  and  are  carried  to 
long  distances.  A  rifle  whose  cahber  is  less  than  0.35  inch  is  knowji  as  a 
small-caliber  rifle.  The  best  known  modern  rifles  are  the  Lee-Metford, 
Krag-Jorgensen,  Mauser,  Mannlicher,  Lebel,  and  Schmidt-Rubin. 

The  old  Springfield  rifle,  of  a  caliber  of  0.45  inch,  projected  a  bullet 
with  a  velocity  of  thirteen  hundred  feet  in  a  second. 

The  Mannlicher  rifle,  of  a  caliber  of  0.25  to  0.32  inch,  sends  a  bullet  with 
a  velocity  of  over  two  thousand  feet  a  second.  This  bullet  revolves  with  great 
velocity  upon  its  own  axis  (two  thousand  times  the  first  second)  and  is  effective 
at  several  miles. 

The  bullet  of  the  modern  rifle  is  conical,  has  a  leaden  core,  and  is  hardened 
by  being  covered  with  a  mantle  or  jacket  of  copper,  steel,  nickel,  or  of  alloys 
of  copper  and  nickel,  or  of  copper,  nickel,  and  zinc.  The  hard  jacket  is 
absolutely  essential,  as  the  speed  of  the  projectile  is  so  great  that  no  soft  bullet 
could  take  the  rifling,  fragments  would  be  torn  from  it  in  the  gun,  and  the 
grooves  of  tne  barrel  would  soon  fill  up  with  metal,  the  gun  becoming  useless. 

The  Lee-Metford  bullet  is  elongated  in  outline,  has  a  core  of  lead  hardened 
with  antimony,  and  the  envelope  is  composed  of  an  alloy  of  nickel  and  copper. 

The  older  projectile  was  apt  to  lodge;  was  often  deflected  in  the  tissues; 
was  flattened  out  on  meeting  with  resistant  structures,  such  as  bone  or  carti- 
lage, and  after  llattening  became  larger  and  tore  and  lacerated  the  soft  parts 
and  c(jmminuted  the  bone  (f'ig.  76). 


Gunshot  Wounds 


20/ 


The  new  projectile  is  apt  to  perforate,  is  rarely  deflected,  and  is  so  hard 
that  its  shape  is  generally  but  little  altered  on  meeting  with  resistant  struc- 
tures, and  hence  it  was  thought  that  the  new  bullet  would  prove  more  humane 
than  the  old  projectile,  and  inflict  wounds  which  would  be  more  easily  treated, 
because  the  bullets  would  not  lodge  and  because  extensive  damage  would  not 
be  inflicted.  This  view  has  proved  to  a  great  extent  correct.  In  many  instances 
a  modern  bullet  will  make  a  clear  track  without  laceration  or  comminution. 
Senn,  Nancrede,  and  other  American  surgeons  in  the  Spanish-American  War 
say  the  modern  projectile  is  humane  at  a  range  over  fifteen  hundred  yards, 
as  it  generally  penetrates  cleanly,  making  a  wound  which  heals  often  by  first 
intention.  Sir  Frederick  Treves  says  "  the  Mauser  bullet  is  a  very  merciful 
one."  In  some  instances,  however,  the  small  bullet  pulpefies  structure  for  a 
considerable  distance  around  the  track  of  the  ball  by  what  is  known  as  the  ex- 
plosive effect.  This  term  does  not  mean  that  the  bullet  has  exploded,  but  that 
its  sudden  impact  against  tissues  has  by  waves  of  force  caused  extensive  and 
distant  damage,  and  often  horrible  and  irreparable  injury.  Explosive  eftects 
are  seen  most  often  at  close  range,  when  the  velocity  of  the  ball  and  the  fre- 


F'g-  75-— 1.  End  view  of  2,  the  Krag-Jorgensen  bullet ;  3,  Mauser  bullet ;  4,  Lee-Metford  bullet,  used 

by  the  United  States  Navy. 


quency  of  its  rotation  are  most  marked.  A  pistol-ball  has  no  explosive  action 
at  all,  and  the  old-time  bullet  possessed  it  only  at  very  close  range.  The 
modern  projectile  always  produces  explosive  effects  up  to  five  hundred  yards. 
Up  to  thirteen  hundred  yards  it  produces  them  upon  the  skull  and  brain. 
At  this  distance  a  single  small  projectile  may  entirely  destroy  the  cranium 
and  brain  (see  Demosthen's  studies  of  the  action  of  the  MannHcher  rifle). 
Explosive  effects  are  noted  at  longer  distances  upon  the  liver,  spleen,  kidneys, 
and  lungs,  and  upon  hollow  viscera  containing  fluid. 

At  a  distance  of  five  hundred  yards  or  less  a  bone  will  be  shattered  into 
many  fragments.  At  a  range  of  fifteen  hundred  or  two  thousand  yards  the 
bone  will  be  cleanly  perforated,  usually  without  comminution.  It  is  often 
extraordinary  how  little  trouble  follows  a  wound  and  how  quickly  healing 
occurs.  This  is  due  to  the  fact  that  the  bullet  is  sterile  when  it  reaches  the 
tissue,  and  that  foreign  bodies  are  rarely  carried  in  with  it.  In  some  observed 
cases  there  have  been  almost  no  symptoms  after  perforation  of  the  lungs,  in 
others  after  perforation  of  the  abdomen  or  joints  or  skull.  It  is  obvious  that 
the  humanity  of  the  modern  rifle  is  largely  a  matter  of  range.  At  a  range  of 
fifteen  hundred  yards  or  more  it  is  a  humane  weapon. 


208 


Contusions   and  Wounds 


The  wound  of  entrance  is  extremely  small,  and  could  be  overlooked  by  a 
careless  observer.  It  is  usually  circular,  but  may  be  triangular.  The  wound 
of  exit  is  also  small,  and  may  be  round  or  may  be  a  slit.  If  the  injury  was 
inflicted  at  close  range,  the  wound  of  exit  is  large.  This  projectile  theoretically 
does  not  flatten,  but  practically  in  many  instances  it  does  flatten  a  little,  and 
in  others  its  coat  is  torn  off  when  it  strikes  hard  bone  at  a  distance  of  less 
than  eighteen  hundred  yards  (Fig.  77).  Treves  points  out  that  if  the  bullet 
smashes  a  bone  and  lodges,  the  shell  peels  off  from  the  core  as  a  rule,  and  the 
bullet  may  be  distorted  or  even  broken  into  fragments.  The  bullet  may  lodge 
at  long  range,  or  if  it  hits  a  man  after  bounding  from  a  stone.  In  Cuba  10 
per  cent,  of  the  wounded  suffered  from  lodged  bullets.  The  old-style  bullet 
rarely  causes  much  primary  hemorrhage,  as  the  ^'essels  as  well  as  the  nerves 
and  tendons  are  usually  pushed  aside  rather  than  cut.  Hence  secondary  hem- 
orrhage is  common  because  of  contusion  of  the  vessel-walls.  The  modern  bullet 


/'■■:i 


Fig.  76. — Deformatioti  of  leaden  bullets  (natural  size)  (Seydel). 


f^'K-  77- — Defcinnatiiiii  of  sniall-caliher  jackeloil  bullets  (after  P.iuiis). 


cuts  rather  than  pushes  aside  the  vessels.  Hence  primary  hemorrhage  is  pro- 
fuse if  a  large  vessel  is  struck,  and  may  prove  fatal.  The  modern  bullet  rarely" 
lodges  and  is  rarely  deflected.  .Skin  is  usually  split  by  it.  Fascia  and  muscle 
are  usually  much  damaged,  Ijut  in  a  transverse  wound  of  muscle  the  fibers 
maybe  separated  rather  than  destroyed  (Conner).  The  effects  of  the  mod- 
ern bullet  have  been  determined  by  careful  study  and  exj^eriment;  by  an  in- 
vestigation of  the  wounds  in  the  Chitral  Expedition  and  of  wounds  inflicted  hy 
accident  or  with  homicidal  or  .suicidal  intent;  by  experiments:  firing  through 
boxes  filled  with  wet  sand;  firing  into  thick  oak;  firing  at  cadavers  at  fixed 
distances  with  reduced  charges  (La  Garde);  firing  at  corpses  and  at  live 
horses  with  service-charges  (Demosthen).  Nancrede  cautions  us  to  rememl:)er 
that  experiments  upon  the  cadaver,  employing  reduced  charges  and  standing 
at  fixed  distances,  are  uncertain  in  their  provings.  "The  difference  between 
the  velocity  of  rotation  and  angle  of  incidence  with  reduced  charges  at  fixed 
distances  and  service-charges  at  actual  distances  is  marked.  The  tension  of 
living  muscles  anrl  fasciae,  as  compared  with    dead  tissues,  and  the  ])hysical 


Symptoms  of  a  Gunsliot-woLind  209 

change  of  the  semi-hquid  fat  of  adipose  tissue  and  medulla  to  a  more  soHd 
condition  by  the  loss  of  animal  heat,  influence  the  results."  * 

All  theoretical  conclusions  have  been  put  to  the  test  in  the  Spanish-Amer- 
ican War  and  the  South  African  War,  and  preconceived  opinions  have  to  a 
great  extent  been  confirmed.  The  effect  of  the  bullet  at  close  range  was  ob- 
served in  the  marines  killed  at  Guantanamo,  in  persons  killed  during  the 
Milan  riots,  and  in  many  instances  in  South  Africa. 

It  has  been  found  that  the  modern  small-caliber  bullet,  unless  it  strikes 
a  vital  part  or  a  large  bone,  lacks  "stopping  power,"  and  in  warfare  with 
savages  the  bullet  must  have  stopping  power,  or  the  wounded  man  will  con- 
tinue to  fight  and  charge.  Civihzed  men  will  usually  stop  when  hit,  savages 
often  will  not;  hence,  in  warfare  with  barbarous  people  the  ordinary  bullet 
must  be  modified.  In  the  Dumdum  bullet  a  portion  of  lead  at  the  apex  of 
the  projectile  is  left  uncovered,  and  the  bullet  when  it  strikes  spreads  out — 
mushrooms,  as  it  is  called — and  inflicts  an  extensive  wound  which  "  stops  " 
the  most  ferocious  and  fanatical.  German  surgeons  denounce  such  bullets  as 
inhumane,  but  Stevenson  and  other  Enghsh  surgeons  say  that  the  Dumdum 
bullet  is  more  humane  than  the  Snider  or  Martini-Henry.  The  name  Dum- 
dum comes  from  the  ordnance  factory,  near  Calcutta,  where  bullets  of  this 
character  were  first  made. 

Wounds  by  Cannon-balls. — A  cannon-ball  weighing  five  or  six  pounds 
may  be  imbedded  in  tissues.  A  ball  or  shell-fragments  may  tear  off  a  limb 
or  lacerate  it  extensively.  In  some  cases  of  injury  by  spent  balls  the  bone  is 
destroyed  and  the  muscles  disorganized  while  the  skin  is  intact. 

Wounds  by  Small  Shot. — The  degree  of  injury  is  in  direct  ratio  to  the 
nearness  of  the  individual  to  the  gun  when  the  discharge  took  place,  to  the 
size  and  number  of  the  shot,  and  to  the  charge  of  powder.  Single  shot  may 
bruise  the  surface  or  may  enter  the  tissues.  When  many  shot  enter  together 
they  strike  as  a  sohd  body.  Single  shot  are  usually  deflected  from  vessels 
and  nerves,  and  rarely  lodge  in  bone,  but  rather  flatten  on  its  surface.  Numer- 
ous shot  entering  together  at  close  range  produce  extensive  burns  and  fearful 
lacerations  and  inflict  damage  which  is  often  irreparable.  Pieces  of  clothing 
or  other  foreign  bodies  may  be  carried  into  the  wound  with  the  shot. 

Blank  Cartridge  Injuries. — These  injuries  only  occur  at  close  range. 
They  consist  of  burns  and  lacerations  and  frequently  a  wad  is  lodged  in  the 
tissues.     Tetanus  is  liable  to  follow  these  injuries. 

Symptoms  of  a  Gunshot-wound. — Hemorrhage  is  often  considerable, 
but  ceases  spontaneously  unless  a  large  vessel  has  been  dixided.  If  hemor- 
rhage is  profuse,  the  constitutional  symptoms  of  hemorrhage  exist.  These 
symptoms   are   of   great    importance    in    abdominal   wounds.     A   pistol-ball 

*  Nancrede  upon  "  Gun.shot  Wounds,"  in  Park's  "■  Surgery  by  American  Authors  "  For 
inforniation  upon  wounds  by  the  modern  firearm,  see  recent  reports  of  Surgeon-General  of 
the  United  States  Army  ;  Demosthen's  study  of  the  wounds  inflicted  by  the  Mannlicher  rifle; 
Prof.  Conner,  in  Dennis's  "  System  of  Surgery;  "  Forwood,  in  "The  International  Text- 
P>ook  of  Surgeiy  ;  "  the  elder  Senn  in  '•  Medico-Surgical  Aspects  of  the  Spanish- American 
War;  "  Sir  Frederick  Treves  in  the  Lancet,  May  12,  1900:  Discussion  in  the  British 
Medical  Association,  1899  ;  reports  of  Mr.  G.  II.  Makins  and  Clinton  T.  Dent  ;  Francis  G. 
Abbott  on  the  "  Surgery  of  the  Grueco-Turkish  War,'"  in  Lancet,  Jan.  14,  1899;  editorial 
in  Boston  Med.  and  Surg.  Jour.,  May  4  and  May  9,  1899  ;  a  study  of  "  Gunshot  Injuries  by 
the  Rifles  of  Reduced  Calibre,"  by  Louis  A.  La  Garde,  in  Boston  Med.  and  Surg.  Jour., 
Nov.   I,  1900  ;  J.  Lynn  Thomas  in  Lancet,  Nov.  3,  1900. 

14 


lO 


Contusions  and  Wounds 


rarely  causes  severe  primary  hemorrhage,  because  it  will  not  often  penetrate 
a  large  artery.  It  is  apt  to  push  aside  a  vessel,  and  secondary  hemorrhage  is 
not  unusual.  Even  if  a  large  vessel  is  wounded  and  a  succession  of  violent 
hemorrhages  occur,  a  man  may  live  for  several  days.  Secondary  hemorrhage 
may  follow  a  gunshot-wound  because  of  contusion  of  vessels  or  of  infection. 

Pain  is  often  not  noticed  at  first,  especially  if  the  injured  individual  was 
greatly  preoccupied  or  excited.  There  may  be  a  feeling  of  numbness,  but 
there  is  usually  a  dull  or  stinging  pain.  If  a  large  nerve  is  injured,  there  may 
be  violent  pain.  Even  trivial  gunshot-wounds  frequently  produce  profound 
shock,  and  yet  it  may  happen  that  severe  wounds  may  be  accompanied 
by  but  slight  shock.  In  most  gunshot-wounds  of  the  brain,  abdomen,  and 
spinal  cord  the  shock  is  very  great. 

General  Considerations  as  to  Treatment. — The  dangers  are  shock, 
hemorrhage,  and  infection.  Bullets  are  aseptic  when  they  enter  a  part,  and 
if  infection  is  not  inserted  in  the  track  of  the  ball  the  wound  will  in  most  in- 


^ 


Fig.  78. — Nelaton's  bullet  probe. 


Fig.  80. — Fluhrei's  aluminum  gravitation  probe  (natural   size,  except   the    length,  which   is  twelve 

inches). 


stances  heal  kindly.  "The  fate  of  a  wounded  man  is  in  the  hands  of  the 
surgeon  who  first  attends  him"  (Nussbaum).  The  danger  of  a  wound  de- 
pends upon  the  size  and  velocity  of  the  bullet,  the  part  struck,  "and  the  degree 
of  asepsis  observed  during  the  first  examination  and  dressing"  (Nancrede). 
The  rules  of  treatment  are:  bring  about  reaction,  arrest  hemorrhage,  pre- 
serve asepsis,  and,  in  some  cases,  remove  the  ball.  Always  notice  if  a  wound 
of  exit  exists.  It  is  a  good  plan,  when  endeavoring  to  determine  the  extent 
of  injury,  to  put  the  parts  in  the  position  they  were  in  when  the  injury  was 
inflicted.  We  should  try  to  ascertain  the  size  and  nature  of  the  weapon,  and 
the  range  at  which  it  was  fired.  Examine  the  clothing  to  see  if  any  fragments 
are  missing  and  could  have  been  carried  in.  Such  fragments  render  sepsis 
almost  inevitable.  The  surgeon  must  not  feel  it  his  duty  to  probe  in  all  cases. 
In  many  cases  it  is  better  not  to  probe  at  all.  Explore  for  the  ball  when  sure 
that  it  has  carried  with  it  foreign  bodies;  when  its  presence  at  the  point  of 
lodgment  interferes  witli  repair;  when  it  is  in  or  near  a  vital  region  (as  the 
brain);  and  when  it  is  necessary  to  know  the  position  of  the  bullet  in  order 
to  determine  the  question  of  amputation  or  resection.  If  the  wound  is  large 
enough,  the  finger  is  the  Vjest  probe. 


Locating  and   Extracting  Bullets  211 

Fluhrer's  aluminum  probe  is  a  valuable  instrument  (Fig.  80).  It  is  em- 
ployed especially  in  brain-wounds,  and  is  allowed  to  sink  into  the  track,  of  the 
ball  by  the  influence  of  gravity  after  the  part  has  been  placed  in  a  proper 
position.  If  a  lead  bullet  is  deeply  imbedded,  it  is  possible  to  distinguish  the 
hard  projectile  from  a  bone  by  inserting  the  asepticized  stem  of  a  clay  pipe,  a 
bit  of  pine  wood,  or  Nelaton''s  porcelain-headed  probe  (Fig.  78).  On  any 
one  of  these  appliances  lead  will  make  a  black  mark.  No  such  test  can 
be  applied  to  a  modern  bullet,  for  this  has  a  hard  metal  jacket,  and  will  not 
make  a  black  mark  on  a  white  substance. 

Though  Nelaton's  probe  will  not  show  the  difference  between  a  hard 
projectile  and  bone,  it  is  a  valuable  instrument  to  follow  the  track  of  a  wound. 
The  porcelain  head  ought  to  be  larger  than  it  is  usually  made — in  fact,  it 
should  be  nearly  the  size  of  the  bullet  (Senn)  (Fig  79). 

In  passing  a  probe  use  no  more  force  than  in  passing  a  catheter  (Senn). 

The  induction  balance  of  Graham  Bell  has  been  employed  to  determine 
the  situation  of  a  bullet.  The  bullet  may  be  located  by  Girdner's  telephonic 
probe.  In  order  to  construct  this  instrument,  take  a  telephone  receiver,  fasten 
one  of  the  wires  to  a  metal  plate  and  the  other  one  to  a  metallic  probe.  Moisten 
a  portion  of  the  patient's  body  and  place  the  metal  plate  in  contact  with  it. 
The  surgeon  places  the  receiver  to  his  ear  and  inserts  the  probe  into  the  wound. 


81. — Bullet-forceps. 


If  the  probe  strikes  metal,  a  click  is  heard  with  distinctness.  A  bullet  may 
be  located  by  Lilienthal's  probe.  This  apparatus  consists  of  a  mouth-piece, 
two  insulated  copper  wires,  and  a  probe.  The  mouth-piece  is  composed  of 
two  plates,  one  of  copper  and  one  of  zinc,  which  are  applied  to  the  sides  of  the 
tongue.  An  insulated  wire  runs  from  each  plate  and  into  the  metal  probe. 
The  tip  of  the  probe  is  composed  of  two  or  four  pieces  of  metal,  is  separated 
from  the  shank  by  a  washer  of  rubber,  and  is  attached  to  the  wares.  The 
operator  closes  the  teeth  upon  the  mouth-piece,  and  inserts  the  probe  into  the 
wound.  If  the  probe  touches  the  bullet,  a  distinct  and  continuous  metallic 
taste  is  appreciable. 

The  best  means  of  discovering  a  bullet  is  to  use  the  fluoroscope  or  take  a 
skiagraph.  In  order  to  locate  it  accurately,  view  it  through  a  series  of  squares, 
insert  guide-pins,  or,  better  than  either  of  these  plans,  employ  Sweet's  appa- 
ratus. Bullets  are  readily  seen  by  the  fluoroscope  in  the  superficial  soft  parts, 
and  are  discovered  in  deeper  structures  (bone,  abdomen,  lung,  brain,  etc.) 
by  taking  skiagraphs. 

In  e.xtracting  the  ball  use  very  strong  forceps  (Fig.  81).  The  old  American 
bullet-forceps  is  useless  for  the  extraction  of  the  hard-jacketed  ball,  as  the 
points  will  not  penetrate  and  the  instrument  will  not  hold. 

If  hemorrhage  is  severe  in  a  gunshot-wound,  enlarge  the  wound,  find  the 
bleeding  vessel,  and  tie  it.     Before  handling  a  gunshot-wound  asepticize  the 


212 


Contusions  and  Wounds 


parts  about  it  and  irrigate  the  wound  with  hot  sterile  salt  solution.  In  some 
situations  a  wound  should  be  drained  with  a  short  tube  or  a  bit  of  iodoform 
gauze;  in  other  regions  this  is  unnecessary.  The  dressing  should  be  anti- 
septic. Primary  union  rarely  takes  place  after  a  wound  inflicted  by  a  pistol- 
ball  or  an  ordinary  rifle-ball,  because  of  the  inevitable  necrosis  of  damaged 
tissue  in  the  track  of  the  ball,  but  in  some  cases  it  can  be  obtained.  Primary 
union  is  frequent  after  injury  by  the  small  hard-jacketed  modern  projectile. 
Healing  begins  in  the  depths  of  the  wound  and  extends  toward  the  wound  of 
entrance,  or,  if  there  be  also  a  wound  of  exit,  toward  both.  Radical  opera- 
tions may  be  demanded:  laparotomy,  trephining,  rib-resection,  joint-resec- 
tion, and  amputation. 

Amputation  is  sometimes  demanded  because  of  great  injury  to  the  soft 
parts  (as  by  a  shell-fragment),  the  sphntering  of  a  bone,  injury  of  a  joint, 
damage  to  the  chief  vessels  or  nerves,  or  the  destruction  of  a  considerable 
part  of  a  limb.  Perform  a  primary  amputation  if  possible,  and  make  the  flaps 
through  tissue  that  will  not  slough.  In  civil  practice,  with  careful  antisepsis, 
more  questionable  tissue  can  be  admitted  into  a  flap  than  in  military  practice, 
where  transportation  will  become  necessary  and  antisepsis  may  be  imperfect 


Fig.  82. — Cartridge  belt  with  first-aid  package  sewed  on  inner  surface. 


or  wanting.  It  has  been  shown  in  recent  years  that  even  when  a  large  joint 
has  been  perforated  by  a  small  hard-jacketed  projectile,  amputation  or  re- 
section is  rarely  required  if  the  wound  was  treated  aseptically  from  the  begin- 
ning. 

Prevention  oj  injection  in  wounds  inflicted  in  war  is  of  great  importance. 
In  warfare  at  the  present  day  an  attempt  is  made  to  hmit  the  death-rate  from 
gunshot-wounds  by  protecting  them  from  infection  at  an  early  period  after 
the  accident.  Esmarch  off'ered  a  suggestion,  which  has  been  adopted  in  the 
armies  of  all  civilized  countries.  Every  soldier  carries  a  package  which  con- 
tains antiseptic  dressings,  and  at  the  first  opportunity  after  the  infliction  of  a 
wound,  if  possible  on  the  field,  these  dressings  are  applied  by  the  soldier  or 
by  a  comrade  (for  even  the  privates  are  instructed  in  the  application),  or  by 
an  ambulance  man.  If  not  applied  on  the  field,  they  are  applied  at  the  first 
dressing-station  by  a  surgeon  or  a  hospital  steward.  Senn  considers  Esmarch's 
package  too  cumbrous.*  He  suggests  a  package  containing  half  an  ounce 
of  compre.ssed  salicylated  cotton.  In  the  center  of  this  cotton  is  an  antiseptic 
powder  (2  gm.  of  boric  acid  and  0.5  gm.  of  salicylic  acid).  The  cotton  is 
wrapped  in  a  triangular  gauze  bandage.  A  safety-pin  is  placed  in  the  bandage 
and  the  entire  bundle  is  wrapped  in  gutta-percha  ti.ssue  (Fig.  82).  Senn  says 

*Jour.  Am.  Med.  Assoc,  July  13,  1895. 


Dissection-wounds  213 

the  triangular  bandage  is  sufficient  to  hold  a  dressing  in  place,  and  it  can  be 
assisted  by  utilizing  the  gunstrap,  safety-belt,  or  articles  of  clothing.*  (For 
gunshot-wounds  of  special  structures,  see  Bones,  Joints,  Abdomen,  Brain,  etc.) 
When  a  wound  has  been  inflicted  by  a  blank  cartridge,  the  surface  should  be 
sterilized,  the  wound  irrigated,  foreign  bodies  removed,  the  parts  sterilized,  and 
dressed  with  hot  antiseptic  fomentations.  In  some  cases  the  wound  should  be 
enlarged;  in  some,  powder  grains  should  be  removed  from  the  skin.  In  view 
of  the  danger  of  lockjaw  and  because  tetanus  bacilli  do  not  multiply  when 
exposed  to  oxygen,  some  surgeons  advocate  keeping  such  wounds  exposed  to 
the  air  throughout  the  treatment.  After  an  injury  with  shot,  bleeding  should 
be  arrested,  the  parts  should  be  cleansed,  bits  of  clothing  and  other  such 
foreign  bodies  should  be  removed,  and  antiseptic  dressings  should  be  applied. 
It  is  not  necessary  to  remove  the  shot  unless  they  are  doing  harm  or  unless 
they  lie  just  beneath  the  skin. 

Poisoned  wounds  are  those  into  which  some  injurious  substance,  chem- 
ical or  bacterial,  was  introduced.  This  poison  may  be  microbic  and  capable 
of  self-multiplication,  or  it  may  be  chemical,  and  hence  incapable  of  multi- 
plication. There  are  three  classes  of  poisons:  t  (i)  mixed  infection,  as  septic 
wounds,  dissection-wounds,  and  malignant  edema;  (2)  chemical  poison, 
such  as  snake-bites  and  insect-stings;  and  (3)  infection  with  such  diseases 
as  rabies,  glanders,  etc. 

Septic  wounds  are  those  which  putrefy,  suppurate,  or  slough.  Septic 
wounds  should  be  opened  freely  to  secure  drainage,  and  hopelessly  damaged 
tissue  should  be  curetted  or  cut  away.  The  wound  should  be  washed  with 
peroxid  of  hydrogen  and  then  with  corrosive  sublimate,  dusted  with  iodoform 
or  orthoform,  either  drained  with  a  tube  or  packed  with  iodoform  gauze,  and 
dressed  with  hot  antiseptic  fomentations.  The  part  must  be  kept  at  rest  and 
internal  treatment  should  be  stimulating  and  supporting.  If  lymphangitis 
arises,  the  skin  over  the  inflamed  vessels  and  gknds  is  to  be  painted  with  iodin 
and  smeared  with  ichthyol,  and  quinin,  iron,  and  whiskey  are  given  internally. 
The  temperature  is  watched  for  evidence  of  general  infection  or  intoxication. 
The  patient  must  be  stirnulated  freely,  nourishing  food  is  given  at  frequent 
intervals,  pain  is  allayed  by  anodynes  if  necessary,  and  sleep  is  secured. 

Dissection=WOunds  are  simple  examples  of  infected  wounds,  and  they 
present  nothing  peculiar  except  virulence.  They  aff'ect  butchers,  cooks, 
surgeons  who  cut  themselves  while  operating  on  infected  areas,  those  who 
make  post-mortems,  and  those  who  dissect.  A  dissection-wound  inflicted 
while  working  on  a  body  injected  with  chlorid  of  zinc  possesses  but  few 
elements  of  danger  unless  the  health  of  the  student  is  much  broken  down. 
If  a  wound  is  simply  poisoned  with  putrefactive  organisms,  there  is  rarely 
serious  trouble.  Post-mortems  are  peculiarly  dangerous  when  the  subject 
has  died  of  some  septic  process.  When  a  wound  is  inflicted  while  dissecting, 
wash  it  under  a  strong  stream  of  water,  squeeze,  and  suck  it  to  make  the  blood 
run,  lay  it  open  if  it  be  a  puncture,  paint  it  with  pure  carbolic  acid,  and  dress 
it  with  iodoform  and  hot  antiseptic  fomentations.  Trouble,  of  course,  may 
follow,  but  often  it  is  only  local,  and  a  small  abscess  forms.  It  should  be 
treated    bv    hot    antiseptic    fomentations    and    early    incision.     Occasionally 

*   Senn,  in  Jour.  Am.  Med.  Assoc,  July  13,  1895. 
-f- "American  Te.\t-book  of  Surgery." 


214  Contusions  and  Wounds 

lymphangitis  arises,  adjacent  glands  inflame,  and  constitutional  symptoms 
arise.  It  is  rarely  that  true  septicemia  or  pyemia  arises  unless  the  wound 
was  inflicted  while  making  a  post-mortem  upon  a  person  dead  of  septicemia 
or  while  operating  on  a  septic  focus.  If  glands  enlarge  and  soften,  it  may  be 
necessary  to  remove  them  surgically. 

Malignant  edema  or  gangrenous  emphysema  arises  most  commonly 
after  a  puncture.  It  is  due  to  a  specific  bacillus  which  produces  great  edema. 
The  emphysema  which  soon  arises  is  due  to  mixed  infection  with  putrefactive 
organisms.  Pus  does  not  form,  but  gangrene  occurs.  The  disease  is  identical 
with  one  form  of  traumatic  spreading  gangrene  (page  144). 

Symptoms. — The  symptoms  are  identical  with  those  of  traumatic  spread- 
ing gangrene  with  emphysema. 

There  is  a  rapidly  spreading  edema,  followed  by  gaseous  distention  of  the 
tissues  and  by  gangrenous  cellulitis.  The  zone  of  edema  is  at  the  margin  of 
the  emphysema,  and  the  process  spreads  rapidly.  The  emphysematous  zone 
crackles  when  pressed  upon.  The  area  of  edema  is  covered  with  blebs  which 
contain  thin,  putrid,  reddish  matter,  and  the  skin  becomes  mottled.  If  a 
wound  exists,  the  discharge  will  be  bloody  and  foul.  If  incisions  are  made, 
a  thin,  brown,  offensive  liquid  flows  out.  High  fever  rapidly  develops,  the 
patient  becomes  delirious,  and  often  coma  arises.  In  most  cases  death  ensues 
in  from  twenty-four  to  forty-eight  hours. 

Treatment. — If  malignant  edema  affects  a  limb,  amputate  at  once,  high 
up.  If  it  affects  some  other  part,  make  free  incisions,  employ  hot,  continuous 
antiseptic  irrigations  or  the  hot  antiseptic  bath,  and  stimulate  freely  (page 

49)- 

Stings  and  Bites  of  Insects  and  Reptiles:  Stings  of  Bees  and 
Wasps. — -A  bee's  sting  consists  of  two  long  lances  within  a  sheath  with  which 
a  poison-bag  is  connected.  The  wound  is  made  first  by  the  sheath,  the  poison 
then  passes  in,  and  the  two  barbed  or  twisted  lances,  moving  up  and  down, 
deepen  the  cut.  The  barbs  on  the  lances  make  it  difificult  to  rapidly  with- 
draw the  .sting,  which  may  be  broken  off  and  remain  in  the  flesh.  Besides 
bees,  hornets,  yellow  jackets,  and  other  wasps  produce  painful  stings.  The 
sting  of  a  wasp  is  rarely  broken  off  in  the  tissues  because  the  beards  on  the 
darts  are  shorter  and  hence  the  sting  is  not  so  firmly  fixed  in  the  flesh,  and  also 
because  these  insects  are  more  rapid  and  nimble  in  their  actions.  Stings  of 
bees  and  wasps  rarely  cause  any  trouble  except  pain  and  swelling.  In  some 
unusual  cases  a  bee-sting  is  fatal ;  persons  have  been  stung  to  death  by  a  great 
number  of  these  insects. 

Symptoms. — If  general  symptoms  ensue,  they  appear  rapidly,  and  con- 
sist of  great  prostration,  vomiting,  purging,  and  delirium  or  unconsciousness. 
These  symptoms  may  disappear  in  a  short  time,  or  they  may  end  in  death 
from  heart-failure.     Stings  of  the  mouth  may  cause  edema  of  the  glottis. 

Treatment.— To  treat  a  bee-sting,  extract  the  sting  with  spHnter  forceps 
if  it  has  been  broken  off  and  is  visible  in  the  wound.  If  it  is  not  visible, 
squeeze  the  part  lightly  in  order  to  expel  it,  or  at  least  expel  the  poison.  Pres- 
sure may  be  most  satisfactorily  made  by  means  of  the  barrel  of  a  key.  The 
poison  is  counteracted  by  touching  with  ammonia  or  washing  the  part  in 
ammonia-water,  touching  with  pure  carbolic  acid,  painting  with  tincture  of 
iodin,  or  soaking  in  a  strong  solution  of  common  salt  or  carbonate  of  sodium. 


Snake  Bites  215 

The  part  may  be  dressed  with  lead-water  and  laudanum,  a  solution  of  washing- 
soda,  or  a  solution  of  common  salt.  If  constitutional  symptoms  appear, 
stimulate. 

Other  Insect=bites  and  Stings.— The  mandibles  of  a  poisonous  spider 
are  terminated  by  a  movable  hook  which  has  an  opening  for  the  emission  of 
poison.  The  bite  of  large  spiders  is  productive  of  inflammation,  swelhng, 
weakness,  and  even  death.  The  bite  of  the  poisonous  spider  of  New  Zealand 
produces  a  large  white  swelling  and  great  prostration;  death  may  ensue,  or 
the  victim  may  remain  in  a  depressed,  enfeebled  state  for  weeks  or  even  for 
months.  The  tarantiUa  is  a  much-dreaded  spider.  The  scorpion  has  in  its 
tail  a  sting.  The  sting  of  a  scorpion  produces  great  prostration,  delirium, 
vomiting,  diaphoresis,  vertigo,  headache,  local  swelling,  and  burning  pain, 
followed  often  by  fever  and  suppuration,  and  occasionally  even  by  gangrene, 
but  it  is  rarely  fatal.  Centipedes  must  be  of  large  size  to  be  formidable  to 
man,  and  the  symptoms  arising  from  their  stings  are  usually  only  local. 

Treatment. — Tie  a  fillet  above  the  bitten  point;  make  a  crucial  incision, 
favor  bleeding,  and  paint  the  wound  with  pure  carbolic  acid  or  some  caustic 
or  antiseptic  (if  in  the  wilds,  burn  with  fire  or  gunpowder) ;  dress  antiseptically 
if  possible,  and  stimulate  as  constitutional  symptoms  appear.  Slowly  loosen 
the  hgature  after  symptoms  disappear.  Chloroform  stupes  and  ipecac  poul- 
tices are  recommended;  also  puncture  with  a  needle  and  rubbing  in  a 
mixture  of  3  parts  of  alcohol  and  i  part  of  camphor  (Bauerjie). 

Snake=bites. — The  poisonous  snakes  of  America  comprise  the  copper- 
heads, water-moccasins,  rattlesnakes,  and  vipers.  The  cobra  of  India  is  a 
deadly  reptile.  In  some  countries  great  numbers  of  people  and  the  lower 
animals  are  killed  by  poisonous  serpents.  In  India  during  1898,  21,921 
persons  and  at  least  80,000  cattle  were  killed  by  snakes  ("Brit.  Med.  Jour.," 
Nov.  25,  1899).  The  symptoms  of  snake-bite  are  similar  in  kind  whether  it 
is  the  bite  of  an  Indian  cobra  or  of  an  American  rattler,  and  they  depend  upon 
the  toxic  power  and  the  dose  of  poison  introduced.  The  symptoms  vary  in 
intensity  according  to  the  virulence  of  the  poison.  The  toxic  power  of  the 
poison  varies  in  different  species  and  also  in  dift'erent  members  of  the  same 
species.  Poison  injected  into  a  vein  may  prove  almost  instantly  fatal.  The 
poison  is  not  absorbed  by  the  sound  mucous  membranes.  Poison  is  harmless 
when  given  by  the  mouth  and  swallowed,  but  if  directly  introduced  into  the 
intestine  of  an  animal  it  is  certainly  fatal.  The  pancreatic  ferment  destroys 
the  toxic  power  of  the  venom  (R.  H.  Elliot,  in  ''Brit.  Med.  Jour.,"  May  12, 
1900).  It  is  discharged  through  the  hollow  fangs  of  the  reptile,  having  been 
forced  out  by  contractions  of  the  muscles  of  the  poison-bag.  In  most  varieties 
of  snakes  the  teeth  lie  along  the  back  of  the  mouth  and  are  only  erected  when 
the  reptile  strikes.  Snake-poison  is  a  thin,  greenish-yellow,  turbid,  sterile 
fluid,  of  acid  reaction  and  of  a  distinctive  odor.  The  poisonous  elements 
are  globulins,  peptones,  and  possibly  animal  alkaloids  (Mitchell  and  Reich- 
ert).  The  two  chief  poisonous  principles  are  called  venom-peptone  and 
venom-globulin  (Gustave  Langmann,  "Medical  Record,"  Sept.  15,  1900). 

Symptoms. — Snake-poison  produces  paralysis  of  the  smaller  blood- 
vessels; edema  and  inflammation  about  the  bite;  destroys  the  coagulating 
power  of  the  blood;  causes  destruction  of  red  corpuscles,  exudation  of  fluid 
elements,  extravasation  about  the  bite  and  in  mucous  and  serous  membranes, 


2i6  Contusions  and  Wounds 

and  nervous  symptoms  of  great  violence.  The  symptoms  are:  pain,  soon 
becoming  intense;  mottled  swelling  of  the  bitten  part,  which  swelling  may 
be  enormous,  and  which  is  due  to  edema  and  extravasation  of  blood,  and 
assumes  a  purpuric  discoloration.  Muscular  twitching,  convulsions,  and 
finally  paralyses  are  usually  noted.  There  may  be  complete  consciousness, 
or  there  may  be  lethargy,  stupor,  or  coma.  The  general  symptoms  are  those 
of  profound  shock,  which  may  present  delirium  (delirious  shock).  Death 
may  be  due  to  paralysis  of  the  heart  or  paralysis  of  resj^ration,  and  may 
occur  in  about  five  hours,  but  as  a  rule  it  is  postponed  for  a  number  of  hours. 
If  death  is  deferred  for  a  day  or  more,  profound  sepsis  comes  upon  the  scene, 
with  glandular  enlargement,  suppuration,  and  sometimes  gangrene. 

Treatment.— Cases  of  snake-bite  must,  as  a  rule,  be  treated  without 
proper  appliances.  The  elder  Gross  was  accustomed  to  relate  in  his  lectures 
how  he  had  seen  an  army  officer  blow  off  his  finger  with  a  pistol  the  mom.ent 
after  it  was  bitten  by  a  rattlesnake,  and  thus  escape  poisoning.  In  general, 
the  rules  are  to  twist  several  fillets  at  different  le\els  above  the  bite,  to  excise 
the  bitten  area,  to  suck  or  cup  it  if  possible,  and  to  cauterize  it  with  a  pure  acid 
or  by  heat.  An  expedient  among  hunters  is  to  cauterize  by  pouring  gunpowder 
on  the  excised  area  and  applying  a  spark,  or  by  laying  a  hot  ember  on  the 
wound.  When  a  hot  iron  is  available,  use  it.  The  fillets  are  not  to  be  removed 
suddenly,  and  they  had  best  be  kept  on  for  some  time.  Remove  the  highest 
constricting  band  first;  if  no  symptoms  come  on  after  a  time, remove  the  next, 
and  so  on;  if  symptoms  appear,  reapply  the  lillet.  The  constitutional  treat- 
ment is  expressed  in  one  word:  stimulate.  Our  only  hope  is  in  large  doses  of 
alcohol,  and,  if  they  can  be  obtained,  ammonia,  ether,  strychnin,  or  digitalis 
hypodermatically  administered.  Large  doses  of  strychnin  hypodermaticallyare 
used  by  many  surgeons  in  India.  Morphin  may  be  required  for  pain.  There 
is  no  specific  for  snake-poison.  Hypodermatic  injections  of  a  i  per  cent, 
solution  of  the  permanganate  of  potassium  in  the  area  adjacent  to  the  bite  are 
commended  by  some.  Others  inject  in  many  places  about  the  wound  a  few 
drops  of  a  lo  per  cent,  watery  solution  of  chlorid  of  calcium.  Halford  of 
Australia  praises  the  intravenous  injection  of  ammonia  (lo  n\^  of  strong  am- 
monia in  20  TTL  of  water).  If  a  man  is  bitten  by  a  large  and  deadly  snake,  the 
surgeon,  if  one  is  at  hand,  should  at  once  amputate  well  above  the  bite.* 
Attempts  are  being  made  to  obtain  a  curative  serum,  .\nimals  can  be  ren- 
dered immune  by  giving  them  at  first  small  doses  of  the  poison  and  gradually 
increasing  the  amount  administered.  It  is  asserted  that  the  serum  of  immune 
animals  will  cure  a  person  bitten  by  a  venomous  snake.  Cures  have  been 
reported  after  the  use  of  Calmette's  antivenene  serum.  The  dose  is  from 
10  c.c.  to  20  c.c.  hypodermatically,  repeated  if  necessary  in  three  or  four  hours. 

The  poisonous  lizard  (Gila  monster)  can  kill  small  animals,  but  it 
is  not  believed  that  its  bite  would  prove  fatal  to  man. 

Anthrax  (malignant  pustule,  charbon,  wool-sorters'  disease,  Milzbrand, 
or  splenic  fever)  is  a  term  used  by  some  as  synonymous  with  ordinary  car- 
buncle, but  it  is  not  here  so  emf)loyed.  Anthrax,  as  met  with  in  man,  is  a 
disease  contracted  in  .some  manner  from  an  animal  with  splenic  fever.  It 
may  be  contracted  by  working  around  diseased  animals,  by  handling  or  tan- 
ning their  hides  or  by  sorting  their  hair  or  wool;  it  may  be  conveyed  by  eating 

*  Charters  James  Symonds,  in  '*  HeatliN  Uii.iionary  of  Practical  .Surgery." 


Treatment   of  Anthrax  217 

infected  meat  or  by  drinking  infected  milk.  Flies  may  carry  the  poison. 
Inhalation  of  poisoned  dust  may  infect  the  lungs.  Catgut  ligatures  may  be 
contaminated  and  carry  the  poison.  Many  attempts,  not  altogether  satis- 
factory, have  been  made  to  render  animals  immune  (Pasteur,  Woolbridge, 
Hankin).  Certain  organisms  are  antagonistic  to  anthrax  (the  streptococcus 
of  erysipelas,  the  pneumococcus,  the  micrococcus  prodigiosus,  and  the  bacillus 
pyocyaneus).  The  author  has  seen  two  cases  of  anthra.x  both  of  which  arose 
in  Philadelphia. 

Forms  of  Anthrax. — There  are  two  forms  of  the  disease — external  and 
internal.  Internal  anthrax  may  be  intestinal  from  eating  diseased  meat  or 
pulmonary  from  inhalation  of  poisoned  dust.  External  anthrax  may  be 
anthrax  carbuncle  or  anthrax  edema.  In  over  80  per  cent,  of  cases  of  external 
anthrax  the  lesion  is  on  an  exposed  portion  of  the  body.  The  local  symptoms 
are  usually  very  trivial  at  first,  but  become  suddenly  worse  after  a  variable 
period,  usually  between  Iweh'e  and  forty-eight  hours.  The  external  form  ap- 
pears in  from  three  to  six  days  after  inoculation,  and  presents  an  itching, 
burning  papule  with  a  red  base;  the  papule  becomes  a  vesicle  which  contains 
bloody  serum;  the  vesicle  bursts  and  dries,  the  base  of  it  swells  and  enlarges, 
other  vesicles  appear  in  circles  around  it,  and  there  is  developed  an  "anthrax 
carbuncle,"  which  shows  a  black  or  purple  elevation  with  a  central  depression 
surrounded  by  one  or  more  rings  of  vesicles.  Pain  is  trivial.  Lymphatic 
enlargements  occur.  Within  forty-eight  hours  after  the  pustule  begins 
micro-organisms  usually  appear  in  the  blood.  In  loose  connective  tissue  the 
lesion  may  be  anthrax  edema,  a  spreading  livid  edema  followed  by  blebs  and 
even  by  gangrene.  In  a  case  seen  by  the  author  in  the  Philadelphia  Hospital 
the  forearm  and  arm  and  shoulder  were  extensively  edematous.  The  con- 
stitutional symptoms  may  rapidly  follow  the  local  lesion,  but  may  be  deferred 
for  a  week  or  more.  The  patient  feels  depressed,  has  obscure  aches  and  pains, 
and  is  feverish,  but  usually  keeps  about  for  a  short  period.  After  a  time  he 
is  apt  to  develop  rigors,  high  irregular  fevers,  sweats,  acute  fugitive  pains, 
diarrhea,  delirium,  typhoid  exhaustion,  dyspnea,  cough,  and  cyanosis.  The 
carbuncle  of  anthrax  is  distinguished  from  ordinary  carbuncle  by  the  central 
depression,  the  adherent  eschar,  the  absence  of  pain,  tenderness,  and  suppura- 
tion of  the  first,  as  contrasted  with  the  elevated  center,  the  multiple  foci  of 
suppuration  and  sloughing,  and  the  acute  pain  of  the  second.  Anthrax 
edema  differs  from  cellulitis  in  the  absence  of  all  tendency  to  form  pus,  and 
from  malignant  edema  by  the  greater  tendency  of  the  latter  to  result  in  gan- 
grene. If  anthrax  has  a  visible  lesion  and  the  constitutional  symptoms  are 
slight  or  absent,  the  chance  of  cure  is  good. 

Treatment. — If  a  person  is  wounded  by  an  object  suspected  of  carrying 
the  infection,  cauterize  the  wound  with  the  hot  iron.  A  sufferer  from  anthrax 
must  be  isolated  in  a  well-ventilated  room.  All  dressings  are  to  be  burned,  all 
discharges  asepticized,  and  after  the  removal  of  the  patient  the  bed-clothes 
are  burned  and  the  room  disinfected.  A  malignant  pustule  should  be  entirely 
excised,  and  the  wound  mopped  out  with  pure  carbohc  acid  or  burned  with  the 
liot  iron,  and  afterward  dressed  with  wet  bichlorid  of  mercury  gauze  which 
is  covered  with  an  ice-bag.  Excision  should  be  practised  even  when  glands 
are  enlarged,  but  it  will  prove  ineffectual  if  organisms  are  present  in  the  blood. 
When  excision  cannot  be  performed  make  crucial  incisions  through  the  lesion, 


2i8  Contusions  and  Wounds 

mop  the  wounds  with  pure  carbolic  acid,  and  inject  about  and  in  the  pustule 
carbolic  acid  (i  :  lo)  every  six  hours  until  the  disease  abates  or  toxic  symp- 
toms appear.  The  adherent  eschar  is  subsequently  removed  by  hot  anti- 
septic fomentations.  Davaine  advised  the  following  plan:  Inject  the  pustule 
and  the  tissues  about  it  at  many  points  every  eight  or  ten  hours  with  i  part 
of  tincture  of  iodin  diluted  with  2  parts  of  water  or  with  a  10  per  cent,  solution 
of  carbolic  acid,  or  with  a  o.i  per  cent,  solution  of  corrosive  sublimate.  Dress 
with  wet  antiseptic  gauze  and  apply  an  ice-bag.  The  skin  over  inflamed 
lymphatic  vessels  and  glands  should  be  painted  with  iodin  and  smeared  with 
ichthyol.  Constitutional  treatment  must  be  sustaining  and  stimulating. 
Maffucci  gives  carbohc  acid  internally,  and  also  uses  it  externally.  Davies- 
Colley  uses  ipecac  locally  and  gives  gr.  v  by  the  mouth  every  four  hours. 
Pulmonary  anthrax  and  intestinal  anthrax  are  always  fatal.  The  treatment 
is  symptomatic. 

Hydrophobia,  Rabies,  or  Lyssa. — Hydrophobia  is  a  spasmodic  and 
paralytic  disease  due  to  infection  through  a  wound  with  the  virus  from  a  rabid 
animal.  The  disease  does  not  appear  to  arise  except  as  the  result  of  inocula- 
tion. The  animal  may  be  a  dog,  a  cat,  a  wolf,  a  fox,  or  a  horse.  It  is  far 
more  common  in  the  carnivora  than  the  herbivora.  It  is  said  that  poultry 
may  suffer  from  it.  Roux  estimates  that  about  14  per  cent,  of  the  people 
bitten  by  mad  animals  develop  the  disease.  If  the  bite  is  on  an  exposed  part, 
it  is  far  more  apt  to  cause  rabies  than  if  the  teeth  pass  through  clothing.  The 
saliva  is  the  usual  vehicle  of  contagion,  but  other  fluids  and  tissues  contain  the 
virus,  especially  the  brain  and  cord.  Hydrophobia  has  been  known  for 
centuries.  It  is  mentioned  by  Aristotle  and  alluded  to  by  Plutarch.  At  the 
present  day  some  ardent  antivivisectionists  dispute  its  existence.  The  fact 
that  an  infant  bitten  by  a  rabid  animal  may  develop  rabies  proves  that  the 
disease  is  not  due  to  the  imagination.  Hydrophobia  is  almost  invariably 
fatal.  No  causative  bacterium  has  been  demonstrated.  The  poison  cannot 
gain  entrance  through  sound  mucous  membrane.  It  used  to  be  thought 
that  the  disease  was  particularly  apt  to  arise  in  hot  weather,  but  it  is  now 
known  that  it  may  occur  any  time  of  the  year.  No  constant  post-mortem 
lesions  have  been  certainly  demonstrated  in  those  dead  of  rabies.  Gowers 
believes  that  in  the  spinal  cord  there  is  hyperemia,  but  no  infiltration  with 
cells,  whereas  in  the  medulla,  especially  about  the  respiratory  center,  there  are 
hyperemia  and  cellular  infiltration  of  the  perivascular  spaces.  But  such 
perivascular  infiltration  can  occur  in  some  other  acute  conditions  and  hence 
is  not  characteristic.  What  is  known  as  the  rabic  tubercle  is  found  in  the 
medulla  and  about  the  motor  cells  of  the  upper  part  of  the  spinal  cord.  Each 
tubercle  consists  of  an  aggregation  of  cells.  Babes  thinks  the  tubercle  char- 
acteristic. Infiltration  of  the  ganglion  with  epithelioid  cells  and  round  cells 
has  been  held  by  some  to  be  characteristic.  But  both  the  rabic  tubercle  and 
ganglion  infiltration  occur  in  other  conditions.  The  disease  is  extremely  rare 
in  the  United  States,  and  the  author  has  never  seen  a  single  case. 

Symptoms. — The  period  of  incubation  of  human  hydrophobia  is  from  a 
few  weeks  to  several  months,  and  it  has  been  alleged  that  it  may  even  be  two 
years,  but  it  is  very  doubtful  if  there  is  ever  a  period  of  incubation  of  over  six  or 
seven  months.  The  initial  symptoms  are  mental  depression,  anxiety,  head- 
ache, malaise,  and  often  pain  or  even  congestion  in  the  cicatrix,  which  symp- 


Treatment  of  Hydrophobia  219 

toms  are  quickly  followed  by  dysphagia.  The  difficuhy  in  swallowing  results 
apparently  from  apnea  produced  instantly  when  an  attempt  is  made  to 
swallow.  Curtis  points  out  that  the  difficulty  is  not  spasm  of  the  pharynx 
and  larynx,  but  is  a  sense  of  immediate  suffocation  due  to  reflex  stimulation 
of  respiratory  inhibition.  If  spasms  occur — and  they  may  occur — they  are 
secondary  to  this  suffocative  state,  a  state  in  which  the  action  of  the  diaphragm 
ceases  for  a  time.  The  air-passages  become  congested  and  the  sufferer  makes 
frequent  and  painful  efforts  to  expel  thick  mucus,  and  the  efforts  produce 
paroxysms  of  suffocation.  Between  the  paroxysms  the  patient  is  evidently 
somewhat  breathless,  and  ^^'arren  tells  us  that  his  speech  is  not  unlike  that 
"of  a  child  who  has  recently  been  crying  and  is  endeavoring  to  control  itself" 
("Surgical  Pathology  and  Therapeutics").  As  the  condition  grows  worse, 
suffocative  attacks,  which  were  at  first  induced  by  attempts  at  swallowing, 
come  to  be  caused  also  by  bright  lights,  sudden  or  loud  noises,  irritations  of 
the  skin,  or  thinking  of  swallowing.  At  length  suffocative  paroxysms  occur 
spontaneously  and  the  patient  jumps,  or  hurls  himself  about,  or  the  muscles 
of  the  entire  body  are  thrown  into  clonic  spasm.  Tonic  spasm  does  not 
occur.  A  condition  of  general  hyperesthe.sia  exists.  The  mind  is  usually 
clear,  although  during  the  periods  of  excitement  there  may  be  maniacal  furor 
with  hallucinations  which  pass  away  in  the  stage  of  relaxation.  The  tempera- 
ture is  moderately  elevated  (101°  to  103°  F.  or  higher).  The  spasmodic  stage 
lasts  from  one  to  three  days,  and  the  patient  may  die  during  this  stage  from 
exhaustion  or  from  asphyxia.  If  he  lives  through  this  period,  the  convulsions 
gradually  cease,  the  power  of  swallowing  returns,  and  the  patient  succumbs 
to  exhaustion  in  less  than  twenty-four  hours,  or  he  develops  ascending  par- 
alysis which  soon  causes  cardiac  and  respiratory  failure.  In  what  is  known 
as  paralytic  rabies,  a  very  rare  form  of  the  disease  in  human  beings,  the 
attack  comes  on  with  the  same  early  symptoms  met  with  in  the  commoner 
form,  but  paralysis  soon  begins  about  the  bitten  part  and  spreads  to  the  other 
limbs  and  to  the  trunk. 

In  hydrophobia  death  is  almost  inevitable.  Practically  all  cases  in  which 
it  is  alleged  that  recovery  ensued  were  not  true  hydrophobia,  but  hysteria. 
An  exception  must  be  made  of  Murri's  case  (page  220).  Wood  says 
that  in  hysteria,  especially  among  boys,  "beast-mimicry"  is  common,  the 
sufferer  snarling  Hke  a  dog;  and  in  the  form  known  as  "spurious  hydro- 
phobia," in  which  there  may  or  may  not  be  convulsions,  there  are  a  dread  of 
water,  emotional  excitement,  snarling,  and  attempts  to  bite  the  bvstanders 
(in  genuine  hydrophobia  no  attempts  are  made  to  bite,  and  no  sounds  are 
uttered  like  those  made  by  a  dog). 

Lyssa  is  separated  from  lockjaw  by  the  paroxysms  of  suffocation  and  the 
absence  of  tonic  spasms  in  the  former,  as  contrasted  with  the  fixation  of  the 
jaws  and  the  tonic  spasms  with  clonic  exacerbations  of  lockjaw. 

Treatment. — When  a  person  is  bitten  by  a  supposed  rabid  animal  and 
is  seen  soon  after  the  injury,  constriction  should  be  applied  if  possible  above 
the  wound,  the  wounded  area  should  be  excised,  cauterized  with  a  hot  iron 
or  the  Paquelin  cautery,  and  dressed  antiseptically.  If  the  patient  is  not 
seen  for  a  number  of  hours  or  a  day  or  two  after  the  injury,  cauterization  is 
useless;  and  it  is  not  only  useless,  but  it  may  delude  the  patient  and  his  friends 
into  a  feeling  of  security.     In  any  case,  send  the  patient  at  once  to  a  Pasteur 


2  20  Contusions  and  Wounds 

institute.  If  the  animal  which  inflicted  the  injury  was  not  hydrophobic,  no 
harm  will  result  from  inoculations;  if  it  was  hydrophobic,  preventive  treat- 
ment may  save  the  patient.  The  method  known  as  the  pre\entive  treatment 
was  devised  by  Pasteur,  who  discovered  the  following  remarkable  facts:  If 
the  virus  of  a  rabid  dog  (street  rabies)  be  placed  beneath  the  dura  of  another 
dog,  it  always  causes  hydrophobia  in  from  si.xteen  to  twenty  days,  and  in- 
variably causes  death.  If  the  virus  is  passed  through  a  series  of  rabbits  it 
gets  stronger  (laboratory  virus),  and  if  inserted  beneath  the  dura  of  a  dog  it 
causes  the  disease  in  from  five  to  six  days,  and  kills  in  four  or  five  days.  The 
virus  can  be  attenuated  by  passing  it  through  a  series  of  monkeys  or  by  keeping 
it  for  a  definite  time.  To  obtain  attenuated  preparations  in  a  convenient 
form  Pasteur  made  emulsions  from  the  spinal  cords  of  hydrophobic  rabbits, 
the  animals  having  been  dead  two  or  three  weeks.  He  found  that  the  emul- 
sion obtained  from  the  rabbit  longest  dead  is  the  weakest.  He  injected  a  dog 
with  emulsions  of  progressively  increasing  strength  and  made  it  immune  to 
hydrophobia.  The  patient  is  injected  with  an  emulsion  made  from  the  dried 
spinal  cords  of  hydrophobic  rabbits.  In  this  emulsion  the  virus  is  attenuated, 
and  day  by  day  the  strength  of  the  injected  virus  is  increased.  These  emul- 
sions cause  the  body-cells  to  form  antitoxin,  and  either  the  virus  of  street 
rabies  does  not  develop  at  all  or  by  the  time  it  begins  to  develop  a  quantity  of 
antitoxin  is  present  to  antagonize  it.  In  the  New  York  Pasteur  Institute 
patients  remain  under  treatment  for  fifteen  days,  two  inoculations  being  given 
daily.  In  cases  in  which  treatment  was  begun  late,  or  in  which  the  head  or 
face  was  bitten,  from  four  to  six  inoculations  are  given  each  day.  The  report 
of  the  Parisian  Pasteur  Institute  shows  that  since  its  foundation  there  has 
been  a  mortality  of  0.5  per  cent.  The  lowest  e.stimated  number  of  those 
attacked  by  hydrophobia  before  this  method  was  used  was  5  per  cent,  of  those 
bitten,  and  all  attacked  died;  hence,  the  Pasteur  treatment  shows  one-twent}'- 
fifth  of  the  mortality  which  attends  other  preventive  methods.  The  value  of 
this  plan  seems  definitely  established.  The  general  public  believe  that  the 
dog  which  did  the  biting  should  be  killed.  The  dog  should,  if  possible,  be 
locked  up  and  watched  rather  than  killed.  It  may  be  proved  in  this  way 
that  it  did  not  have  hydrophobia.  If  it  were  necessary  to  kill  the  dog 
or  if  the  dog  was  killed  at  once  or  soon  after,  the  physicians  of  the  New  York 
Pasteur  Institute  advise  that  the  dog's  head  be  cut  from  the  body  with  an 
aseptic  knife  and  a  piece  of  the  medulla  oblongata  be  abstracted.  The  bit  of 
medulla  is  to  be  placed  in  a  mixture  of  equal  parts  of  glycerin  and  water  which 
was  previously  sterilized  by  boiling.  The  bottle  should  be  sealed  and  sent 
to  the  Institute,  in  order  that  inoculations  may  be  made  upon  animals  to 
prove  the  existence  or  absence  of  hydrophobia.  In  the  paroxysm  of  hydro- 
phobia the  treatment  m  the  past  was  ])urely  palliative.  If  we  employ  only 
palliative  methods,  keep  the  ])atient  in  a  dark,  quiet  room,  relieve  thirst  by 
enemata,  saturate  him  with  morphin,  empty  the  bowels  by  enemata,  attend 
to  the  bladder,  and  during  the  paroxysms  anesthetize.  Murri,  of  Bologna, 
cured  a  case  of  hydrophobia  by  injecting  emulsions  of  cords  of  rabbits  dead 
six,  five,  four,  and  three  days  resj)cctivcly.  It  would  be  proper  to  try  this 
remerly  if  hvdrophobia  develops. 

Glanders,  Farcy,  or  Equinia.— Glanders  is  an  infectious  eruptive  fever 
occurring  in  horses  and  communicable  to  man.     If  the  nodules  occur  in  a 


Actinomycosis  221 

horse's  nares,  the  disease  is  called  "glanders";  if  beneath  the  skin,  it  is 
termed  "farcy."  This  disease  is  due  to  a  bacillus,  and  is  communicated 
to  man  through  an  abraded  surface  or  a  mucous  membrane.  The  charac- 
teristic lesions  are  infective  granulomata,  v/hich  in  the  nose  form  ulcers  and 
under  the  skin  develop  into  abscesses. 

Acute  and  Chronic  Glanders. — In  acute  glanders  there  is  septic  inflam- 
mation at  the  point  of  inoculation;  nodules  form  in  the  nose,  and  ulcerate; 
there  is  profuse  nasal  discharge;  the  glands  of  the  neck  enlarge;  there  are 
fever  and  an  eruption  like  smallpox  on  the  face  and  about  the  joints  (Osier), 
and  severe  muscular  pain.  Acute  glanders  is  always  fatal.  Chronic  glanders 
lasts  for  months,  is  rarely  diagnosticated,  being  mistaken  for  catarrh,  and  is 
often  recovered  from.  The  diagnosis  can  be  made  by  injecting  a  guinea-pig 
with  the  nasal  mucus. 

Acute  and  Chronic  Farcy. — Acute  farcy  arises  at  the  site  of  a  skin- 
inoculation;  it  begins  as  an  intense  intlammation,  from  which  run  out  inflamed 
lymphatics  that  present  nodules  or  "farcy-buds."  Abscesses  form.  There 
are  joint-pain  and  the  constitutional  symptoms  of  sepsis,  but  no  involvement 
of  the  nares.  Chronic  farcy  may  last  for  months.  In  it  nodules  occur  upon 
the  extremities,  which  nodules  break  down  into  abscesses  and  eventuate  in 
ulcers  resembling  those  of  tuberculosis. 

Treatment. — In  treating  this  disease  the  point  of  infection  is  at  once  to  be 
incised  and  cauterized,  dusted  with  iodoform,  and  dressed  antiseptically. 
The  skin  o^'er  enlarged  glands  and  swollen  lymphatics  is  to  be  painted  with 
iodin  and  smeared  with  ichthyol.  Bandages  are  applied  to  edematous  ex- 
tremities. Ulcers  are  curetted,  touched  with  pure  carbolic  acid,  dusted  with 
iodoform,  and  dressed  antiseptically.  The  nostrils  should  be  sprayed  at 
frequent  intervals  with  peroxid  of  hydrogen,  and  frequently  syringed  with  a 
solution  of  sulphurous  acid.  The  mouth  must  be  rinsed  repeatedly  with 
solutions  of  chlorate  of  potassium.  Abscesses  are  to  be  opened,  mopped  with 
pure  carbolic  acid,  and  dressed  antiseptically.  Stimulants  and  nourishing 
diet  are  imperatively  demanded.  Morphin  is  necessary  for  the  muscular 
pain,  restlessness,  and  insomnia.  Digitalis  is  given  to  stimulate  the  circu- 
lation and  kidney  secretion.  Sulphur  iodid,  arsenite  of  strychnin,  and  bichlo- 
rate  of  potassium  have  been  used.  Diseased  horses  ought  at  once  to  be  killed 
and  their  stalls  should  be  torn  to  pieces,  purified,  and  entirely  rebuilt.  A 
man  with  chronic  glanders  should  be  removed  to  the  seaside.  The  nasal 
passages  must  be  kept  clean  and  the  ulcers  must  be  cauterized  and  dressed 
with  iodoform  gauze.     Nutritious  foods,  tonics,  and  stimulants  are  necessary. 

Actinomycosis  is  an  infectious  disorder  characterized  by  chronic  in- 
flammation, and  is  due  to  the  presence  in  the  tissues  of  the  actinomyces,  or  ray- 
fungus.  This  disease  occurs  in  cattle  (lumpy  jaw)  and  in  pigs,  and  can  be 
transmitted  to  man,  usually  by  the  food.  At  the  point  of  inoculation  (which 
is  generally  about  the  mouth)  arises  an  infective  granuloma,  around  which 
inflammation  of  connective  tis.sue  occurs,  suppuration  eventually  taking  place. 
Inoculation  in  the  mouth  is  by  way  of  an  abrasion  of  mucous  membrane  or 
through  a  carious  tooth.  Chewing  straw  which  contains  the  fungi  is  the 
most  common  method  of  infection.  The  ray-fungi  mav  pass  into  the  lungs, 
causing  pulmonary  actinomycosis;  into  the  intestines,  causing  intestinal  ac- 
tinomycosis; into  the  skin,  the  bones,  the  subcutaneous  tissues,  the  heart,  the 


222  Contusions  and  Wounds 

brain,  the  liver,  etc.  Cases  of  human  actinomycosis  until  very  recently  were 
looked  upon  as  sarcomata.  Many  sinuses  form,  but  large  abscesses  do  not 
arise. 

The  pus  of  actinomycosis  contains  many  sulphur-yellow  bodies,  visible 
to  the  naked  eye  and  composed  of  fungi.  These  bodies  feel  gritty  when  rubbed 
between  the  fingers  because  of  the  presence  of  lime  salts. 

In  actinomycosis  the  adjacent  lymph-glands  are  very  rarely  involved,  and 
if  metastasis  occurs  it  takes  place  by  the  veins.  The  condition  causes  but 
slight  pain.  A  diagnosis  must  be  made  from  syphilis,  sarcoma,  and  tubercu- 
losis. The  formation  of  a  tumor,  followed  by  sinuses,  the  appearance  of  the 
pus,  and  the  microscopic  study  of  the  discharge  are  significant.  It  is  well  to 
remember  that  an  individual  with  actinomycosis  reacts  to  tuberculin  like  a 
person  with  tuberculosis.  Actinomycosis  may  last  for  years,  or  it  may  prove 
fatal. 

Cutaneous  actinomycosis  may  be  secondary  to  visceral  infection  with  the 
disease,  may  be  a  purely  local  condition,  or  may  be  associated  with  some 
adjacent  area  of  bone-infection.  The  gummatous  form  of  actinomycosis 
resembles  a  gummatous  syphilitic  area,  and  in  it  many  small  purulent 
pockets  open  by  fistulae  (Monestie). 

In  the  anthracoid  form  there  are  no  distinct  purulent  collections,  but  many 
fistulae  discharge  pus  at  various  points  (Monestie). 

An  area  of  cutaneous  actinomycosis  is  characterized  by  the  existence  of 
violet,  blue,  gray,  or  black  maculae,  varying  in  size  from  that  of  a  pin's  head 
to  that  of  a  bean,  the  center  of  each  macule  being  white  and  containing  a 
minute  quantity  of  pus  (Derville). 

In  actinomycosis  of  bone  the  bone  enlarges  and  becomes  painful,  the  parts 
adjacent  swell  from  infiltration  and  soften,  pus  forms  and  reaches  the  surface 
through  fistulae,  and  the  skin  becomes  involved  secondarily. 

Abdominal  actinomycosis  takes  origin  from  the  gastro-intestinal  tract, 
an  actinomycotic  nodule  of  the  intestine  having  ulcerated,  adhesions  having 
formed,  and  an  actinomycotic  abscess  having  arisen,  or  actinomycotic  disease 
of  the  intestine  having  spread.  Over  fifty  per  cent,  of  such  conditions  attack 
the  cecum.  A  fecal  fistula  may  form  and  the  liver  may  be  involved.  The 
prognosis  of  actinomycosis  is  reasonably  good  in  many  cases.  The  majority 
of  cutaneous  cases  and  many  osseous  cases  can  be  cured.  The  mortality  in 
the  abdominal  cases  is  large.  Grill  says  that  of  77  abdominal  cases  treated 
surgically  45  died,  22  recovered,  and  10  were  improved.  Actinomycosis  has 
a  strong  tendency  to  redevelop  even  after  apparently  thorough  excision.  A 
case  of  cutaneous  actinomycosis  of  the  arm,  seen  by  the  author,  was  operated 
on  twenty  times.  Ulceration  took  place  into  the  axillary  artery  and  death  was 
narrowly  averted.     Recovery  finally  ensued. 

Treatment. — Free  excision  if  possible;  otherwise  incision,  cauterization 
with  [)ure  carbolic  acid,  and  packing  with  iodoform  gauze.  Give  internally 
large  doses  of  iodid  of  potas.sium.     This  drug  alone  has  cured  many  cases. 


Syphilitic  Stages  223 


XVI.  SYPHILIS. 

Definition. — Syphilis  is  a  chronic  contagious,  and  sometimes  heredi- 
tary, constitutional  disease.  Its  first  lesion  is  an  infecting  area  or  chancre, 
which  is  followed  by  lymphatic  enlargements,  eruptions  upon  the  skin  and 
mucous  membranes,  affections  of  the  appendages  of  the  skin  (hair  and  nails), 
"  chronic  inflammation  and  infiltration  of  the  cellulovascular  tissue,  bones, 
and  periosteum"  (White),  and,  later,  often  by  gummata.  This  disease  is 
probably  due  to  a  microbe,  but  Lustgarten's  bacillus  has  not  been  proved  to 
be  the  cause.  One  fact  against  its  being  the  cause  is  its  presence  in  the  non- 
contagious late  gummata.  White  quotes  Fenger  in  his  assumption  that 
syphilitic  fever  is  due  to  absorption  of  to.xins;  that  the  eruptions  of  skin  and 
mucous  membranes  in  the  secondary  stage  arise  from  local  deposit  and  multi- 
plication of  the  virus;  that  many  secondary  symptoms  result  from  nutritive 
derangement  caused  by  tissue-products  passing  into  the  circulation;  that  the 
virus  exists  in  the  body  after  the  cessation  of  secondary  symptoms;  and  that 
it  may  die  out  or  may  awaken  into  activity,  producing  "  reminders." 

During  the  primary  and  secondary  stages  fresh  poison  cannot  infect,  and 
this  is  true  for  a  time  after  the  disappearance  of  secondary  symptoms.  Im- 
munity in  the  primary  stage  is  due  to  products  absorbed  from  the  infected 
area.  Colles's  immunity  is  that  acquired  by  mothers  who  have  borne  syph- 
ilitic children,  but  who  themselves  show  no  sign  of  the  disease.  Profeta's 
immunity  is  the  immunity  against  infection  possessed  by  many  healthy  children 
born  of  syphilitic  parents.  Tertiary  syphilitic  lesions  are  not  due  to  the  poison 
of  syphilis,  but  to  tissue-products  resulting  from  the  action  of  that  poison, 
or  to  nutritive  failure  as  a  consequence  of  the  disease.  Tertiary  syphilis  is 
not  transmissible,  but  it  secures  immunity. 

Transmission  of  Syphilis. — This  disease  can  be  transmitted — (i)  by 
contact  with  the  tissue-elements  or  virus — acquired  syphilis;  and  (2)  by 
hereditary  transmission — hereditary  syphilis.  The  poison  cannot  enter 
through  an  intact  epidermis  or  epithelial  layer,  and  abrasion  or  solution  of 
continuity  is  requisite  for  infection.  Syphilis  is  usually,  but  not  always,  a 
venereal  disease.  It  may  be  caught  by  infection  of  the  genitals  during  coition, 
by  infection  of  the  tongue  or  lips  in  kissing,  by  smoking  poisoned  pipes,  by 
drinking  out  of  infected  vessels,  or  by  beastly  practices.  The  initial  lesion 
of  syphilis  may  be  found  on  the  finger,  penis,  eyelid,  lip,  tongue,  cheek,  palate, 
anus,  nipple,  etc.  A  person  may  be  a  host  for  syphihs,  carry  it,  give  it  to 
another,  and  yet  escape  it  himself  (a  surgeon  may  carry  it  under  his  nails,  and 
a  woman  may  have  it  lodged  in  her  vagina).  Syphilis  can  be  transmitted 
by  vaccination  with  human  lymph  which  contains  the  pus  of  a  syphilitic 
eruption  or  the  blood  of  a  syphihtic  person.  \'accine  lymph,  even  after 
passage  through  a  person  with  pox,  will  not  conve}-  syphilis  if  it  is  free  from 
blood  and  the  pus  of  specific  lesions;  it  is  not  the  lymph  that  poisons,  but  some 
other  substance  which  the  lymph  may  carry. 

Syphilitic  Stages. — Syphilis  was  divided  by  Ricord  into  three  stages: 
(i)  the  primary  stage — chancre  and  indolent  bubo;  (2)  the  secondary  stage 
— disease  of  the  upper  layer  of  the  skin  and  mucous  membranes;  and  (3)  the 
tertiary  stage — affections   of   connective   tissues,   bones,    fibrous   and   serous 


2  24  Syphilis 

membranes,  and  parenchymatous  organs.  This  division,  which  is  useful 
clinically,  is  still  largely  employed,  but  it  is  not  so  sharp  and  distinct  as  was 
believed  by  Ricord;  it  is  only  artificial.  For  instance,  ozena  may  develop  dur- 
ing a  secondary  eruption,  and  bone  disease  may  appear  early  in  the  case. 

Syphilitic  Periods. — White  divides  the  po.x  into  the  following  periods: 
(i)  period  of  primary  incubation — the  time  between  exposure  and  the  ap- 
pearance of  the  chancre;  from  ten  to  ninety  days,  the  average  being  three 
weeks;  (2)  period  of  primary  symptoms — chancre  and  bubo  of  adjacent 
lymph-glands;  (3)  period  of  secondary  incubation — the  time  between  the  ap- 
pearance of  the  chancre  and  the  advent  of  secondary  symptoms:  about  six 
weeks  as  a  rule ;  (4)  period  of  secondary  symptoms — lasting  from  one  to  three 
years;  (5)  intermediate  period — there  may  be  no  symptoms  or  there  may  be 
light  symptoms  which  are  less  symmetrical  and  more  general  than  those  of 
he  secondary  period:  it  lasts  from  two  to  four  years,  and  ends  in  recovery 
or  tertiary  syphilis;  (6)  period  of  tertiary  symptoms — indefinite  in  duration. 
The  fifth  and  sixth  periods  may  never  occur,  the  disease  having  been  cured. 

Primary  Syphilis. — The  primary  stage  comprises  the  chancre  or  in- 
fecting sore  and  bubo.  A  chancre  or  initial  lesion  is  an  infective  granuloma 
resulting  from  the  poison  of  syphilis.  A  chancre  may  be  derived  from  the 
discharges  of  another  chancre,  from  the  secretion  of  mucous  patches  and 
moist  papules,  from  syphilitic  blood,  or  from  the  pus  or  secretion  of  any  secon- 
dary lesion.  Tertiary  lesions  cannot  cause  chancre.  It  appears  at  the  point 
of  inoculation,  and  is  the  first  lesion  of  the  disease.  During  the  three  weeks 
or  more  requisite  to  develop  a  chancre  the  poison  is  continuously  entering  the 
system,  and  when  the  chancre  develops  the  system  already  contains  a  large 
amount  of  poison.  A  chancre  is  not  a  local  lesion  from  which  syphilis  springs, 
but  is  a  local  manifestation  of  an  existing  constitutional  disease,  hence  excision 
is  entirely  useless.  If  we  take  the  discharge  of  a  chancre  and  insert  it  at  some 
indifferent  point,  into  the  person  from  whom  we  took  it,  a  new  indurated 
chancre  will  not  be  formed,  because  the  individual  already  has  syphilis,  but 
auto-inoculation  with  the  discharge  of  an  irritated  chancre  can  cause  a  non- 
indurated  sore.  If  we  take  the  discharge  of  a  chancre  and  insert  it  into  a 
healthy  person,  an  indurated  chancre  follows.  Hence  we  say  that  primary 
syphilis  is  not  auto-inoculable,  but  is  hetero-inoculable.  A  soft  sore  can  be 
produced  in  the  lower  animals  by  inoculation  with  the  virus  of  a  chancre,  but 
a  hard  sore  cannot.  Some  observers,  notably  Kaposi,  of  Vienna,  advocate  the 
unity  theory.  This  theory  maintains  that  both  hard  and  soft  sores  are  due  to 
the  same  virus,  the  infective  power  of  the  soft  chancre  simply  being  less  than 
that  of  the  hard  sore,  the  possibility  of  constitutional  infection  depending,  not 
upon  differences  in  the  poison,  but  rather  upon  differences  in  the  soil  and  in 
the  local  processes.  The  unicists  advocate  excision  of  chancres,  soft  or  hard, 
to  prevent,  if  possible,  constitutional  involvement.  Most  syphilographers 
believe  in  the  duality  theory,  which  we  have  previously  set  forth.  This 
theory  took  origin  from  the  classical  investigations  of  Bassereau  and  Rollet. 
The  duality  theory  maintains  that  the  soft  sore  is  caused  by  a  poison  different 
from  that  which  originates  the  hard  sore,  and  that  a  true  soft  sore  never  infects 
the  .system.* 

*  For  a  full  discussion  of  these  points  see  the  writings  of  Fournier,  Alfred  Cooper,  and 
von  Zeissl,  and  especially  the  great  work  of  Taylor. 


Mixed  Infection  of  Chancre  and  Chancroid  225 

Initial  Lesions. — An  initial  lesion,  hard  chancre,  or  infecting  sore 
never  appears  until  at  least  ten  days  after  exposure;  it  may  not  appear  for 
many  weeks,  but  it  usually  arises  in  about  twenty-five  days.  There  are  three 
chief  forms  of  initial  lesion:  (i)  a  purple  patch  exposed  by  peeling  epidermis, 
without  induration  and  ulceration — a  rare  form;  (2)  an  indurated  area  under 
the  epidermis,  without  ulceration — a  very  common  form;  and  (3)  a  round, 
indurated,  cartilaginous  area  with  an  elevated  edge,  which  ulcerates,  exposing 
a  velvety  surface  looking  like  raw  ham;  it  bleeds  easily,  rarely  suppurates, 
does  not  spread,  and  the  discharge  is  thin  and  watery.  This  is  the  "  Hunterian 
chancre,"  which  is  rarer  than  the  second  variety,  but  commoner  than  the  first, 
and  which  ulcerates  because  of  dirt,  caustic  applications,  or  friction. 

A  chancre  is  rarely  multiple;  but  if  it  is  so,  all  the  sores  appear  together  as 
a  result  of  the  primary  inoculation;  they  do  not  follow  one  another  because  of 
auto-infection.  A  hard  sore  does  not  suppurate  unless  irritated  by  caustics, 
friction,  or  dirt,  or  unless  there  be  mixed  infection  with  chancroid;  its  nature 
is  not  to  suppurate.  The  hardness  may  affect  only  the  base  and  margins  of 
an  ulcer  or  it  may  affect  considerable  areas,  but  it  has  well-defined  margins 
and  feels  like  cartilage  encapsuled,  so  that  it  can  be  picked  up  between  the 
fingers.  This  hardness  or  sclerosis  is  due  to  gradual  infiammatorv  exudation 
into  "the  tissues  at  the  base  of  the  ulcer  and  to  growth  of  the  nodule"  (von 
Zeissl).  It  feels  distinct  from  the  surrounding  tissues,  like  a  foreign  body 
lying  in  the  part.  A  chancre  untreated  may  last  many  months.  The  indu- 
ration usually  disappears  soon  after  the  appearance  of  secondary  symptoms. 
A  copper-colored  spot  remains,  and  does  not  disappear  until  the  disease  is 
cured.  Induration  may  again  appear  before  the  outbreak  of  some  distant 
lesion. 

Mixed  Infection  of  Chancre  and  Chancroid. — Von  Zeissl  says:  "If 
syphihtic  contagion  is  mixed  with  pus,  a  chancre  begins  as  a  circumscribed 
area  of  hyperemia  and  swelling,  which  undergoes  ulceration,  and  does  not 
develop  hardness  for  a  period  of  from  ten  days  to  several  weeks,  and  may 
develop  a  nodule  after  the  first  ulcer  has  entirely  healed."  This  condition  is 
seen  when  mixed  infection  occurs,  the  chancroid  poison  being  quick,  and  the 
syphilitic  poison  being  slow,  to  act.  If  chancroid  poison  is  deposited  some 
time  after  the  syphilitic  poison  has  been  absorbed,  the  induration  may  appear 
in  a  few  days  after  the  chancroid  begins.  A  soft  chancre  may  appear  upon  an 
existing  syphilitic  nodule  and  may  eat  out  the  induration. 

Diagnosis  of  Chancre, — It  is  necessary  to  distinguish  a  chancre  from  a 
chancroid  and  from  ulcerated  herpes.  A  chancroid  appears  in  from  two  to 
five  days  after  contagion  (always  less  than  ten  days) ;  it  may  be  multiple  from 
the  start,  but,  even  if  beginning  as  one  sore,  other  sores  appear  by  auto-inocu- 
lation; it  begins  as  a  pustule,  which  bursts  and  exposes  an  ulcer;  the  ulcer 
is  circular,  has  thin,  sharp-cut,  or  undermined  edges,  a  sloughy,  non-granu- 
lating base,  and  gives  origin  to  a  thin,  purulent,  offensive  discharge  which  is 
both  auto-  and  hetero-inoculable.  These  soft  sores  have  no  true  sclerotic 
area,  do  not  bleed,  produce  no  constitutional  symptoms,  and  are  apt  to  be 
followed  by  acute  inflammatory  buboes  which  tend  to  suppurate.  A  chan- 
croid causes  pain,  and  the  original  ulcer  enlarges  greatly.  A  chancre  appears 
in  about  twenty-five  days  after  inoculation  (never  before  ten  da}'s) ;  it  is  gen- 
erally single,  but  if  multiple  sores  exist,  they  all  appear  together,  for  their  dis- 

15 


226  Syphilis 

charge  is  not  auto-inoculable  if  the  sore  is  not  irritated;  an  auto-inoculation 
of  the  products  of  an  irritated  chancre  can  at  most  produce  only  a  soft  purulent 
ulcer.  A  chancre  begins  as  an  excoriation  or  as  a  nodule;  if  an  ulcer  forms, 
its  floor  is  covered  with  granulations  and  it  is  red  and  smooth ;  the  discharge 
is  thin  and  scanty  and  not  offensive;  the  edges  are  thick  and  sloping;  it  is 
surrounded  by  an  area  of  induration,  and  bleeds  when  touched,  there  appear 
about  the  same  time  with  it  indolent  multiple  enlargements  of  the  adjacent 
glands,  which  rarely  suppurate,  and  it  is  followed  b}-  secondary  symptoms. 
A  chancre  causes  little  pain,  and  after  it  has  existed  for  a  few  days  rarely 
shows  any  tendency  to  spread.  A  urethral  chancre  appears  after  the  usual 
period  of  incubation ;  it  is  situated  near  the  meatus,  one  lip  of  which  is  usually 
indurated;  the  discharge  is  slight,  often  bloody,  never  purulent;  indurated  mul- 
tiple buboes  arise;  the  sore  can  be  seen,  and  constitutional  symptoms  follow. 

Herpetic  ulceration  has  no  period  of  incubation;  it  may  follow  fever,  but 
usually  arises  from  friction  or  irritation  due  to  dirt  or  acrid  discharges.  It 
appears  as  a  group  of  vesicles,  all  of  which  ma\-  dr}-  up,  or  some  may  dry  up 
and  others  ulcerate,  or  they  may  run  together  and  ulcerate.  The  edges  of  an 
herpetic  ulcer  are  in  "segments  of  small  circles"  (White);  the  ulcer  is  super- 
ficial, has  but  little  discharge,  and  does  not  ha\e  much  tendency  to  spread; 
it  has  no  induration;  it  is  painful;  it  is  not  accompanied  by  bubo  unless  sup- 
puration is  extensive.     Herpes  is  not  followed  b\'  constitutional  involvement. 

A  chancre  may  be  mistaken  for  cancer  of  the  tongue.  "  A  chancre  of  this 
region  is  brownish-red,  a  cancer  being  bright  red.  A  chancre  is  soft  in  the 
center;  a  cancer  presents  uniformity  of  induration.  A  chancre  gives  origin 
to  a  thin,  purulent  discharge,  free  from  blood;  a  cancer  furnishes  a  non- 
purulent, bloody  discharge.  A  chancre  is  followed  by  indolent  lymphatic 
enlargements  under  the  jaw;  a  cancer  is  followed  by  painful  enlargements." 
A  cancer  is  slower  in  evolution,  is  not  followed  by  constitutional  symptoms, 
and  the  lymphatic  enlargements  are  much  later  in  appearing  than  in  chancre. 

Phagedena. — A  chancre  or  a  chancroid  may  be  attacked  by  phagedena,  a 
destructive  form  of  ulceration  which  was  once  common,  but  at  present  is  rare. 
The  ulceration  often  spreads  on  all  sides  and  also  deeply  into  the  tissues.  In 
some  cases  it  spreads  in  only  one  direction  (serpiginous  ulceration),  in  some 
cases  sloughing  occurs.  Phagedena  occurs  only  in  the  debilitated  (anemic, 
drunkards,  strumous  subjects,  sufferers  from  diabetes,  Bright's  disease,  etc. ; 
salivation  can  cause  it).  The  phagedenic  ulcer  is  irregular,  with  congested 
and  edematous  edges,  and  a  foul,  sloughy  floor. 

Chancre  Redux. — Some  observers  believe  that  reinfection  with  syphilis 
is  not  very  unusual  (Hutchinson).  Most  authorities  maintain  that  it  is  very 
rare  (Taylor).  The  latter  school  maintains  that  the  region  once  occu})ied  by 
a  chancre  may,  after  many  years,  become  indurated  anew.  Fournier  pointed 
out  this  fact  thirty  years  ago.  Such  a  reinduration  is  railed  chancre  redu.x, 
or  relapsmg  chancre. 

If  syphilitic  manifestations  follow  such  an  induration,  we  must  conclude 
that  reinfection  has  truly  occurred.  If  they  do  not  follow,  and  this  is  the  rule, 
the  lesion  is  not  really  a  chancre,  but  is  probably  a  gumma  in  an  early  stage  of 
development.     Mauriac  pointed  out  this  last  fact.* 

*  Mracek,  in  VVien.  kliii.  Rundschau,  1896.  II.  (i.  Antony,  in  (hicaf^to  Medical  Re- 
corder, April,  1899. 


General  Syphilis  227 

Syphilitic  Bubo. — In  syphilitic  bubo  anatomically  related  l\mphatic 
glands  enlarge  about  the  same  time  as  induration  of  the  initial  lesion  begins. 
In  the  very  beginning  these  glands  may  be  a  little  painful,  but  the  pain  is 
slight  and  of  temporary  duration.  These  enlargements  are  called  "indolent 
buboes";  they  may  be  as  small  as  peas  or  as  large  as  walnuts,  are  freel\-  mov- 
able, and  very  rarely  suppurate.  The  lesion  of  the  glands  is  hyperplasia  of  all ' 
the  gland-elements  and  of  their  capsules,  due  to  absorption  of  the  virus.  If 
the  patient  is  tuberculous,  the  bubo  is  apt  to  become  enormous,  lobulated,  and 
persistent.  If  the  chancre  appears  on  the  penis,  the  superficial  inguinal  and 
femoral  glands  enlarge,  usually  on  the  same  side  of  the  body  as  the  sere.  If 
the  sore  is  on  the  frenum,  both  groins  are  involved.  If  a  chancre  appears  on 
the  lip  or  tongue,  the  bubo  is  beneath  the  jaw.  These  buboes  may  remain 
for  many  months;  they  do  not  suppurate  unless  the  sore  suppurates  or  unless 
the  patient  is  of  the  tuberculous  type;  and  they  finally  disappear  by  absorption 
or  fatty  degeneration.  About  six  weeks  after  buboes  have  formed  in  the 
glands  related  to  the  lesion  all  the  lymphatics  of  the  body  enlarge.  General 
lymphatic  involvement  arises  about  the  same  time  as  the  secondary  eruption. 
The  enlargement  of  the  post-cervical  and  epitrochlear  glands  is  diagnostically 
important.  Glandular  enlargements  persist  until  after  the  eruptions  have 
disappeared. 

Glandular  enlargement  always  occurs  in  syphilis,  but  the  bubo  e.xists  in 
only  one-third  of  the  chancroid  cases.  The  bubo  of  syphilis  is  multiple,  con- 
sisting of  a  chain  of  movable  glands  (the  glandular  Pleiades  of  Ricord) ;  the 
bubo  of  chancroid  is  one  inflamed  and  immovable  mass.  The  bubo  of  syph- 
ilis is  indurated,  painless,  small,  and  slow  in  growth;  the  bubo  of  chancroid 
shows  inflammatory  hardness,  is  painful,  large,  and  rapid  in  growth;  the  first 
rarely  suppurates,  the  second  often  does.  The  skin  over  a  syphilitic  bubo  is 
normal;  that  over  a  chancroidal  bubo  may  become  red  and  adherent.  A  syph- 
ilitic bubo  is  not  cured  by  local  treatment,  but  is  cured  by  the  internal  use  of 
mercury  and  is  followed  by  secondary  symptoms.  A  chancroidal  bubo  re- 
quires local  treatment,  is  not  cured  by  mercury,  and  is  not  followed  by  secon- 
daries. Herpes,  balanitis,  and  gonorrhea  rarely  cause  bubo,  but  when  they  do 
the  bubo  in  each  case  is  similar  to  that  caused  by  chancroid.  .\  positive 
diagnosis  of  syphilis  can  be  made  when  an  indurated  sore  is  followed  by 
multiple  indolent  buboes  in  the  groin  and  by  enlargement  of  distant  glands. 

General  Syphilis. — As  the  general  lymphatic  enlargement  becomes 
manifest  a  group  of  symptoms  known  as  "syphilitic  fever"  may  appear.  In 
many  mild  cases,  however,  fever  is  absent  and  the  eruption  is  the  first  sign 
of  constitutional  involvement.  The  patient  usually  thinks  he  has  a  severe 
cold,  is  feverish  and  restless;  complains  of  headache,  lassitude,  sleeplessness, 
and  anorexia;  his  face  is  pale;  he  has  intermitting  rheumatoid  pains  in  the 
joints  and  muscles,  especially  of  the  shoulders,  arms,  chest,  and  back,  which 
pains  change  their  location  constantly  and  prevent  sleep;  night-sweats  occur, 
and  the  pulse  is  quite  frequent.  The  fever  usually  reaches  its  height  in  forty- 
eight  hours,  and  falls  as  the  eruption  develops.  The  eruption  develops 
usually  in  from  forty-eight  to  seventy-two  hours  after  the  onset  of  the  fever, 
but  may  not  do  so  for  one  week  or  even  more.  The  fever  and  the  discomfort 
are  worse  at  night.  In  type  the  fever  may  be  intermittent,  remittent,  or  c()n- 
tinued.     Prolonged  syphilitic  fever  with  delay  in  the  appearance  of  tlic  cru])- 


228  Syphilis 

tion  CTives  rise  sometimes  to  great  errors  in  diagnosis.  In  syphilitic  fever  there 
are  anemia,  trivial  leukocytosis,  and  a  marked  fall  in  hemoglobin.  Syphilitic 
fever  mav  reappear  during  the  progress  of  the  disease. 

Secondary  Syphilis. — The  phenomena  of  secondary  syphilis  are  due 
to  poisoned  blood.  Fenger  states  that  the  poison  is  present  in  the  blood 
during  outbreaks,  but  not  during  the  quiescent  periods  between  outbreaks. 
Secondary  syphihs  is  characterized  by  plastic  inflammation,  by  the  forma- 
tion of  fibrous  tissue,  and  by  thickening  of  tissue.  Superficial  ulcerations 
may  occur.     Structural  overgrowths  appear  (for  instance,  warts). 

Syphilitic  Skin  Diseases. — SyphUodermata  (syphilides)  are  due  to 
circumscribed  inflammation,  and  may  be  dry  or  purulent.  There  is  no  one 
eruption  characteristic  of  syphilis.  This  disease  may  counterfeit  any  skin 
disease,  but  it  is  an  imitation  which  is  not  perfect  and  is  never  a  counterpart. 
Syphilitic  eruptions  are  often  circumscribed ;  they  terminate  suddenly  at  their 
edges,  and  do  not  graduaUy  shade  into  the  sound  skin.  In  color  they  are  apt 
to  be  brownish-red,  hke  tarnished  copper;  especially  is  this  the  case  in  late 
syphilides.  Hutchinson  cautions  us  to  remember  than  an  ordinary  non- 
specific eruption  may  be  copper-colored,  especially  in  people  with  dark  com- 
plexion and  when  it  occurs  on  the  legs.  Eruptions  are  apt  to  leave  a  brownish 
stain.  Early  syphilitic  eruptions  are  symmetrical.  Syphilitic  eruptions  have 
an  affection  for  particular  regions,  such  as  the  forehead,  the  abdomen  and 
chest,  the  neck  and  scalp,  about  the  lips  and  the  alae  of  the  nose,  the  navel, 
anus,  groins,  between  the  toes,  and  upon  the  palms  and  soles.  Early  secon- 
dary eruptions  rarely  appear  on  the  face  or  hands.  Specific  eruptions  are  poly- 
morphous, various  forms  of  eruption  being  often  present  at  the  same  time,  so 
that  roseola  is  seen  here,  papules  there,  etc.  These  syphilides  do  not  cause 
as  much  itching  as  do  non-specific  eruptions,  except  when  they  occur  upon  the 
scalp,  about  the  anus,  or  between  the  toes.  The  late  secondary  eruptions 
tend  to  an  arrangement  in  curved  lines. 

Forms  of  Eruption. — The  chief  forms  of  eruption  are:  (i)  erythema, 
(2)  papular  syphilides,  (3)  pustular  syphilides,  and  (4)  tubercular  syphilides. 
Besides  these  eruptions  pigmentation  may  occur  (pigmentary  syphihde), 
and  blood  may  extravasate  (purpuric  syphilide). 

Prince  A.  Morrow  does  not  believe  in  erecting  the  vesicular  syphilides  into 
a  special  group.  He  tells  us  that  vesicles  sometimes  form  on  erythemato- 
papular  lesions,  but  their  presence  is  an  accident  and  not  a  regular  phenom- 
enon. So,  too,  the  bullous  syphilide  is  a  rare  accident  in  a  case,  and  even 
when  it  occurs  soon  becomes  pustular.  The  pemphigoid  syphilide  is  found 
almost  exclusively  in  hereditary  disease.* 

I.  Erythema  {macula,  roseola,  or  spots).  This  eruption  usually  comes  on 
gradually,  crop  after  crop  of  spots  appearing,  and  many  days  passing  before 
an  extensive  area  is  covered.  Occasionally,  however,  it  arises  suddenly 
(after  a  hot  bath,  after  taking  violent  e.xercise,  or  after  eating  an  indigestible 
meal).  This  eruption  consists  of  circumscribed,  irregularly  round,  hyperemic 
spots,  about  one-eighth  of  an  inch  in  diameter,  whose  color  does  not  entirely 
disappear  on  pressure  in  an  old  eruption  but  does  in  a  recent  one.  The  color 
is  at  first  light  pink,  but  it  becomes  red,  purple,  or  even  brown.  In  the  [)apular 
form  of  erythema  the  spots  are  slightly  elevated.     Erythema  is  rare  ui)on 

*  Morrow's  "System  of  Genitourinary  Diseases,  Syphilidogy,  and  Dermatology." 


Papular  Syphilides  229 

the  face  and  the  dorsum  of  the  hands  and  feet.  It  attacks  especially  the  chest 
and  belly,  but  appears  often  on  the  forehead,  the  bend  of  the  elbow,  and  the 
inner  portion  of  the  thigh,  the  neck,  and  the  flexor  surface  of  the  forearms 
and  arms.  It  appears  first  on  the  abdomen  and  last  on  the  legs.  Usually 
ervthema  follows  syphilitic  fever,  about  six  weeks  after  the  chancre  appears, 
and  the  number  and  distinctness  of  the  spots  are  in  proportion  to  the  violence 
of  the  fever.  No  fever  or  slight  fever  means  there  will  be  but  few  spots  and 
they  will  soon  disappear.  In  rare  cases  the  eruption  is  very  transitory,  lasting 
but  a  few  hours,  but  it  usually  continues  for  several  weeks  if  untreated.  It 
may  pass  away  or  may  be  converted  into  a  papular  eruption.  Mercury  will 
cause  it  to  disappear  in  a  couple  of  weeks.  In  examining  for  this  form  of 
.eruption  in  a  doubtful  case,  let  cold  air  blow  upon  the  chest  and  belly  (Hearn) ; 
this  blanches  the  sound  skin  and  makes  clear  any  discoloration.  No  desqua- 
mation attends  the  macular  eruption,  but  a  brownish  stain  remains  for  a  vari- 
able time  after  the  eruption  fades.  Erythema  means,  as  a  rule,  a  mild  and 
curable  attack.  Macule  may  be  combined  with  the  next  form,  constituting 
a  maculopapular  eruption. 

The  maculopapular  syphilides  are  evolved  from  the  macular  syphilides. 
They  are  slightly  elevated,  are  situated  upon  hyperemic  bases,  and  the  sum- 
mits of  some  of  them  may  undergo  slight  desquamation.  A  roseolar  area 
may  show  one  or  several  of  these  macular  papules.  They  are  apt  to  arrange 
themselves  in  segments  of  a  circle,  and  are  symmetrically  distributed.  This 
eruption  usually  appears  early,  but  may  appear  late.  It  may  fade  and  reap- 
pear several  times  in  the  same  patient.     The  eruption  lasts  a  few  weeks. 

2.  Papular  syphilides,  which  are  papules  or  elevations  covered  with 
dry  skin,  may  or  may  not  desquamate.  If  they  do  desquamate,  the  process 
begins  over  the  center.  They  usually  appear  from  the  third  to  the  sixth 
month  of  the  disease.  They  may  be  preceded  by  fever,  and  often  reappear 
again  and  again.  They  are  at  first  red,  but  become  brownish.  They  are 
firm  in  feel  and  vary  in  size  from  the  head  of  a  pin  to  a  five-cent  piece  or  larger. 
They  may  be  present  as  miliary  papules,  lenticular  papules,  papules  which 
scale  off  (papulosquamous  eruption),  and  moist  papules.  Papules  on  fading 
leave  coppery-looking  stains.  Papules  upon  the  palms  and  soles  constitute 
the  so-called  "  palmar  and  plantar  psoriasis,"  which  appears  from  three  months 
to  one  year  after  the  appearance  of  the  chancre.  Papules  just  below  the  line 
of  the  hair  on  the  forehead  constitute  the  corona  venerea.  Papular  syphilides 
appear  especially  upon  the  forehead,  the  neck,  the  abdomen,  and  the  ex- 
tremities. The  papiilar  or  squamous  syphilide  of  the  palms  and  soles  begins 
as  a  red  spot  which  becomes  elevated  and  brownish;  the  epidermis  thickens 
and  is  cast  off,  and  there  then  remains  a  central  red  spot  surrounded  by  under 
mined  skin.  If  papules  are  in  regions  where  they  are  kept  moist  (as  about 
the  anus),  they  become  covered  with  a  sodden  gray  film  which  after  a  time  is 
cast  off  and  leaves  the  papule  without  epidermis.  The  sodden  papules  are 
called  flat  condylomata,  moist  or  humid  papules  or  plates.  Papules  which 
are  at  first  small  may  become  large.  The  small  or  miliary  papules  constitute 
syphilitic  lichen.  The  lenticular  papules  are  most  common,  and  strongly 
tend  to  scale  off.  The  papular  syphilides  give  a  worse  prognosis  for  the  con- 
stitutional disease  than  do  spots. 


230  Syphilis 

3.  Pustular  syphilides  arise  from  papules.  The  condition  is  known 
as  acne  when  the  apex  of  the  papule  softens,  impetigo  when  the  whole  papule 
suppurates,  and  ecthyma  or  riipia  when  the  corium  is  also  deeply  involved. 
Vesicles  occasionally  precede  pustules.  The  pustular  eruption  appears  a 
number  of  months  after  infection  and  later  than  the  papular.  The  pustular 
eruption  gives  a  very  bad  prognosis  for  the  constitutional  disease.  Rupia  is 
formed  by  a  pustule  rupturing  or  a  papule  ulcerating,  the  secretion  drying 
and  forming  a  conical  crust  which  continually  increases  in  height  and  diam- 
eter, while  the  ulceration  extends  at  the  edges.  When  the  crust  is  pulled  off 
there  is  seen  a  foul  ulcer  with  congested,  jagged,  and  undermined  edges. 
Rupia  may  be  secondary  or  tertiary,  and  it  invariably  leaves  scars.  It  appears 
only  after  at  least  six  months  have  passed  since  the  chancre  began.  Secondary 
rupia  is  symmetrical.     Tertiary  rupia  is  asymmetrical. 

4.  Tubercular  syphilides  are  greatly  enlarged  papules  intermediate 
between  ordinary  papules  and  gummata. 

Diagnosis  between  Secondary  and  Tertiary  Syphilides. — A  secondary 
eruption  is  distinguished  from  a  tertiary  eruption  by  the  following:  the  first 
tends  to  disappear,  the  second  tends  to  persist  and  to  spread ;  the  first  is  gen- 
eral and  symmetrical,  the  second  is  local  and  asymmetrical;  the  first  does  not 
spread  at  its  edge,  the  second  tends  to  spread  at  its  edge,  and  this  tendency, 
which  is  designated  "  serpiginous,"  produces  an  ulcer  shaped  like  a  horseshoe 
(Jonathan  Hutchinson).  Secondary  lesions  appear  within  certain  limits  of 
time,  develop  regularly,  and  are  dispersed  by  mercurial  treatment.  Tertiary 
lesions  appear  at  no  fixed  time,  develop  irregularly,  and  are  not  cleared  up 
by  mercury. 

Affections  of  the  Mucous  Membranes. — The  chief  lesions  in  syphil- 
itic affections  of  the  mucous  membranes  are  mucous  patches,  warts,  and  condylo- 
mata. The  first  phenomena  of  secondary  syphilis  are,  as  a  rule,  symmetrical 
ulcers  of  the  tonsils,  painless,  of  temporary  duration,  and  superficial  (Hutchin- 
son). The  borders  of  the  ulcers  are  gray,  and  the  areas  are  reniform  in  shape. 
Catarrhal  inflammations  often  occur.  Eruptions  appear  on  the  mucous 
membranes  as  upon  the  skin.  Mucous  patches  are  papules  deprived  of  epithe- 
lium; they  are  gray  in  color,  are  moist,  and  give  off  an  offensive  and  virulent 
discharge.  They  usually  appear  as  areas  of  congestion,  swelling,  and  abrasion 
of  the  epidermis  upon  the  lips,  palate,  gums,  tongue,  cheeks,  vagina,  labia, 
vulva,  scrotum,  anus,  and  under  the  prepuce.  A  moist  papule  of  the  skin  is 
really  a  mucous  patch.  These  patches,  which  are  always  circular  or  oval,  are 
among  the  mo.st  constant  lesions  of  the  secondary  stage,  appearing  from  time 
to  time  during  many  months.  If  a  patch  has  the  papilla^  destroyed,  it  is  called 
a  "  bald  patch. "  If  the  papules  present  hypertrophied  papilla;  fused  together, 
there  appear  enlargements  with  flat  tops,  termed  condylomata;  if  the  papillae 
of  the  papules  hypertrophy  and  do  not  fuse,  the  growths  are  called  warts 
(Fig.  91).  Mucous  lesions  of  the  mouth  are  commonest  in  smokers  and  in 
those  with  bad  or  neglected  teeth.  Hutchinson  says  that  persistence  in  smoking 
during  .syphilis  may  cause  leukomata,  or  persistent  white  patches.  The  vagina 
and  lips  of  the  vulva  during  the  secondary  stage  are  often  covered  with  mucous 
patches.  The  uterus  may  contain  mucous  lesions  which  poison  the  uterine 
discharge.  The  larynx  may  suffer  from  inflammation,  eruptions,  and  ulcera- 
tion (hence  the  hoarse  voice  which  is  so  usual).     The  nasal  mucous  mem- 


Affections  of  the  Eye  231 

brane  may  also  suffer.  The  rectal  mucous  membrane  may  be  attacked 
with  patches,  and  so  may  the  glans  penis,  the  inner  surface  of  the  prepuce, 
and  the  urethra.  Early  in  the  secondary  stage  in  some  cases  there  is  a  slight 
muco-purulent  urethral  discharge,  and  examination  with  an  endoscope  shows 
redness  of  the  mucous  membrane  of  the  anterior  urethra.  The  discharge  is 
contagious.  The  condition  may  be  followed  by  constriction  of  the  urethral 
caliber.     Distinct  ulceration  may  take  place. 

Affections  of  the  Hair. — In  syphilis  the  hair  is  usually  shed  to  a.  great 
extent.  This  loss  may  be  widespread  (beard,  mustache,  head,  eyebrows, 
pubic  hair,  etc.)  or  it  may  be  limited.  Complete  baldness  sometimes  ensues, 
but  it  is  rarely  permanent.  The  hairs  of  the  head  are  first  noticed  to  come 
out  on  the  comb;  on  pulling  them  they  are  found  loose  in  their  sheaths — so 
loose  that  Ricord  has  said  "  a  man  would  drown  if  a  rescuer  could  pull  only 
upon  the  hair  of  the  head."  The  falling  out  of  the  hair,  which  is  known  as 
alopecia,  usually  begins  soon  after  the  fever  or  about  the  time  of  the  erup- 
tion, but  it  may  be  postponed  until  much  later.  The  skin  of  a  syphilitic  bald 
spot  is  never  smooth,  but  is  scaly.  The  hair  may  thin  generally,  baldness 
may  appear  in  twisting  lines,  or  it  may  be  complete  only  in  limited  areas.  Alo- 
pecia results  from  shrinking  of  the  hair-pulp,  death  of  the  hair,  and  casting  off 
of  the  sheath. 

Affections  of  the  Nails. — Paronychia  is  inflammation  and  ulceration  of 
the  skin  in  contact  with  a  nail  and  extending  to  the  matrix.  The  nail  is  cast 
oft'  partially  or  entirely.  Onychia  is  inflammation  of  the  matrix,  and  is  mani- 
fested by  white  spots,  brittleness  or  extended  opacity,  twisting,  and  breaking 
off  of  the  nail.  The  parts  around  are  not  affected.  The  damaged  nail  drops 
oft'  and  another  diseased  nail  appears. 

Affections  of  the  Ear. — Temporary  impairment  of  hearing  in  one  or 
both  ears  is  not  uncommon  in  syphilitic  affections  of  the  ear.  Rarely,  per- 
manent symmetrical  deafness  is  produced.  Meniere's  disease  is  sometimes 
caused  by  syphilis. 

Affections  of  the  Bones  and  Joints. — In  syphilis  there  may  be  slight 
and  temporary  periostitis.  Pain  and  tenderness  arise  in  various  bones,  the 
pain  being  worse  at  night  {osteocopic  pains).  Osteoperiostitis  usually  arises 
with  or  after  the  onset  of  the  secondary  eruption,  but  in  rare  instances  pre- 
cedes the  syphilides.  The  bones  usually  involved  are  the  tibiae,  clavicles,  and 
skull.  Intense  headache  may  be  due  to  periostitis  of  the  inner  surface  of  a 
cranial  bone  (Mauriac).  Local  periostitis  may  form  a  sojt  node  which  by 
ossification  becomes  a  hard  node.  Pain  like  that  of  rheumatism  affects  the 
joints.  Symmetrical  synovitis  has  been  noted.  Secondary  syphilitic  disease 
of  bone,  periosteum,  and  joints  lasts  only  a  short  time  and  is  never  destructive. 

Affections  of  the  Eye. — Iritis  is  the  commonest  eye  trouble  which  may 
arise  during  secondary  syphilis.  It  appears  from  three  to  six  months  after  the 
chancre,  and  begins  in  one  eye,  the  other  eye  soon  becoming  affected.  The 
symptoms  are  a  pink  zone  in  the  sclerotic,  a  congested,  red  or  muddy  iris,  irreg- 
ularity of  the  pupil  accentuated  by  atropin,  the  existence  of  pain  and  photo- 
phobia, and  sometimes  hazy  or  even  clouded  pupil.  Rheumatic  iritis  causes 
much  pain  and  photophobia,  syphilitic  iritis  comparatively  little;  there  is  less 
swelling  in  the  first  than  in  the  second;  the  former  tends  to  recur,  the  latter 
does  not.    Iritis  is  usuallv  recovered  from,  sjood  vision  being  retained.    Diffuse 


232  Syphilis 

retinitis  and  disseminated  choroiditis  never  occur  until  a  number  of  months 
have  passed  since  the  infection.  The  symptoms  are  failure  of  sight,  muscae 
vohtantes,  and  very  little  photophobia.  The  diagnosis  of  retinitis  and  cho- 
roiditis is  made  by  the  ophthalmoscope. 

Affections  of  the  Testes. — Syphilitic  Sarcocele. — The  testicle  en- 
larges because  of  plastic  inflammation.  Both  glands  usually  suffer,  but  not 
always.  Fluid  distends  the  tunica  vaginalis.  The  epididymis  escapes.  The 
testicle  is  not  the  seat  of  pain,  is  troublesome  because  of  its  weight,  and  has 
very  little  of  the  proper  sensation  on  squeezing.  The  plastic  exudate  is  gen- 
erally largely  absorbed,  but  it  may  organize  into  iibrous  tissue,  the  organ 
passing  into  atrophic  cirrhosis. 

Intermediate  Period. — Secondary  lesions  cease  to  appear  in  from 
eighteen  months  to  three  years.  In  the  intermediate  period  no  symptoms 
may  appear,  but  the  disease  is  still  for  some  time  latent  and  is  not  cured. 
Symptoms  may  arise  from  time  to  time.  These  symptoms,  which  are 
called  "reminders,"  are  not  so  severe  as  tertiary  symptoms,  are  apt  to  be 
symmetrical,  and  do  not  closely  resemble  secondary  lesions.  Among  the 
reminders  we  may  name  palmar  psoriasis  and  sarcocele.  Sarcocele  in  this 
stage  is  bilateral  and  rarely  painful.  Bilateral  indolent  epididymitis  occa- 
sionally occurs.  Sores  on  the  tongue,  a  papular  skin-eruption,  and  choroiditis 
may  arise.  Gummata  occasionally  occur  in  this  stage,  but  they  are  apt  to  be 
symmetrical  and  non-persistent.  Arteritis  may  occur,  beginning  in  the  intima 
or  adventitia,  and  causing,  it  may  be,  aneurysm,  thrombosis,  or  embolism. 
Obhterative  endarteritis  may  cause  gangrene.  Vascular  changes  are  notably 
common  in  the  vessels  of  the  brain,  and  thrombosis  may  occur,  in  which  case 
paralysis  comes  on  gradually,  preceded  by  numbness,  although  sudden 
paralysis  may  take  place.  These  paralyses  may  be  limited,  extensive,  transi- 
tory, or  permanent.  The  nervous  system  often  suffers  in  this  stage  (anesthetic 
areas  and  retinitis).  The  viscera  are  often  congested  and  infiltrated  (tonsils, 
liver,  spleen,  kidneys,  and  lungs). 

Tertiary  SyphiUs. — This  stage  is  not  often  reached,  the  disease  being 
cured  before  it  has  been  attained.  It  is  not  so  much  a  stage  of  syphilis  as  a  con- 
dition of  impaired  nutrition  which  results  from  the  disease.  This  view  finds 
confirmation  in  the  fact  that  tertiary  lesions  do  not  furnish  the  contagion. 
The  primary  stage  disappears  without  treatment,  the  secondary  stage  tends 
ultimately  to  spontaneous  disappearance,  but  tertiary  lesions  tend  to  persist 
and  to  recur.  Tertiary  lesions  may  be  single  or  may  be  widely  scattered; 
when  multiple  they  are  not  symmetrical  except  by  accident.  These  lesions 
may  attack  any  tissue,  even  after  many  years  of  apparent  cure;  they  all  tend 
to  spread  locally,  they  all  leave  permanent  atrophy  or  thickening,  they  all  tend 
to  relapse,  and  a  local  influence  is  often  an  exciting  cause. 

Tertiary  skin-eruptions  are  liable  to  ulcerate.  Various  eruptions  may 
occur:  papular  syphilides,  pustular  syphilides,  gummatous  syphilides,  ser- 
piginous syphilides,  and  pigmentary  syphilides.  The  characteristic  syphilide 
is  nipia,  which  is  formed  by  a  pustule  rupturing  or  a  papule  ulcerating.  A 
brown  or  black  crust  forms  because  of  the  drying  of  the  discharge,  ulceration 
continues  under  the  crust,  new  crusts  form,  and,  as  the  ulcer  is  constantly 
increa.sing  peripherally,  the  new  crusts  are  larger  in  diameter  than  the  old 
ones,  and  the  mass  assumes  the  form  of  a  cone.     An  ulcer  which  has  destroyed 


Various   Lesions  233 

the  deeper  layers  of  the  skin  is  exposed  by  tearing  off  the  crust.  On  healing 
a  rupial  ulcer  always  leaves  a  permanent  scar. 

Serpiginous  ulcers  are  common  in  tertiary  syphilis,  and  are  especially 
common  about  the  knees,  nostrils,  forehead,  and  Hps.  Serpiginous  ulceration 
is  spoken  of  as  syphihtic  lupus.  It  is  preceded  by  a  widespread,  brown- 
colored  nodular  cutaneous  infiltration.  The  nodules  suppurate,  run  together, 
crust,  and  produce  an  ulcer  which  spreads  rapidly  and  assumes  the  shape  of 
a  horseshoe. 

The  Gumma. — The  gumma  is  the  typical  tertiary  lesion.  In  some  cases 
there  is  a  solitary  gumma;  in  others,  two  or  three  or  even  many  gummata. 
A  gumma  is  a  mass  of  granulation  tissue,  grayish-yellow  in  color,  containing 
many  cells  and  few  fibers.  Organization  of  the  gumma  fails  to  take  place 
because  of  a  want  of  sufficient  blood-supply,  the  cellular  mass  is  apt  to  undergo 
caseation,  and  when  this  occurs  an  ulcer  forms.  One  portion  of  the 
mass  may  caseate,  another  portion  may  become  fibrous.  In  some  cases  the 
entire  gumma  becomes  fibrous.  A  gumma  varies  in  diameter  from  one- 
eighth  of  an  inch  to  two  or  three  inches,  presents  a  center  of  gummy  degen- 
eration, a  surrounding  area  of  immature  fibrous  tissue,  and  an  outer  zone  of 
embryonic  tissue  and  leukocytes.  .A.  gumma,  when  it  is  spontaneously 
evacuated,  exhibits  a  small  opening  or  many  openings  with  very  thin  red  and 
undermined  edges;  the  ulcer  is  slow  to  heal,  and  forms  a  thin  scar,  white  in 
the  center,  but  pigmented  at  the  margins  and  usually  depressed  (Jonathan 
Hutchinson,  Jr.).  The  gummatous  ulcer  is  deep,  circular  in  outline,  with 
undermined  edges  and  an  uneven  floor  covered  with  a  thick,  white,  adherent 
slough.  Sometimes  there  is  no  slough,  but  an  extensive  area  is  infiltrated. 
A  gummatous  ulcer  may  coalesce  with  one  or  more  adjacent  ulcers.  The 
discharge  is  scanty  and  tenacious.  These  ulcers  are  often  seen  upon  the 
legs,  and  when  once  healed  rarely  recur.  A  gumma  in  the  internal  organs 
may  become  a  fibrous  mass.  Gummata  form  in  the  skin,  subcutaneous 
tissues,  muscles,  tongue,  joints,  bursae,  testes,  spinal  cord,  brain,  and  internal 
organs.  In  tertiary  syphilis  an  inflammation  may  not  form  a  circumscribed 
gumma,  but,  instead,  may  produce  a  diffuse  degenerating  mass.  This  type 
of  inflammation,  which  is  seen  in  bones,  is  called  "gummatous.''  A  healing 
gumma  in  a  mucous  canal  such  as  the  rectum  or  larynx  causes  thickening 
and  stricture.  Tertiary  syphilis  is  a  common  cause  of  amyloid  degeneration 
and  the  most  frequent  cause  of  arterial  and  nervous  sclerosis. 

Various  Lesions. — Hutchinson  enumerates  the  lesions  of  tertiary  syphihs 
as  follows:  Periostitis,  forming  nodes  or  causing  sclerotic  hypertrophy,  or 
suppuration,  or  necrosis;  gummata  in  various  parts;  disease  of  the  skin  of  the 
type  of  rupia  or  lupus;  gumma  or  inflammation  of  the  tongue,  causing  scle- 
rosis; structural  changes  in  the  nervous  system,  causing  ataxia,  ophthalmo- 
plegia externa  and  interna,  general  paresis,  optic  atrophy,  and  paralyses  of 
cerebral  nerves;  amyloid  degenerations;  and  chronic  inflammation  of  certain 
mucous  membranes  (of  the  mouth,  pharynx,  vagina,  rectum,  etc.).  with  thick- 
ening and  ulceration.  Gummatous  osteoperiostitis  of  the  vertebras  may 
arise,  and  this  may  be  associated  with  disease  of  the  membranes  or  cord. 
Syphilitic  inflammation  of  vertebrae  is  called  syphilitic  spondylitis.  Unilateral 
enlargement  of  the  epididymis  is  sometimes  noted,  the  mass  feeling  heavy, 
achins:  a  little,  but  not  beins  verv  tender.     Unilateral  sarcocele  mav  be  met. 


234  Syphilis 

Visceral  Syphilis. — Amyloid  changes  may  occur  in  any  of  the  viscera  of 
an  individual  with  tertiary  syphilis,  and  such  changes  may  be  found  in  people 
in  whom  suppuration  never  occurred.  The  lungs  may  undergo  fibroid 
induration  (syphilitic  phthisis).  Syphilitic  phthisis  is  a  non-febrile  malady. 
Gummata  may  form  in  the  heart,  liver,  spleen,  or  kidneys.  The  capsule  and 
fibrous  septa  of  the  liver  may  thicken,  the  organ  being  puckered  by  contrac- 
tion. Albuminuria  may  occur  in  tertiary  syphilis.  It  may  be  caused  by 
fibroid  changes  in  the  kidneys,  by  the  formation  of  gummata,  or  by  amyloid 
degeneration.  Its  occurrence  should  be  watched  for.  Mercury  and  iodid 
of  potassium  have  been  regarded  as  causative  of  albuminuria  in  some  cases. 

Syphilis  may  cause  disease  of  the  stomach,  and  probably  does  so  more 
frequently  than  was  formerly  supposed,  because  it  is  difficult  to  distinguish 
from  more  common  diseases.  The  condition  may  be  gummatous  infiltration 
of  the  walls  of  the  stomach,  multiple  and  minute  gummata,  ulcerations  re- 
sulting from  breaking  down  of  gummata,  or  syphilitic  endarteritis  of  the 
gastric  vessels.  When  ulcers  heal  cicatricial  contraction  results.  Syphilitic 
ulcers  and  gummata  of  the  stomach  may  be  cured  by  efficient  antisyphilitic 
treatment.     Like  lesions  may  form  in  the  intestines. 

Flexner,  Mracek,  Frankel,  Fournier,  and  others  have  discussed  this  sub- 
ject.* 

Nervous  syphilis  may  be  manifested  by  disorders  of  the  brain,  cord,  or 
nerves.  It  is  rare  after  severe  secondaries,  and  is  most  common  when  sec- 
ondaries were  light  or  so  trivial  as  to  have  escaped  observation.  Severe 
secondaries  seem  to  cast  off,  mitigate,  or  exhaust  the  poison.  Nervous  syph- 
ilis may  result  directly  from  the  specific  disease,  and  such  lesions  are  truly 
syphilitic.  It  may  result  indirectly  from  the  specific  disease,  and  such  lesions 
are  called  parasyphilitic.  For  instance,  a  gumma  of  the  brain  is  a  true  syphil- 
itic lesion,  but  locomotor  ataxia  following  syphihs  is  a  parasyphilitic  lesion. 
Syphilitic  lesions  are  improved  or  cured  by  antisyphilitic  treatment,  para- 
syphilitic conditions  are  not.  Brain  syphilis  is  usually  a  late  phenomenon 
(from  one  to  thirty  years  after  infection).  The  lesion  may  be  gumma  of  the 
membranes  (tumor),  gummatous  meningitis,  arterial  atheroma,  or  obliterative 
endarteritis.  A  gumma  may  eventuate  in  a  scar,  a  cyst,  or  a  calcareous  mass. 
The  symptoms  of  brain  syphilis  depend  on  the  nature,  seat,  and  rate  of  devel- 
opment of  the  lesions.  It  is  to  be  noted  that  syphilitic  palsy  is  apt  to  be  limited, 
progressive,  and  incomplete.  Epilepsy  appearing  after  the  thirtieth  year  is 
very  probably  specific  if  alcohol  as  a  cause  can  be  ruled  out.  Persistent  head- 
ache, tremor,  insomnia  or  somnolence,  transitory,  limited,  and  erratic  palsies, 
unnatural  slowness  of  utterance,  amnesia,  vertigo,  and  epilepsy  are  very 
suggestive  of  syphihs.  Sudden  ptosis  is  very  significant;  so  is  sudden  palsy 
of  one  or  more  of  the  extrinsic  eye-muscles.  In  syphilitic  insomnia  the  patient 
cannot  get  to  sleep  at  night  for  a  long  while,  but  when  he  once  gets  to  sleep  he 
reposes  well.  The  type  of  insanity  which  is  most  apt  to  arise  is  a  likeness  or 
counterpart  of  general  paralysis,  and,  like  ordinary  paresis,  it  is  not  curable. 
Spinal  syphilis  may  cause  sclerosis,  a  condition  like  Landry's  paralysis, 
softening,  and  tumor.  Neuritis  is  not  uncommon  in  syphilis.  Many  of  the 
diseases  which  follow  syphilis  are  due  to  it  only  indirectly,  and  are  not  bene- 
fited by  specific  treatment.     Among  them  are  paresis  and  locomotor  ataxia. 

*See  editorial  in  Jour.  Ainc-r.  Med.  A.ssoc,  March  24,  1900. 


Treatment  235 

Justus's  Test  for  Syphilis. — The  test  consists  in  first  estimating  the 
amount  of  hemoglobin  present,  then  making  a  single  mercurial  inunction, 
and  again  estimating  the  hemoglobin.  It  is  claimed  that  the  corpuscles  of 
an  untreated  syphilitic  are  unduly  sensitive,  and  if  the  disease  is  present  a 
mercurial  inunction  will  cause  a  loss  of  10  to  20  per  cent,  of  hemoglobin 
within  twenty-four  hours,  which  fall  persists  for  a  few  hours  and  is  then  fol- 
lowed by  a  rise  to  a  level  above  that  which  e.xisted  when  the  test  was  applied. 
The  absolute  value  of  this  test  is  doubtful.  It  is  often  demonstrable  in  sec- 
ondarv,  tertiary,  or  congenital  syphilis.  It  usually  fails  in  latent  ca.ses  and 
in  earlv  secondarv  svphilis,  and  in  some  diseases  other  than  syphilis  the  reac- 
tion can  be  obtained. 

Treatment  of  the  Primary  Stage. — A  chancre  should  not  be  excised. 
The  disease  is  constitutional  when  the  chancre  appears,  and  excision  and 
cauterization  inflict  needless  pain  and  do  no  good.  The  initial  lesion  should 
never  be  cauterized  unless  it  is  phagedenic  or  becoming  so.  Order  the  patient 
to  soak  the  penis  for  five  minutes  twice  daily  in  warm  salt  water  (a  teaspoonful 
of  salt  to  a  cupful  of  water),  and  then  to  spray  the  sore  with  peroxid  of  hydro- 
gen diluted  with  an  equal  bulk  of  water.  The  ulcer  is  then  dried  with  ab- 
.sorbent  cotton  and  on  it  is  dusted  a  powder  composed  of  equal  parts 
of  bismuth  and  calomel.  The  buboes  in  the  groin  require  no  local  treat- 
ment unless  they  tend  to  suppurate.  If  they  persist  or  become  large, 
paint  them  with  iodin  or  rub  ichthyol  ointment  or  mercurial  ointment 
into  them,  and  apply  a  spica  bandage  to  the  groin.  Some  authorities 
give  mercury  in  this  stage,  in  order  to  prevent  secondaries.  The  younger 
Gross  opposed  this  strongly,  and  affirmed  a  wish  to  see  the  secondary  erup- 
tion— first,  because  it  proves  the  diagnosis;  and,  second,  because  it  affords 
valuable  prognostic  indications  (an  erythematous  eruption  means  a  light  case, 
an  earl\-  pustular  eruption  means  a  grave  case  with  serious  complications) ; 
I  have  always  followed  the  plan  of  Gross,  and  do  not  order  mercury  until 
constitutional  symptoms  develop.  If  phagedena  arises,  place  the  patient  at 
once  upon  stimulants  and  nutritious  diet,  secure  sleep,  and  destroy  the  ulcer 
bv  the  use  of  nitric  acid  or  the  cautery  while  the  patient  is  anesthetized.  After 
cauterization  dust  the  sore  with  iodoform  and  dress  with  wet  antiseptic 
gauze.  Several  times  a  day  change  the  dressings,  and  at  each  change  spray 
the  sore  with  peroxid  of  hydrogen,  irrigate  with  bichlorid  of  mercury  solu- 
tion, and  dust  with  iodoform.  It  may  be  necessary  to  cauterize  several  times. 
In  some  cases  it  will  be  necessary  to  employ  continuous  irrigation  with  an 
antiseptic  fluid.  These  cases  are  sometimes  fatal  and  usually  produce 
great  destruction  of  tissue.  In  chancre  redux  watch  carefully  for  the  de- 
velopment of  symptoms,  in  order  to  determine  if  the  condition  is  really  one 
of  reinfection  or  if  we  are  dealing  with  a  gumma  which  resembles  a  chancre 
in  appearance. 

Treatment  of  theSecondary  Stage.— The  chance  of  cure  in  most  cases 
is  excellent  if  the  patient  follows  advice.  The  prognosis  is  much  worse  if  the 
patient  is  a  hard  drinker  or  is  the  victim  of  Bright's  disease,  diabetes,  tuber- 
culosis, or  any  other  chronic  exhausting  malady.  In  the  secondary  stage  the 
aim  is  to  cure  the  disease.  That  it  can  be  cured  is  known  from  the  fact  that 
reinfection  occurs  in  some  persons.  The  old  axiom,  "Syphilis  once,  syphilis 
ever,"  is  not  true. 


236  Syphilis 

Diet  and  General  Care. — In  the  beginning  of  treatment  the  patient  must 
see  his  physician  every  day  or  two  until  the  proper  dose  of  mercury  has  been 
ascertained.  For  the  following  six  months  he  should  see  his  physician  once 
a  week,  and  during  the  next  six  months  once  every  other  week.  During  the 
second  year  he  needs  to  see  him  once  every  month.  Of  course,  if  complica- 
tions arise  at  any  period  the  visits  must  be  more  frequent.  At  the  beginning 
of  the  attack  he  must  have  his  teeth  put  in  perfect  order.  Tobacco  is  abso- 
lutely forbidden  because  its  use  favors  the  development  of  mucous  patches  in 
the  mouth.  Alcohol  as  a  beverage  is  prohibited.  It  is  used  only  as  a  medi- 
cine. The  teeth  should  be  gently  scrubbed  with  a  soft  brush  in  the  morning, 
in  the  evening,  and  after  each  meal,  and  a  mild  astringent  or  antiseptic  mouth- 
wash is  to  be  used  several  times  a  day.  The  patient  should  wear  flannel  in 
winter.  The  author  believes  Guiteras's  rules  are  sound,  and  in  accordance 
with  them  directs  the  patient  to  refrain  from  kissing  any  one  on  the  lips  and 
from  using  a  common  towel,  wash-rag,  cup  or  glass,  pipe  or  razor.  He  is  told 
to  sleep  alone  in  bed,  to  wash  his  hands  often,  to  wear  gloves,  and  to  keep  his 
fingers  out  of  his  mouth.  Every  morning  he  should  take  a  warm  bath,  being 
especially  careful  to  cleanse  the  anus,  perineum,  axillae,  groins,  and  between 
the  toes;  and  after  the  bath  these  parts  should  be  dusted  with  borated  talc 
powder.  A  Turkish  bath  once  a  week  is  ordered  by  Guiteras  when  no  skin- 
eruption  exists.  The  patient  must  avoid  drafts,  cold  and  wet ;  must  take  a 
moderate  amount  of  gentle  outdoor  exercise,  and  must  sleep  eight  hours  out  of 
the  twenty-four.  The  diet  is  of  importance,  and  in  this,  too,  the  author  fol- 
lows Guiteras  and  orders  the  patient  to  avoid  eating  anything  fried,  or  any 
meat  or  fish  which  has  been  canned,  salted,  or  preserved.  Fruits,  pickles, 
tea,  condiments,  alcoholic  beverages,  clams,  pork,  veal,  and  pastry  are  not  to 
be  taken.  (See  article  by  Luke  Begg  in  "  Phila.  Med.  Jour.,"  June  7, 
1901.) 

Medical  Treatment. — Mercury  must  be  used,  the  form  being  a  matter 
of  choice.  Fournier  advocated  intermittent  treatment.  In  this  plan  give 
gr.  J  of  protiodid  of  mercury  daily  for  six  months,  then  stop  for  a  month; 
then  give  mercury  for  three  months,  then  stop  two  months.  During  the  first 
year  the  patient  is  under  treatment  nine  months,  and  during  the  second  year 
eight  months.  Some  prefer  the  intermittent  and  others  the  continuous  plan 
of  treatment.  The  author  prefers  the  continuous  plan.  In  following  the 
continuous  plan  find  the  patient's  tolerance  to  mercury,  and  keep  him  for  two 
years  on  daily  doses  below  the  amount  he  will  tolerate.  Gross's  rule  for  con- 
tinuous treatment  is  to  order  pills  of  green  iodid  of  mercury,  each  pill  con- 
taining gr.  3-.  The  patient  is  ordered  one  pill  after  each  meal  to  begin  with; 
the  next  day  the  after-breakfast  dose  is  increased  to  two  pills;  the  following 
day  the  after-dinner  dose  is  two  pills,  and  so  on,  one  pill  being  added 
every  day.  This  advance  is  continued  until  there  is  slight  diarrhea,  griping, 
a  metallic  taste,  or  tenderness  on  snapping  the  teeth  together,  whereupon  one 
pill  is  taken  off  each  day  until  all  unfavorable  symptoms  disappear.  Then 
the  dose  is  reduced  one-half  and  this  amount  is  called  the  tonic  dose.  This 
experimentation  finds  a  dose  on  which  the  patient  can  be  kept  with  entire 
safety  for  a  long  time;  but  if  it  is  found  that  colic  or  diarrhea  is  apt  to  recur, 
there  must  be  added  to  each  pill  gr.  y^  of  opium.  The  patient  is  given  mer- 
cury in  this  way  for  two  years.     Every  time  new  symptoms  appear  the  dose 


Treatment  237 

is  raised,  and  as  soon  as  they  disappear  it  is  lowered  to  the  standard.  If  the 
protiodid  is  not  tolerated,  give  the  bichlorid: 

R      Hydrarg.  chlor.  corros. ,  gr.  j; 

Syr.  sarsaparilla;  comp.,  fo'y- — •'^^• 

Sig. — f  3  ,  in  water,  after  meals. 

Mercury  with  chalk  in  i-  or  2 -grain  doses  four  times  a  day,  with  or  without 
Dover's  powder  in  i-grain  doses,  may  be  used.  Mercurial  inunctions  pro- 
duce a  rapid  effect,  but  irritate  the  skin.  The  drug  should  be  rubbed  in  with 
a  gloved  hand.  There  can  be  used  once  a  day  ^  dram  of  oleate  of  mercury 
(10  per  cent.)  or  i  dram  of  mercurial  ointment,  rubbed  into  the  skin.  The 
first  day  it  is  rubbed  into  the  inside  of  one  thigh,  the  second  day  into  the  inside 
of  the  other  thigh;  the  third  day  into  the  inside  of  one  arm;  the  fourth  day 
into  the  other  arm;  next,  into  one  groin  and  then  into  the  other  groin,  and  then 
inunction  is  again  made  at  the  point  of  original  application,  and  so  on.  After 
the  rubbing  the  patient  puts  on  underclothes  and  goes  to  bed,  and  in  the 
morning  takes  a  bath.  The  ointment  may  be  smeared  on  a  rag,  which  is  then 
worn  between  the  stocking  and  sole  of  the  foot  during  the  day. 

Fumigation  is  performed  by  volatilizing  each  night  oj  of  calomel.  The 
patient  sits  naked  on  a  cane-seat  chair,  and  is  wrapped  up  to  the  neck  in  a 
blanket  which  drops  tent-like  to  the  floor;  the  calomel  is  put  upon  an  iron 
plate  under  the  chair,  and  is  heated  by  an  alcohol  lamp  beneath  the  plate. 
The  skin  becomes  coated  with  calomel,  and  the  subject,  after  putting  on  woolen 
drawers  and  an  undershirt,  gets  into  bed.  Hypodermatic  injections  of  mer- 
cury are  used  by  some  physicians.  They  cause  an  eruption  to  disappear 
rapidly,  but  may  produce  abscesses,  and  relapses  are  prone  to  occur.  I 
agree  with  Dr.  Orville  Horwitz  that  the  hypodermatic  method  will  not  abort 
the  disease;  should  never  be  a  routine  treatment;  in  suitable  cases  it  is  very 
valuable  for  symptomatic  use,  as  when  lesions  on  the  face  or  in  important 
structures  make  a  rapid  impression  desirable  or  necessary;  in  cases  which  ob- 
stinately relapse  under  other  treatment,  and  in  syphilis  of  the  nervous  system. 
J.  William  White,  after  a  large  experience  with  this  method,  says  that  hypo- 
dermatic injections  of  corrosive  sublimate  are  painful  and  are  strongly  objected 
to  by  many  patients;  that  this  method  of  treatment  is  occasionally  dangerous 
and  even  fatal;  that  it  is  liable  to  be  followed  by  local  complications  (erythema, 
jiodosities,  cellulitis,  abscess,  sloughing) ;  that  it  cannot  be  carried  out  by  the 
patient,  but  requires  the  surgeon's  constant  intervention.  This  syphilographer 
concludes  that  hypodermatic  medication  does  not  offer  advantages  justifying 
its  use  as  a  systematic  method  of  treatment,  and  that  it  encourages  insufficient 
treatment — those  "short  heroic  courses"  which  Hutchinson  shows  are  fol- 
lowed by  the  gravest  tertiary  lesions.  "  The  claim  that  by  a  few  injections 
the  time  of  treatment  can  be  measured  by  months  or  even  by  weeks,  instead 
of  by  years,  would  seem,  as  Mauriac  has  said,  to  involve  the  idea  that  mercury 
given  hypodermatically  acquires  some  new  and  powerful  curative  property 
which,  given  in  other  ways,  it  does  not  possess."  *  The  usual  plan  is  to  give 
daily  a  hypodermatic  injection  of  corrosive  sublimate  deep  into  the  back  or 
buttock,  the  dose  being  gr.  {  of  the  drug.  Thirty  such  injections  are  used 
unless   some   contraindication   demands   their   discontinuance   sooner.     The 

*  J.  William  White,  in  Morrow's  ''  System  of  Genito-urinary  Diseases,  Svphilology,  and 
Dermatolosv. " 


238  Syphilis 

treatment  is  then  stopped.  If  the  symptoms  recur,  however,  the  patient  is 
given  another  course,  the  daily  dosage  being  gr.  ^,  the  treatment  being  again 
stopped  after  thirty  injections,  but  being  continued  anew  in  J-grain  doses  if 
the  symptoms  recur.  The  following  preparation  is  used  by  some  syphilo- 
graphers:  0.5  of  a  part  of  corrosive  subhmate,  3  parts  of  guaiacol,  and  97  parts 
of  sterile  olive  oil.  Thirty  minims  contains  gr.  yq  of  corrosive  sublimate.  This 
mixture  should  be  thrown  deeply  into  the  buttock  and  it  causes  no  pain.  The 
use  of  grav  oil  hypodermatically  has  warm  advocates.  It  is  claimed  that  it 
provokes  but  little  pain  and  irritation,  and  that  it  is  a  very  efficient  remedy. 
The  oil  must  be  warmed  and  shaken  before  being  used.  Lang  injects  gr.  f 
to  gr.  i^  of  the  50  per  cent,  gray  oil,  or  twice  this  quantity  of  the  30  per  cent, 
oil,  twice  during  the  first  week,  once  during  the  second  week,  and  after  this 
once  a  week  or  once  every  other  week  for  an  indefinite  period  of  time.  It  may 
be  given  oftener  if  symptoms  arise  or  persist. 

Taylor  believes  that  gray  oil  may  give  rise  to  unpleasant  and  sometimes 
even  to  dangerous  symptoms,  and  that  it  should  be  used  with  extreme  care  and 
only  in  selected  cases  in  which  other  remedies  are  contraindicated.  He  says 
that  in  reading  about  the  hypodermatic  method  he  has  been  struck  with  the 
fact  that  "  the  most  serious  results  have  almost  invariably  followed  injections 
in  which  fatty  matters  have  been  the  vehicle  of  suspension."  * 

Some  surgeons  employ  intravenous  injections  of  mercury.  Lane  injects, 
at  first  every  other  day  and  later  daily,  20  "I  of  a  i  per  cent,  solution  of  cyanid 
of  mercury.  The  skin  in  front  of  the  elbow  is  rendered  aseptic,  a  fillet  is  tied 
around  the  arm,  the  needle  is  inserted  into  a  vein,  the  fillet  is  loosened,  the 
fluid  is  injected,  and  the  needle  is  withdrawn.  This  method  of  using  mercury 
is  painless  and  produces  a  rapid  effect.  It  may  be  used  in  nervous  .syphilis, 
but  should  not  be  used  as  a  routine.  In  whatever  way  mercury  is  given,  do 
not  allow  it  to  produce  salivation  (hydrargyrism  or  ptyalism).  Always  re- 
member that  mercury  may  cause  albuminuria  and  examine  the  urine  at  regular 
intervals  during  a  course  of  the  drug.  If  albumin  appears  in  the  urine,  cut 
down  the  dose  of  mercury  or  stop  the  drug  for  a  time.  In  the  beginning  of  a 
case  of  svphilis,  if  the  kidneys  are  found  to  be  diseased,  give  the  mercury 
cautiouslv,  and  never  fail  to  examine  the  urine  at  regular  intervals.  An 
individual  can  take  more  mercury  in  summer  than  in  winter  because  during 
the  warm  weather  perspiration  favors  elimination. 

Throughout  the  mercurial  course  the  patient  should  be  weighed  once  a 
week,  and  if  it  is  at  any  time  found  that  the  weight  is  decreasing,  tonics,  con- 
centrated food,  and  cod-liver  oil  are  ordered.  If  the  weight  continues  to 
grow  less  and  the  health  begins  obviously  to  fail,  stop  the  mercury  for  a  time, 
continue  the  cod-liver  oil,  tonics,  and  nourishing  food,  and  order  hot  baths, 
fresh  air,  iron,  and  chlorid  of  gold  and  sodium.  In  order  to  cure  syphilis 
mercury  should  be  given  for  two  years,  and  the  mercurial  course  must  be 
followed  by  at  least  a  six  months'  course  of  iodid  of  potash.  Reminders  re- 
quire both  iodid  of  potash  and  mercury  (mixed  treatment). 

Acute  Ptyalism,  or  Salivation.— In  acute  ptyalism  the  .saliva  Ije- 
comes  thick  and  excessive  in  amount ;  the  gums  become  spongy  and  tender  and 
Hablc  to  bleed.  Tenderness  is  detected  early  by  snapping  the  teeth.  A 
metallic  taste  is  complained  of;  the  breath  becomes  fetid;  the  oral  .structures 

*  "Venereal  Disea.ses,"  by  Robert  W.  Taylor. 


Treatment  of  Complications  in  the  Secondary  Stage  239 

swell;  the  teeth  loosen;  the  saliva  is  produced  in  great  quantity;  and  there  are 
purging,  colic,  and  exhaustion.  Sometimes  there  are  fever  and  a  diffuse 
scarlatiniform  eruption  upon  the  skin.  A  chronic  hydrargyrism  may  be 
shown  by  sahvation,  gastro-intestinal  disorder,  emaciation,  mental  depression, 
weakness,  albuminuria,  and  tremor.  To  avoid  salivation,  advance  the  dose 
with  great  caution  and  instruct  the  patient  as  to  the  first  signs  of  the  trouble. 
He  should  use  a  soft  toothbrush  and  an  astringent  mouth-wash  (gr.  xlviij  of 
boric  acid  to  siv  each  of  Listerine  and  water).  When  ptyalism  is  noted,  dis- 
continue the  administration  of  the  drug.  Employ  the  above  mouth-wash  or 
one  composed  of  a  saturated  solution  of  chlorate  of  potassium.  Order  gr. 
Y^-jj  of  atropin  twice  a  day,  and  in  bad  cases  spray  the  mouth  with  peroxid  of 
hydrogen  and  use  silver  nitrate  locally  (gr.  xx  to  oj)-  Give  stimulants  (iron, 
quinin,  and  strychnin)  and  nutritious  food.  A  weekly  Turkish  bath  is  of 
great  service.  In  chronic  hydrargyrism  stop  the  administration  of  the  drug, 
use  tonics,  stimulants,  open-air  exercise,  Turkish  baths,  and  nutritious  food. 
The  chlorid  of  gold  and  sodium  forms  a  substitute  for  mercury.  The  use  of 
iodid  of  potassium  is  of  questionable  value  in  ptyalism. 

Treatment  of  Complications  in  the  Secondary  Stage. — The  compli- 
cations of  the  secondary  stage  usually  require  local  applications  in  addition 
to  general  remedies.  Mucous  patches  in  the  mouth  should  be  touched  with 
bluestone  every  day,  an  astringent  mouth-wash  bemg  employed  several  times 
daily.  If  the  patches  ulcerate,  they  should  be  touched  once  a  day  with  lunar 
caustic;  if  these  areas  proliferate,  they  should  be  excised  and  cauterized. 
Vegetations  or  growing  papules  on  the  skin  must,  if  calomel  powder  fails  to 
remove  them,  be  cut  away  with  scissors  and  be  cauterized  with  chromic  acid 
or  with  the  Paquelin  cautery.  Condylomata  demand  washing  with  ethereal 
soap  several  times  daily,  thorough  drying,  dusting  with  equal  parts  of  calomel 
and  subnitrate  of  bismuth  or  with  borated  talcum,  and  covering  with  dry 
bichlorid  gauze.     If  these  simple  procedures  fail,  excise  and  cauterize. 

For  psoriasis  of  the  palms  and  soles  diachylon  ointment,  mercurial  plaster, 
or  painting  with  tincture  of  iodin  should  be  employed.  Ulcers  of  paronychia 
are  dressed  with  iodoform  and  corrosive  sublimate  gauze.  Deep  cutaneous 
ulcers  are  cleaned  once  a  day  with  ethereal  soap,  sprayed  with  peroxid  of 
hydrogen,  dressed  with  iodoform  and  corrosive  sublimate  gauze  and  bandaged. 
When  the  process  of  granulation  is  well  established  dress  with  i  part  of  un- 
guent, hydrarg.  nitratis  to  7  parts  of  cosmolin.  In  sarcocele  mercurial  oint- 
ment should  be  rubbed  into  the  skin  of  the  scrotum  or  the  testicle  be  strapped. 
In  alopecia  the  hair  should  be  kept  short,  and  every  night  the  scalp  should  be 
cleaned  with  equal  parts  of  green  soap  and  alcohol  rubbed  into  a  lather  with 
water.  After  the  soap  has  been  washed  out  some  hair  tonic  should  be  rubbed 
into  the  scalp  with  a  sponge.  A  favorite  preparation  of  Erasmus  Wilson's 
consisted  of  the  following  ingredients: 

K  .      01.  amygd.  dil., 

Liq.  animoniEe,  da  f5J; 

Sp.  rosemarini, 

Aquae  mellis,  aa  f^iij. — M. 

Ft.  lotio. 

One  part  of  tincture  of  cantharides  to  8  parts  of  castor  oil  ma}'  be  rubbed  into 
the  scalp.     Solutions  of  quinin  are  esteemed  by  some.     A  useful  wash  for  the 


240  Syphilis 

scalp  is  the  following:  oj  of  borate  of  sodium,  oj  of  spirits  of  camphor,  Hi] 
of  glycerin,  and  sufficient  orange-fiower  water  to  make  foiv. 

In  treating  persistent  skin-lesions,  inunctions,  injections,  fumigations,  or 
mercurial  baths  may  be  used.  Baths  are  suited  to  patients  with  dehcate  skins, 
to  those  whose  digestion  fails  when  mercury  is  given  by  the  mouth,  and  to 
those  whose  lungs  will  not  tolerate  fumigations.  Half  an  ounce  of  corrosive 
sublimate  with  4  scruples  of  sal  ammoniac  are  mixed  in  about  4  ounces  of 
water;  this  is  added  to  a  bath  at  a  temperature  of  95°  F.  The  patient  gets 
into  this  bath,  covers  the  tub  with  a  blanket,  leaving  only  his  head  exposed, 
and  remains  in  the  bath  an  hour  or  so.  Mercurial  baths  may  rapidly  cause 
sahvation. 

Tertiary  Stage. — If  at  any  time  during  the  case  there  appear  tertiary 
symptoms,  the  patient  should  be  put  on  mixed  treatment.  In  any  case,  after 
two  years  of  mercury  add  iodid  of  potassium  to  the  treatment.  White's  rule 
is  to  use  mixed  treatment  for  at  least  six  months  (if  any  symptoms  appear), 
the  six  months'  course  dating  from  their  disappearance.  This  emphasizes 
the  fact  that  the  iodids  alone  will  not  cure  tertiary  syphilis.  In  obstinate 
tertiary  lesions  and  in  nervous  syphilis  the  iodids  should  be  run  up  to  an 
enormous  amount  (from  30  to  250  grains  per  day).  Sometimes  people  can 
take  large  doses  of  iodid  when  small  doses  produce  iodism.  Cyon  explains 
this  curious  fact  as  follows:  small  doses  combine  with  some  products  of  the 
thyroid  gland  and  form  toxic  iodo-thyrin.  Large  doses  are  diuretic,  form 
soluble  salts,  and  are  rapidly  eliminated.  An  easy  way  to  give  iodid  is  to  order 
a  saturated  solution  each  drop  of  which  equals  about  one  grain  of  the  drug. 
Each  dose  of  the  iodid  is  given  one  hour  after  meals  and  in  at  least  half  a  glass 
of  water.  If  the  iodid  disagrees,  it  may  be  given  in  water  containing  one  dram 
of  aromatic  spirit  of  ammonia  or  in  milk.  The  iodid  of  sodium  may  be 
tolerated  better  than  the  potassium  salt,  or  the  iodids  of  sodium,  potassium, 
and  ammonium  may  be  combined.  In  giving  the  iodids  begin  with  a  small 
dose.  During  a  course  of  the  iodid  always  give  tonics  and  insist  on  plenty  of 
fresh  air.  Arsenic  given  daily  tends  to  prevent  skin-eruptions.  The  iodids 
when  they  disagree  produce  iodism — a  condition  which  is  made  manifest  by  a 
flow  of  mucus  from  the  nose,  conjunctival  irritation,  a  bad  taste  in  the  mouth, 
exhaustion,  anorexia,  nausea,  and  tremor.  In  some  subjects  there  are  out- 
breaks of  acne,  vesicular  eruptions,  or  even  bullae  or  hemorrhages.  Iodism 
calls  for  the  abandonment  of  the  drug,  and  the  administration  of  increasing 
doses  of  Fowler's  solution,  of  arsenic,  of  laxatives,  of  diuretic  waters,  or,  if 
there  is  great  exhaustion,  of  stimulants.  In  some  cases  belladonna  is  of 
service.  Some  patients  who  cannot  take  the  alkaline  iodids  may  take  syrup 
of  hydriodic  acid.  After  the  patient  has  been  for  six  months  under  mixed 
treatment  without  a  symptom,  stop  all  treatment  and  await  developments. 
If  during  one  year  no  symptoms  recur,  the  patient  is  probably  cured;  if  symp- 
toms do  recur,  there  must  be  six  months  more  of  treatment  and  another  year  of 
watching. 

The  Question  oj  Marriage. — Fournier  has  insisted  that  it  is  a  great  wrong 
to  tell  a  syphilitic  that  he  can  never  marry.  He  must  not  marry  until  he  is 
cured,  and  he  is  not  cured  until,  after  the  cessation  of  the  use  of  iodid,  he  goes 
one  year  without  treatment  and  without  symptoms. 


Hereditary  Syphilis  241 

Hereditary  Syphilis. — Transmitted  congenital  syphilis  is  heredi- 
tary syphilis  manifest  at  birth.  Acquired  syphilis  (except  in  the  case  of  a 
woman  who  obtains  the  disease  from  a  fetus)  always  presents  the  chancre  as 
an  initial  lesion;  hereditary  syphihs  never  does.  Hereditary  syphilis  may 
present  itself  at  birth,  and  usually  shows  itself  within,  at  most,  the  first  six 
months  of  extra-uterine  Hfe.  In  rare  cases  (tardy  hereditary  syphilis)  the 
disease  does  not  become  manifest  until  puberty. 

Rules  oj  Inheritance. — According  to  von  Zeissl,*  the  rules  of  inheritance  are 
as  follows: 

1.  If  one  parent  is  syphilitic  at  the  time  of  procreation,  the  child  may  be 
syphilitic. 

2.  Syphilitic  parents  may  bring  forth  healthy  children. 

3.  If  a  mother,  healthy  at  procreation,  bears  a  child  syphilitic  from  the 
father,  the  mother  must  have  latent  pox  or  must  be  immune,  having  become 
infected  through  the  placental  circulation.  She  often  shows  no  symptoms, 
having  received  the  poison  gradually  in  the  blood,  and  having  thus  received, 
it  may  be  said,  preventive  inoculations.  Certain  it  is  that  mothers  are  almost 
never  infected  by  suckling  their  syphilitic  children  (Colles's  law). 

4.  If  both  parents  were  healthy  at  the  time  of  procreation,  and  the  mother 
afterward  contracts  syphihs,  the  child  may  become  syphihtic,  and  the  earlier 
in  the  pregnancy  the  mother  is  diseased,  the  more  certain  is  the  child  to  be 
tainted.     This  is  known  as  "infection  in  utero.'" 

5.  The  more  recent  the  parental  syphilis,  the  more  certain  is  infection  of 
the  offspring.     The  children  are  often  stillborn. 

6.  When  the  disease  is  latent  in  the  parents  it  is  apt  to  be  tardy  in  the 
children. 

7.  The  longer  the  time  which  has  passed  since  the  disappearance  of 
parental  symptoms,  the  more  improbable  is  infection  of  the  children. 

8.  In  most  instances  parental  syphihs  grows  weaker,  and  after  the  parents 
beget  some  tainted  children  they  bring  forth  healthy  ones. 

Syphilis  in  the  mother  is  more  dangerous  to  the  offspring  than  syphilis  in 
the  father.  The  frequent  immunity  of  the  mother  is  due  to  the  fact  that  her 
tissues  produce  antitoxins  under  the  influence  of  the  slowly  absorbed  virus. 

Many  women  aft'ected  with  hereditary  syphilis  are  sterile.  Many  syph- 
ilitic women  abort  before  the  eighth  month,  most  commonl}-  in  the  fifth 
month.  The  fetus  very  often  dies  at  an  early  period  of  gestation.  This  may 
be  due  to  a  gummatous  placenta  or  to  a  degeneration  of  placental  follicles. 

Evidences  oj  Hereditary  Syphilis  (manifest  at,  or  oftener  soon  after,  birth). 
— Hutchinson  says  that  at  birth  the  skin  is  almost  invariably  clear.  In  from 
six  to  eight  weeks  "  snuffles"  begin,  which  are  soon  followed  by  a  skin-eruption, 
by  body-wasting,  and  by  a  chain  of  secondary  symptoms  (iritis,  mucous 
patches,  pains,  condylomata,  etc.).  The  child  looks  like  a  withered-up  old 
man.  Eruptions  are  met  with  on  the  palms  and  soles.  Intertrigo  is  usual. 
Cracks  occur  at  the  angles  of  the  mouth,  and  leave  permanent  radiating  scars. 
The  abdomen  is  tumid,  and  there  is  apt  to  be  exhausting  diarrhea.  The 
secreting  and  absorbing  glands  of  the  intestinal  tract  atrophy. f  It  is  doubtful 
if  distinct  gummatous  tumors  form  in  hereditary  syphilis.     The  type  of  dis- 

*  "  Pathology  and  Treatment  of  Syphilis." 
I  Coutts,  in  Brit.  Med.  Jour.,  1894,  No.  1643. 

16 


242  Syphilis 

ease  induced  is  a  diffuse  interstitial  cellular  change  in  the  viscera,  and  the 
viscera  are  much  more  apt  to  suffer  than  in  acquired  syphilis.  The  liver, 
spleen,  and  pancreas  often  enlarge  from  interstitial  changes,  and  the  lungs 
sometimes  are  attacked  in  the  same  manner.  Sometimes  synovitis  or  arthritis 
arises.  Atrophic  lesions  may  appear  in  the  bones.  In  the  skull  the  bone  may 
be  softened  by  removal  of  its  salts  or  be  thinned  by  the  pressure  of  the  brain. 
In  the  long  bones  the  epiphyseal  lines  suffer,  the  attachment  of  the  epiphyses 
to  the  shafts  is  weak,  and  separation  is  easily  induced.  Epiphysitis  is  com- 
mon, rarely  causes  pain,  and  rarely  leads  to  suppuration,  except  in  children 
who  are  old  enough  to  walk  (Coutts).  Osteophytic  lesions  of  the  skull  are 
shown  by  symmetrical  spots  of  thickening  upon  the  parietal  and  frontal  bones 
(natiform  skulls).  In  the  long  bones  osteophytes  are  frequently  formed.  A 
child  with  precocious  hereditary  syphihs  is  apt  to  die,  but  if  it  lives  from  six 
months  to  one  year  the  symptoms  for  a  time  disappear,  and  for  years  the  dis- 
ease may  be  latent.  Diagnosis  is  difficult  after  the  third  or  fourth  year,  espe- 
cially if  the  disease  be  associated  with  rickets  or  tuberculosis.  When  later 
symptoms  arise  they  may  be  various,  namely:  noises  in  the  ears,  often  fol- 
lowed by  deafness;  interstitial  keratitis;  dactyhtis  (speciiic  inflammation  of 
all  the  structures  of  a  finger) ;  synovitis  in  any  joint;  ossifying  nodes;  develop- 
mental osseous  defects;  suppurative  periostitis;  ulcerations;  death  of  bone; 
falling  in  of  the  nose;  nervous  maladies;  occasionally  sarcocele,  etc.  In 
hereditary  syphilis  the  eye-symptoms  are  of  great  diagnostic  importance.  In 
212  cases  of  congenital  syphilis  Fournier  found  eye-trouble  in  loi.  Keratitis 
and  choroiditis  are  the  most  usual  forms  (Silex).  Bone-trouble  occurs  in 
almost  half  of  the  cases,  but  is  not  often  severe  enough  to  cause  symptoms. 
The  tongue  often  shows  a  smooth  base  (Virchow's  sign).  Hirschberg  be- 
lieved choroiditis  to  be  pathognomonic.  The  descendants  of  syphihtic 
parents  may  exhibit  certain  pathological  conditions  which  are  not  directly 
syphilitic.  Fournier  calls  such  phenomena  parasyphilitic.  Among  these 
phenomena  are  arrest  of  development  of  the  body  at  large  or  of  special  struc- 
tures, weakness  of  constitution,  and  stigmata  of  degeneration. 

Diagnosis. — In  the  diagnosis  of  hereditary  syphilis  the  condition  of  the 
teeth  is  of  considerable  importance:  the  temporary  teeth  decay  soon,  but 
present  no  characteristic  defect.  If  the  upper  permanent  central  incisors  are 
examined,  they  are  often,  but  by  no  means  always,  found  defective.     Other 

teeth  may  show  defects,  but  in  these  alone 
arc  characteristic  defects  likely  to  appear. 
In  hereditary  syphilis  they  may  present  an 
ap])earance  of  marked  deviation  from  health, 
and  are  then  called  "Hutchinson  teeth"  (Fig. 
FiK.  s.^.— iiutriiinson  uetii.  ^^)       jf  ihgy  are  dwarfed,  too  short  and  too 

narrow,  and  if  they  display  a  single  central 
cleft  in  their  free  edge,  then  the  diagnosis  of  syphilis  is  probable.  If  the 
cleft  is  jjresent  and  the  dwarfing  absent,  or  if  the  peculiar  form  of  dwarf- 
ing be  present  without  any  conspicuous  cleft,  the  diagnosis  may  still  be  made. 
The  view  that  teeth  of  this  nature  prove  the  existence  of  hereditary  syphilis 
and  that  they  (Kxur  only  in  syphilis  has  been  abandoned  by  Hutchinson  him- 
self. In  fact,  only  one-fifth  of  congenital  syphiiitics  have  these  teeth,  and 
one-third  of  the  cases  of  Hutchinson  teeth  arc  in  indixiduals  free  from  .'^yjihilis. 


Treatment  of  Hereditary  Syphilis  243 

In  early  infancy  the  diagnosis  of  syphiHs  is  made  Idv  the  snuffles,  the  broad 
nose,  the  skin-eruptions,  the  wasted  appearance,  the  .sores  at  the  mouth- 
angles,  the  tenderness  over  bones,  condylomata,  and  the  history  of  the  parents. 
The  diagnosis  at  a  later  period  is  made  by  the  existence  of  symmetrical  in- 
terstitial keratitis,  choroiditis,  the  smooth  base  of  the  tongue,  deafness  which 
comes  on  without  pain  or  running  from  the  ear,  ossifying  nodes,  white  radiat- 
ing scars  about  the  mouth-angles,  sunken  nose,  natiform  skull,  deformity  of 
long  bones,  painless  inflammation  of  epiphyses,  and  Hutchinson  teeth.  It 
must  be  remembered  that  a  child  born  apparently  healthy  and  presenting 
no  secondary  symptoms  may  show  bone-disease,  keratitis,  or  syphilitic  deaf- 
ness at  puberty. 

Treatment. — In  infants  mercurial  inunctions  are  to  be  used  until  the 
symptoms  disappear,  but  mercury  must  not  be  forced  or  be  continued  too  long 
after  the  symptoms  are  gone.  There  must  be  rubbed  into  the  sole  of  each 
foot  or  the  palm  of  each  hand  5  grains  of  mercurial  ointment  every  morning 
and  night.  Brodie  advised  spreading  the  ointment  (in  the  strength  of  ^j  to 
the  ounce)  upon  flannel  and  fastening  it  around  the  child's  belly.  If  the  skin 
is  so  tender  that  mercury  must  be  administered  by  the  mouth,  order  that  gr.  ^2- 
to  gr.  ^  of  mercury  with  chalk,  with  i  grain  of  sugar,  be  taken  three  times  a 
day  after  nursing.  If  tertiary  symptoms  appear,  and  in  any  case  when  the 
secondaries  disappear,  give  gr.  ss  to  gr.  j  or  more  of  iodid  of  potassium  several 
times  a  day  in  syrup.  White  advocates  the  continuance  of  the  mixed  treat- 
ment intermittently  until  puberty.  Local  lesions  require  local  treatment, 
as  in  the  adult.  A  syphilitic  child  must  be  nursed  by  its  mother,  as  it  will 
poison  a  healthy  nurse.  If  the  baby  has  a  sore  mouth,  it  must  be  fed  from  a 
bottle;  and  if  the  mother  cannot  nurse  the  child,  it  must  be  brought  up  on 
the  bottle.  For  the  cachexia  use  cod-liver  oil,  iodid  of  iron,  arsenic,  and  the 
phosphates. 


244  Tumors   or   Morbid   Growths 


XVII.  TUMORS  OR  MORBID  GROWTHS. 

Division. — Morbid  growths  are  divided  into  (i)  neoplasms  and  (2) 
cysts. 

Neoplasms. — A  neoplasm  is  a  pathological  new  growth  which  tends  to 
persist  independently  of  the  structures  in  which  it  lies,  and  which  performs 
no  physiological  function.  We  say  that  a  tumor  performs  no  physiological 
function  in  order  to  make  clear  that  it  is  never  a  useful  addition  to  the  economy, 
but  we  must  not  imagine  that  the  cells  of  a  tumor  are  devoid  of  physiological 
activity.  As  Fiitterer  ("Medicine,"  March,  1902)  has  shown,  the  cells  of  a 
carcinoma  of  the  liver  may  secrete  bile,  and  even  the  cells  of  a  secondary  focus 
developing  in  the  course  of  hepatic  carcinoma  may  also  secrete  bile.  The 
cells  of  a  tumor  may  be  active,  but  this  activity  is  not  useful  and  does  not  con- 
stitute physiological  function.  A  hypertrophy  is  differentiated  from  a  tumor 
by  the  facts  that  it  is  a  result  of  increased  physiological  demands  or  of  local 
nutritive  changes,  and  that  it  tends  to  subside  after  the  withdrawal  of  the 
exciting  stimulus.  Further,  a  hypertrophy  does  not  destroy  the  natural  con- 
tour of  a  part,  while  a  tumor  does.  Inflammation  has  marked  symptoms:  its 
swelling  does  not  tend  to  persist,  it  terminates  in  resolution,  organization  or 
suppuration,  and  examination  of  a  section  under  the  microscope  differentiates 
it  from  tumor.  Inflammation,  too,  has  an  assignable  exciting  cause.  A  new 
growth  is  a  mass  of  newly  formed  tissue;  hence  it  is  improper  to  designate 
as  tumors  those  sweUings  due  to  extravasation  of  blood  (as  in  hematocele), 
or  of  urine  (as  in  ruptured  urethra),  to  displacement  of  parts  (as  in  hernia, 
floating  kidney,  or  dislocation  of  the  liver),  or  to  fluid  distention  of  a  natural 
cavity  (as  in  hydrocele  or  bursitis). 

Classes  of  Tumors. — There  are  two  classes  of  tumors;  the  first  class 
includes  those  derived  from  or  composed  of  ordinary  connective  tissue  or  of 
higher  structures.  These  all  originate  from  cells  which  are  developed  from 
the  mesoblast.  There  are  two  groups  of  connective-tissue  tumors:  (a)  the 
typical,  benign,  or  innocent,  which  find  their  type  in  the  healthy  adult  human 
body;  and  (h)  the  atypical  or  malignant,  which  find  no  counterpart  in  the 
healthy  adult  human  body,  but  rather  in  the  immature  connective  tissues  of 
the  embryo. 

The  second  class  of  tumors  includes  those  which  are  derived  from  or  com- 
posed of  e[)ithelium:  (a)  the  typical,  or  innocent,  composed  of  adult  epithe- 
lium; and  (b)  the  atypical,  or  malignant,  composed  of  embryonic  epithehum. 

Miiller's  Law. — Miiller's  law  is  that  the  constituent  elements  of  neoplasms 
always  have  their  types,  counterparts,  or  close  imitations  in  the  tissues,  either 
embryonic  or  mature,  of  the  human  body. 

Virchow's  Law. — Virchow's  law  is  that  the  cells  of  a  tumor  spring  from 
pre-existing  cells.     There  is  no  special  tumor-cell  or  cancer-cell. 

The  starting-point  of  a  tumor  is  a  focus  of  embryonal  cells,  which  focus 
may  have  originated  before  the  person  was  born  or  may  ha\'e  resulted  after 
birth  from  some  disease  or  injury.  The  nature  of  the  tumor  depends  first 
upon  the  embryonal  layer  from  which  it  took  origin.  Conngctive-tissue  tumors 
spring  from  the  mesoblast;  epithelial  tumors  spring  from  the  epiblast  or  the 
hypoblast.     The  nature  of  the  tumor  depends  also  upon  the  stage  in  which 


Causes  245 

the  growth  of  its  cells  is  arrested.  If  the  cells  remain  embryonal,  the  growth 
is  regarded  as  malignant;  if  they  become  fully  developed,  it  is  regarded  as 
innocent. 

The  term  "'heterologous"  is  no  longer  used  to  signify  that  the  cellular 
elements  of  a  tumor  have  no  counterpart  in  the  healthy  organism,  but  is 
employed  to  signify  that  a  tumor  deviates  from  the  type  of  the  structure  from 
which  it  takes  its  origin  (as  a  chondroma  arising  from  the  parotid  gland). 
Tumors  when  once  formed  almost  invariably  increase  and  persist,  though 
occasionally  warts,  exostoses,  and  fatty  tumors  disappear  spontaneously. 
Tumors  may  ulcerate,  inflame,  slough,  be  infiltrated  with  blood,  or  undergo 
mucoid,  calcareous,  or  fatty  degeneration. 

Causes. — The  causes  of  tumors  are  not  positively  recognized,  those 
alleged  being  but  theories  varying  in  probability  and  ingenuity. 

The  inclusion  tlieory  oj  Cohnheim  supposes  that  more  embryonic  cells  exist 
than  are  needful  to  construct  the  fetal  tissues,  that  masses  of  them  remain  in 
the  tissues,  and  that  these  may  be  stimulated  later  into  active  growth.  The 
embryonic  hypothesis  seems  to  receive  a  certain  force  from  the  facts  that 
e.xostoses  do  sometimes  develop  from  portions  of  unossified  epiphyseal  carti- 
lage, and  that  tumors  often  arise  in  regions  where  there  was  a  suppression  of 
a  fetal  part,  closure  of  a  cleft,  or  an  involution  of  epithelium  (epithelioma  is 
usual  at  mucocutaneous  junctions).  This  theory,  which  does  not  explain  the 
origin  of  most  neoplasms,  cannot  successfully  be  maintained  even  as  a  common 
predisposing  cause. 

Hereditation  is  extremel\-  doubtful.  S.  W.  Gross  found  hereditar}-  in- 
fluence by  no  means  frequent  in  cancer  of  the  breast.  It  is  aflfirmed  by  some, 
denied  by  others,  and  doubted  by  a  number.  At  most,  hereditary  influence 
may  only  predispose.  Nevertheless,  cases  have  occurred  which  cannot  be 
explained  by  the  term  coincidence.  In  the  celebrated  "  Middlesex  Hospital 
case,"  a  woman  and  five  daughters  had  cancer  of  the  left  breast.  A.  Pearce 
Gould  had  charge  of  a  woman  for  cancer  of  the  left  breast.  The  mother  of 
this  patient,  the  mother's  two  sisters,  and  two  of  the  mother's  cousins  had  died 
of  cancer.  Power  reports  a  remarkable  instance  of  family  predisposition  to 
cancer.  A  patient  had  his  right  breast  removed  for  cancer  in  1896.  In  1897 
cancerous  glands  were  removed  from  the  axilla.  In  1898  he  was  seen  again 
with  an  irremovable  recurrent  growth.  His  father  died  of  cancer  of  the 
breast.  He  had  two  brothers,  one  of  whom  died  of  cancer  of  the  throat  when 
sixty-five  years  of  age,  the  other  haviitg  died  of  cancer  of  the  axilla  when  he 
was  only  twenty-four  years  old.  Of  his  eight  sisters,  four  died  of  cancer  of 
the  breast,  and  the  two  who  are  li\'ing  both  suffer  from  cancer  of  the  breast. 
One  sister  died  when  an  infant,  and  one  died  after  giving  birth  to  a  child.* 

Injury  and  inflammation  may  undoubtedly  prove  exciting  causes.  A 
blow  is  not  infrequently  followed  by  sarcoma;  the  irritation  of  a  hot  pipe-stem 
may  excite  cancer  of  the  lip;  the  scratching  of  a  jagged  tooth  may  cause  cancer 
of  the  tongue;  chimney-sweeps'  cancer  arises  from  the  irritation  of  dirt  in 
the  scrotal  creases;  and  warts  often  arise  from  constant  contact  with  acrid 
materials. 

Physiological  activity  fa\ors  the  (le\elopment  (if  sarcoma,  and  physiological 
decline  favors  the  development  of  carcinoma. 

*  P>rit.   Med.   lour.,    julv  l6.    189S. 


246  Tumors  or  Morbid   Growths 

Parasitic  Influence. — This  theory  does  not  maintain  that  the  tumor  is  the 
parasite,  but  that  it  contains  the  parasite,  although  Pfeiffer  and  Adamciewicz 
did  at  one  time  assert  that  a  cancer-cell  is  not  a  body-cell,  but  a  parasite  re- 
sembling an  epithelial  cell.  Some  facts  render  a  parasitic  origin  of  malignant 
growths  not  improbable;  as,  for  instance,  the  likeness  of  some  tumors  to 
infective  granulomata,  their  occasional  secondary  development  in  distant 
parts  of  the  body,  the  resemblance  of  the  secondary  to  the  primary  growths, 
and  the  tenacity  of  their  persistence.  A  parasitic  origin  of  cancer  is  pointed 
to  by  its  geographical  distribution,  the  disease  being  very  common  in  lov^^  and 
marshy  districts,  and  Haviland  and  others  maintain  that  certain  houses  be- 
come infected,  the  disease  appearing  in  these  houses  among  successive  families 
inhabiting  them.     They  speak  of  such  abodes  as  "  cancer-houses." 

Some  surgeons  believe  that  cancer  is  contagious,  but  most  observers  deny 
it.  Guelliott,  of  Rheims,  believes  that  cancer  is  primarily  a  local  infection. 
He  believes  this  because  Morea  and  Hanau  have  inoculated  it  from  one  animal 
to  another  of  the  same  species,  and  if  this  can  be  brought  about  experimentally 
he  sees  no  reason  why  it  cannot  happen  accidentally.  This  surgeon  says  that 
cancer  is  very  unequally  distributed,  that  genuine  cancer-centers  and  "  cancer- 
houses"  exist,  and  that  numerous  cases  of  accidental  infection  have  occurred.* 
Mayet,  of  Lyons,  holds  that  cancer  can  be  reproduced  by  grafting  or  by  in- 
jection of  cancer-fluid.  Graf  could  not  find  "cancer-houses"  after  a  careful 
search. t  Geissler  claims  to  have  produced  the  disease  in  a  dog  by  planting 
fragments  of  cancer  in  the  subcutaneous  tissue  and  vaginal  tissue,  but  Czerny, 
Rosenbach,  and  others  dispute  the  claim.  Roswell  Park  believes  that  Gay- 
lord  has  really  produced  adenocarcinoma  in  the  lower  animals.  Hauser 
disputes  the  assertion  that  cancer  must  be  an  infectious  disease  because  it  is 
followed  bv  secondar\'  growths.  Secondary  growths  in  an  infectious  disease 
are  caused  by  the  bacterium;  secondary  growths  in  cancer  are  caused  by  the 
transference  of  cells  of  primary  growth. J  Hauser  says  with  truth  that  the 
close  connection  between  innocent  and  malignant  growths  renders  the  para- 
site view  untenable,  because  to  hold  it  we  would  be  forced  to  believe  that  every 
tumor  has  a  special  jxirasite  or  that  one  parasite  may  cause  many  kinds  of 
tumors. 

There  seems  to  be  no  doubt  that  dutotransference  of  cancer  can  occur, 
although  it  rarely  does  so.  Sippel  has  reported  a  case  in  which  vaginal 
carcinoma  developed  at  the  jjoint  where  the  vagina  was  in  contact  with  a  pre- 
existing cancer  of  the  portio.§  Cornil  has  seen  cancer  transferred  from  one 
of  the  labia  majora  to  the  other,  and  from  one  lip  to  the  other.  Geissler  was 
unaljle  to  transplant  cancer,  and  Gratia  also  failed  in  his  attempts.  Duplay 
and  FJazin  say  that  transmissibility  is  possible,  but  only  under  conditions  which 
are  not  practically  realized.     Haviland  believes  strongly  in  "cancer-houses."  || 

Tillmanns  elaborately  discussed  the  subject  of  cancer  in  the  Congress  of 
1895.  His  conclusions  seem  most  sound  and  scientific.  He  says  there  is 
no  evidence  of  a  bacterial  origin  of  cancer.  The  parasitic  origin  has  not  been 
proved,  and  protozoa  have  not  certainly  been  found.     Cancer  can  be  trans- 

*  Aniei-.  Journal  of  Med.  Sciences,  June,  1895. 

fArchiv.  f  klin.  Chin,  1895.  1.,  p.   144. 

J  Hauser.  in  Pjiolog.  Centralbl.,  Oct.   i,  1895. 

^Centralbl.  f.  (Jynaic.,  No.  4,  1894. 

II  Lancc-t,  Ai)ril  27,  1894. 


Malignant  and  Innocent  Tumors  247 

ferred  from  one  part  to  another  part  of  the  same  individual,  or  from  one  indi- 
vidual to  another  of  the  same  species,  but  never  to  one  of  a  different  species. 
It  is  possible  that  cancer  can  spread  by  contagion;  this  is  very  rare,  but  can 
happen  (as  when  penile  cancer  is  followed  by  cervix  cancer  in  a  wife).  Be- 
cause it  is  sometimes  possible  to  transfer  cancer,  this  does  not  prove  that  the 
disease  is  parasitic  or  infectious;  it  sinipl}  shows  that  tissue  has  been  success- 
full}'  transplanted. 

Actinomycosis,  long  thought  to  be  a  true  tumor,  is  now  known  to  arise 
from  the  ray-fungus.  There  can  be  no  doubt  that  changes  in  the  liver  which 
practically  constitute  a  new  growth  can  arise  from  the  growth  of  a  cell  called 
by  Darier  the  "  psorosperm."  A  disease  due  to  psorosperms  is  called  a 
'"psorospermosis."  It  is  affirmed  by  some  that  moUuscum  contagiosum, 
follicular  keratosis,  cancer,  and  Paget's  disease  are  due  to  psorosperms. 
Some  claim  to  find  the  parasite  in  all  cases  of  cancer,  while  others  can  find  it 
in  only  4  or  5  per  cent,  of  the  cases. 

Heneage  Gibbes  affirms  *  that  dilatation  of  the  bile-ducts  of  a  rabbit's 
liver  is  caused  by  the  chronic  irritation  arising  from  multiplication  of  the  coc- 
cidium  oviforme  in  them,  and  not  in  the  columnar  cells  of  the  bile-ducts,  as  has 
been  stated;  and,  further,  that  the  large  majority  of  glandular  cancers  show 
nothing  that  can  be  considered  parasitic,  the  suspicious  appearances  noted 
in  some  few  cases  being  due  to  endogenous  cell-formation.  The  coccidium 
oviforme  is  a  genus  of  the  sporozoa,  class  protozoa,  the  lowest  division  of  the 
animal  kingdom.  To  this  class  belong  the  monera  and  infusoria.  (For  a 
further  discussion  of  this  subject  .see  page  41.) 

Malignant  and  Innocent  Tumors. — Malignant  growths  infiltrate 
the  tissues  as  they  grow;  benign  tumors  only  push  the  tissues  away;  hence 
malignant  tumors  are  not  thoroughly  encapsuled,  while  innocent  tumors  are 
encapsuled.  Malignant  tumors  grow  rapidly;  innocent  tumors  grow  slowly. 
Malignant  tumors  become  adherent  to  the  skin  and  cause  ulceration;  innocent 
tumors  rarely  adhere  and  rarely  cause  ulceration.  Many  malignant  tumors 
give  rise  to  secondary  growths  in  adjacent  lymphatic  glands  (cancer,  except 
in  the  esophagus  and  antrum  of  Highmore,  always  does  so);  sarcoma  rarely 
causes  them,  unless  the  growth  be  melanotic  or  unless  it  arises  from  the  testicle 
or  tonsil.  Innocent  tumors  never  cause  secondary  lymphatic  involvement, 
although  the  glands  near  the  tumor  may  enlarge  from  accidental  inflammatory 
complications.  The  malignant  tumors,  especially  certain  sarcomata  and 
soft  cancers,  may  be  followed  by  secondary  growths  in  distant  parts  and 
various  structures  (bones,  viscera,  brain,  muscles,  etc.) ;  innocent  tumors  are 
not  followed  by  these  secondary  reproductions,  although  multiple  fatty  tumors 
or  multiple  lymphomata  ma}'  exist.  Malignant  tumors  destroy  the  general 
health ;  innocent  tumors  do  not  unless  by  the  accident  of  position.  Malignant 
tumors  tend  to  recur  after  removal;  innocent  tumors  do  not  if  operation  was 
thorough.  The  special  histological  feature  of  a  malignant  growth  is  the 
possession  by  its  cells  of  a  power  of  reproduction  which  knows  no  limit,  the 
cells  of  the  tumor  living  among  the  body-cells  like  a  parasite,  and  invading 
and  destroying  the  body-cells. 

*  Amer.  Journal  of  Med.  Sciences,  July,  1893. 


248  Tumors  or  Morbid   Growths 

Classification. — Tumors  may  be  classified  as  follows: 

I.  Connective-tissue  tumors  (those  derived  from  the  mesoblast). 

1.  Innocent  tumors,  or  those  composed  of  mature  connective  tissue: 
Lipomata,  or  fatty  tumors;  fibromata,  or  fibrous  tumors;    chondro- 

mata.  or  cartilaginous  tumors;  osteomaia,  or  bony  tumors;  odonto- 
mata,  or  tooth-tumors;  myxoinata,  or  mucous  tumors;  myomata,  or 
muscle-tumors;  neuromata,  or  tumors  upon  nerves;  gliomata,  or  tu- 
mors composed  of  neuroglia;  aiigiomata,  or  tumors  formed  of  blood- 
vessels; lymphangiomata,  or  tumors  formed  of  lymphatic  vessels. 
The  term  lymphoma,  meaning  a  tumor  of  a  lymphatic  gland,  was 
formerly  applied  to  hypertrophy  and  hyperplasia  of  a  lymphatic 
gland,  no  matter  whether  caused  by  syphilis,  tubercle,  Hodgkin's 
disease,  or  any  other  morbid  impression.  The  term  has  been 
largely  abandoned  except  as  expressing  enlargement  of  a  gland, 
and  does  not  convey  any  suggestion  as  to  the  cause.  It  is  doubtful 
if  there  is  such  a  thing  as  a  true  lymphoma,  understanding  by  the 
term  a  neoplasm  arising  from  and  composed  of  lymphoid  cells  and 
resembling  lymphatic  structure.  In  the  described  cases  the  possi- 
bility of  infection  as  a  cause  has  not  been  eliminated. 

2.  Malignant  tumors,  or  those  composed  of  embryonic  connective  tissue: 
Sarcomata  and  adrenal  tumors. 

EndotheUomata  are  regarded  as  a  variety  of  sarcomata. 

II.  Epithelial  tumors  (those  derived  from  the  epiblast  or  hypoblast). 

1.  Innocent  tumors,  or  those  composed  of  mature  epithelial  tissue: 
Adenomata,  or  tumors  whose  type  is  a  secreting  gland;  and  papillo- 

mata,  or  tumors  whose  type  is  found  in  the  papillae  of  skin  and 
mucous  membranes. 

2.  Malignant  tumors,  or  those  composed  of  embryonic  epithelial  tissue 
Carcinomata,  or  cancers. 

III.  Cystomata  are  cystic  tumors,  the  cyst-walls  of  which  are  new  growths 
and  the  contents  of  which  are  produced  by  the  cells  of  the  newly 
formed  cyst-walls. 

IV.  Teratomata  (tumors   containing   epiblastic,   hypoblastic,   and    meso- 

blastic  elements). 

Innocent  Connective=tissue  Tumor. — The.se  growths  mimic  or  imi- 
tate some  connective  tissue  or  higher  tissue  of  the  mature  and  healthy 
organism. 

Lipomata  are  congenital  or  ac(|uired  tumors  composed  of  fat  contained 
in  the  cells  of  connective  tissue,  which  cells  are  bound  together  by  fibers.  If 
the  fibers  are  excessively  abundant,  the  growth  is  spoken  of  as  a  fihrojatty 
tumor.  A  fatty  tumor  has  a  distinct  capsule,  tightly  adherent  to  surrounding 
parts,  but  loosely  attached  to  the  tumor;  hence  enucleation  is  ea.sy.  Fil)rous 
trabecula;  run  from  the  capsule  of  a  subcutaneous  lipoma  to  the  skin;  hence 
movement  of  the  integument  over  the  tumor  or  of  the  tumor  itself  causes 
dimpling  of  the  skin.  An  ordinary  circumscribed  lipoma  is  of  doughy  soft- 
ness, is  lobulated,  of  uniform  consistence,  and  on  being  tapped  imparts  to  the 
finger  a  tremor  known  as  pseudofluctuation.  A  fatty  tumor  is  mobile,  ahhough 
it  may  be  attached  to  the  skin  at  points  by  trabecular.  Lipomata  are  most 
frequent  in  middle  life,  and  their  commonest  situations  are  in  the  subcutaneous 


Lipomata 


249 


tissues,  especially  of  the  back  or  of  the  dorsal  surfaces  of  the  limbs:  thev 
usually  occur  singly,  but  may  be  multiple  and  sometimes  symmetrical.  Senn 
described  the  case  of  a  woman  who  had  a  fatty  tumor  in  each  axilla.  A  lipoma 
may  grow  to  an  enormous  size  (in  Rhodius's  case  the  tumor  weighed  sixty 
pounds),  and  the  growth  may  be  progressive  or  may  be  at  times  stationary 
and  at  other  times  active.  The  skin  over  a  fatty  tumor  sometimes  atrophies 
or  even  ulcerates;  the  tumor  itself  may  inflame  or  partly  calcifv.  When  a 
lipoma  has  once  inflamed  it  becomes  immovable.  Subcutaneous  lipoma 
of  the  palm  of  the  hand  or  sole  of  the  foot  bears  some  resemblance  clinically 
to  a  compound  ganglion;  it  is  apt  to  be  congenital.  Lipomata  of  the  head 
and  face  are  rare.  In  the  .subcutaneous  tissues  of  the  groins,  neck,  pubes, 
axillae,  or  scrotum  a  mass  of  fat  may  form,  unlimited  by  a  capsule  and  known 
as  a  "diffuse  lipoma."     A  diffuse  lipoma  may  dip  down  among  the  muscles. 


Fig.  84. — Fatly  tumor. 


Such  masses  attain  large  size.  The  typical  diffu.se  lipoma  is  occasionally 
seen  on  the  neck.  It  begins  back  of  the  mastoid  process  on  one  side  or  on 
both  sides.  When  large,  it  completely  surrounds  the  neck,  a  huge  double  chin 
forming  in  front,  a  great  mass  hanging  on  each  side,  and  the  posterior  portion 
being  divided  into  two  halves  by  a  median  depression.  A  nevolipoma  is  a 
nevus  with  much  fibrofatty  tissue.  A  \-er\-  \ascular  fatt}-  tumor  is  called  lipoma 
telangiectodes.  If  the  tumor  stroma  contains  large  veins,  the  growth  is  called 
a  cavernous  lipoma.  .\  tumor  containing  much  blood  can  be  diminished  in 
size  by  pre.ssure.  Fatty  tumors  may  arise  in  the  subserous  tissue,  and  when 
such  a  growth  arises  in  either  the  femoral  or  inguinal  canal  or  the  linea  alba 
it  resembles  an  omental  hernia  and  is  spoken  of  as  a  jat-hcrnia.  In  the  retro- 
peritoneal tissues  enormous  fibrofatty  tumors  occasionally  grow,  and  these 
neoplasms  tend  to  become  sarcomatous.  Lipomata  may  arise  from  beneath 
synovial  membranes  and  will  ]:)roject  into  the  joints,  being  still  covered  by 


250 


Tumors  or  Morbid   Growths 


synovial  membrane.  Fatty  tumors  occasionally  arise  in  submucous  tissues, 
between  or  in  muscles,  from  periosteum,  and  from  the  meninges  of  the  spinal 
cord  (J.  Bland  Sutton).  A  fatty  tumor  may  undergo  metamorphosis.  The 
stroma  may  be  attacked  by  a  myxomatous  process  or  a  calcareous  degenera- 
tion. The  fat-cells  themselves  may  become  calcareous.  Oil-cysts  some- 
times form.  A  xanthoma  is  a  growth  composed  of  fatty  tissue  in  and  about 
which  there  is  marked  infiltration  with  small  cells.  Such  a  tumor  is  flattened 
and  slightly  elevated.  Several  or  many  of  these  growths  occur  in  the  same 
person.  The  eyelids  are  the  most  common  seat  of  xanthoma.  The  tumor 
may  undergo  involution  or  may  become  sarcomatous. 

Diabetics  are  liable  to  develop  xanthomata. 

Treatment. — K  single  subcutaneous  lipoma  should  be  extirpated.  The 
capsule  must  be  incised,  when  the  tumor  can  be  torn  out  forcibly  or  can  be 
enucleated  by  dissection ;  drainage  is  always  employed  for  twenty-four  hours, 
as  butyric  fermentation  will  be  apt  to  occur,  and  necrosis  of  small  particles 
of  fat  predisposes  to  infection.  Multiple  subcutaneous  lipomata,  if  very 
numerous,  should  not  be  interfered  with  unless  troublesome  because  of  their 
size  or  situation,  when  the  growth  or  growths  causing  trouble  should  be  re- 
moved. It  is  difficult  to  extirpate  entire  a  diffuse  Hpoma,  and  several  opera- 
tions may  be  needed  to  effect  complete  removal.  Liquor  potassae,  once  recom- 
mended as  possessing  power,  when  taken  internally,  to  limit  the  growth  of 
multiple  hpomata  or  diffuse  Hpoma,  seems  to  be  useless.  Subperitoneal  Hpo- 
mata  are  rarely  diagnosticated  until  the  belly  has  been  opened  or  the  growth 
has  been  removed. 

Fibromata  are  tumors  composed  of  bundles  of  fibrous  tissue.  There 
are  two  forms,  the  hard  and  the  soft.  A  hard  fibroma  consists  of  wavy  fibrous 
bundles  lying  in  close  contact.  Here  and  there  connective-tissue  corpuscles 
exist  between  the  fibers.  A  fibroma  has  no  distinct  capsule,  though  surround- 
ing tissues  are  so  compressed  as  to  simulate  a  capsule.  Fibromata  are  occa- 
sionally congenital,  are  most  usual  in  young  adults,  but  they  may  occur  at  any 
period  of  life,  and  in  any  part  of  the  body  containing  connective  tissue.  Pure 
fibromata,  which  are  rare,  are  generally  solitary,  grow  slowly,  are  of  uniform 
consistence,  have  not  much  circulation,  and  are  hard  and  movable.  Fibro- 
mata may  form  upon  nerves,  they  may  arise  in  the  mammary  gland,  they  may 
develop  in  the  lobe  of  the  ear,  and  they  may  spring  from  various  fibrous  mem- 
branes, from  the  periosteum  of  the  base  of  the  skull  (nasopharyngeal  fibro- 
mata), and  from  the  gums  (fibrous  epulides).  A  sojt  fibroma  contains  much 
areolar  tissue,  the  spaces  of  which  are  filled  with  fluid,  so  that  the  tissue  seems 
edematous.  Soft  fibromata  grow  from  the  skin,  mucous  membranes,  sub- 
cutaneous tissue,  intermuscular  planes,  and  periosteum.  Soft  fibromata  are 
especially  apt  to  arise  from  the  skin  of  the  scrotum,  labia,  inner  surface  of 
arm  and  thigh,  and  of  the  belly  wall  of  a  pregnant  woman.  They  are  not  un- 
usually multiple,  grow  slowly,  but  more  rapidly  than  the  hard  fibromata,  and 
may  become  quite  large  and  possess  distinct  pedicles.  Fibromata  may  become 
cystic,  calcareous,  osseous,  colloidal,  or  sarcomatous,  and  may  inflame,  ulcer- 
ate, or  even  become  gangrenous. 

A  painjul  subcukineous  tubercle,  which  is  a  form  of  fibroma  commonest  in 
females,  arises  in  the  subcutaneous  cellular  tissue,  usually  of  the  extremities. 
It  is  firm,  very  tender,  movable,  rarely  larger  than  a  pea,  and  the  skin  over  it 


Fibromata  251 

seems  healthy.  Violent  pain  occurs  in  paroxysms  and  radiates  o\er  a  con- 
siderable area,  of  which  the  tubercle  is  the  center.  These  paroxysms  may 
occur  only  once  in  man}'  days  or  many  times  in  one  day.  Pain  is  always 
developed  by  pressure,  and  may  be  linked  with  spasm.  Nerve-fibrillae  are 
now  known  to  exist  in  these  tubercles,  a  fact  which  was  long  denied. 

A  moie  is  z.  abroma  of  the  skin  which  is  congenital  or  appears  in  the  early 
weeks  of  life.  It  is  rounded  or  flat,  is  usually  pigmented  and  of  a  brown  color, 
is  slightly  elevated  above  the  cutaneous  level,  and  has  a  few  hairs  or  an  abun- 
dant crop  of  hair  growing  from  it,  and  varies  in  size  from  a  pin's  head  to 
several  inches  in  diameter,  or  may  even  occupy  an  extensive  area  of  a  limb  or 
of  the  trunk.  The  tumor  rarely  grows  after  the  thirteenth  or  fourteenth  year. 
A  mole  may  become  malignant,  melanotic  carcinoma  may  arise  from  its 
epithelial  structures,  or  melanotic  sarcoma  from  its  connective-tissue  ele- 
ments. A  mole  is  an  extremely  vascular  structure;  it  bleeds  freely  when  cut 
or  scratched,  and  it  sometimes  ulcerates.  Occasionally  several  or  many  moles 
exist  in  the  same  individual.  If  a  mole  begins  to  increase  rapidly  in  size, 
operation  is  imperative,  as  rapid  growth  probably  indicates  malignant  change. 

Fibrous  epulis  is  a  fibroma  arising  from  the  gums  or  periodontal  membrane 
(J.  Bland  Sutton)  in  connection  with  a  carious  tooth  or  retained  snag;  it  is 
covered  by  mucous  membrane,  grows  slowly,  may  attain  a  large  size,  and 
sometimes  has  a  stem,  but  is  more  often  sessile.  It  may  undergo  myxomatous 
change  or  may  become  sarcomatous. 

Fibrous  tumors  may  arise  from  the  ovary,  the  intestine,  and  the  larynx. 
Pure  fibromata  of  the  uterus  are  very  rare,  but  fibromyomata  are  very  com- 
mon (see  Myomata,  page  255);  hence  the  term  "uterine  fibroid"  should  be 
abandoned. 

MoUuscum  fibrosum  is  an  overgrowth  of  the  fibrous  tissue  of  both  the  skin 
and  the  subcutaneous  structure.  Senn  excludes  this  form  of  growth  from 
consideration  with  fibromata  because  of  its  infective  origin.  It  may  be  hmited 
or  widely  extended;  it  may  appear  as  an  infinite  number  of  nodules  scattered 
over  the  entire  body  or  as  hanging  folds  of  fibrous  tissue  in  certain  areas. 
Keloid  is  a  fibroma  of  the  true  skin.  It  is  a  hard,  fibrous,  vascular  growth, 
with  a  broad  base,  arising  in  scar-tissue;  it  is  crossed  by  pink,  white,  or  dis- 
colored ridges,  and  is  named  from  a  fancied  likeness  to  the  crab.  It  has 
rarely  attacked  mucous  membrane.  It  is  more  common  in  negroes  than 
in  whites,  and  is  most  frequent  in  the  cicatrices  of  burns,  though  it  may 
arise  in  the  scar  of  any  injury,  as  the  scar  from  piercing  the  ears,  and  in  the 
scars  of  syphilitic  lesions,  tuberculous  processes,  smallpox,  or  vaccination.  It 
is  rare  in  early  childhood  and  in  old  age.  It  grows  slowly,  lasts  for  many 
years,  and  may  eventually  undergo  involution  and  disappear.  It  is  almost 
useless  to  remove  keloid  b\'  operation,  as  it  will  usually  return.  The  fibrous 
tissue  of  keloid  springs  from  the  outer  walls  of  the  blood-vessels  (Warren). 
The  papilla;  of  the  skin  above  the  tumor  are  destroyed  or  replaced  by 
fibrous  tissue. 

Morphea,  spontaneous  or  true  keloid,  is  a  name  used  to  designate  a  growth 
of  this  description  which  does  not  arise  from  a  scar;  but  it  seems  certain  that 
scar-tissue  was  present,  though  possibly  in  small  amount  from  trivial  injury. 

Fibrous  and  papillomatous  growths  covered  with  endothelium  may  spring 
from  any  serous  memljrane.     Such  a  growth  of  the  choroid  plexus  calcifies 


252  Tumors   or   Morbid   Growths 

earlv  and  constitutes  a  psammoma  or  brain-sand  tumor.  Such  tumors  are 
met  with  not  only  in  the  choroid  plexus,  but  also  in  the  conarium  and  the  dura. 
All  psammomata  are  not  fibrous;  some  are  gliomatous  and  some  are  endo- 
theliomatous.  A  cholesteatoma  is  a  fibrous  growth  covered  with  endothelium 
and  containing  layers  of  crystaUine  fat.  It  occurs  especially  in  the  pia  mater, 
but  may  arise  in  either  of  the  other  membranes  or  even  in  the  brain  substance, 
and  is  called  a  pearl  tumor. 

Treatment. — When  in  accessible  regions  fibromata  should  be  enucleated. 
Fibromata  should  not  be  let  alone,  because  any  fibrous  tumor  may  become  a 
sarcoma.  If  a  hard  fibroma  of  the  skin  exists  the  skin  is  incised  and  the  tumor 
is  "shelled  out."  A  soft  fibroma  is  removed  by  an  incision  carried  round  the 
base  of  its  pedicle.  A  painful  subcutaneous  tubercle  should  be  excised.  If 
a  mole  shows  the  slightest  disposition  to  enlarge,  or  if  it  is  subjected  to  pressure 
or  irritation,  it  should  be  removed,  because  if  allowed  to  remain  it  might 
develop  into  a  malignant  growth.  It  is  often  desirable  to  remove  a  hairy  or 
pigmented  mole,  not  only  because  it  may  become  mahgnant,  but  also  because 
it  is  unsightly.  Fibrous  epulis  requires  the  cutting  away  of  the  entire  mass, 
the  removal  of  the  related  snag  or  carious  tooth,  and  sometimes  the  biting 
away  of  a  portion  of  the  alveolus  with  rongeur  forceps.  A  naso-pharyngeal 
fibrous  polyp  usually  contains  sarcomatous  elements  or  becomes  a  spindle- 
cell  sarcoma.  If  it  has  a  pedicle,  it  may  be  removed  by  the  cautery  loop.  In 
a  severe  case  a  part  of  the  superior  maxillary  bone  is  removed  by  osteoplastic 
resection  to  permit  of  extirpation.  Keloid  should  rarely  be  operated  upon: 
it  will  only  return,  and  will  also  recur  in  the  stitch  holes.  Trust  to  time  for 
involution,  or  use  pres.sure  with  flexible  collodion,  by  which  method  J-  M. 
DaCosta  cured  a  case  following  smallpox.  It  may  be  necessary  to  operate 
because  of  ulceration.  If  it  is  necessary  to  operate,  remove  the  keloid  and 
considerable  adjacent  tissue  and  fill  the  gap  with  Thiersch  grafts.  The 
administration  of  thyroid  extract  may  be  of  benefit  (a  gr.  v  tablet  three  or  four 
times  a  day).  This  drug  must  be  given  cautiously,  as  it  may  cause  attacks 
characterized  by  fever,  dyspnea,  and  rapid  pulse.  Thiosinamin  hypoder- 
matically  has  been  used,  it  is  claimed,  with  benefit.  A  10  per  cent,  solution 
is  made,  and  from  10  to  15  minims  can  be  injected  into  the  gluteal  muscles 
every  third  day.     I  have  seen  two  keloids  cured  by  the  use  of  the  :x:-rays. 

Chondromata  (enchondromata)  are  tumors  formed  either  of  hyaline 
cartilage,  of  fibrocartilage,  or  of  both.  Chondromata  are  apt  to  arise  from 
certain  glands,  the  long  bones,  the  pelvis,  the  rib  cartilages,  and  the  bones  of 
the  hands  or  feet,  and  often  spring  from  unossified  portions  of  epiphyseal 
cartilage.  They  may  be  single  or  multiple,  and  are  most  commonly  met  with 
in  the  young.  They  have  distinct  adherent  capsules;  they  grow  slowly,  and 
if  of  osseous  origin  progressively  hollow  out  the  bones  by  pressure;  they  cause 
no  pain;  they  impart  a  sensation  of  firmness  to  the  touch,  unless  mucoid 
degeneration  forms  zones  of  softness  or  fluctuation;  they  are  inelastic,  smooth 
or  nodular,  immovable,  and  often  ossify.  A  chondroma  may  grow  to  an 
enormous  .size.  A  chondroma  of  the  parotid  gland  or  testicle  practically 
always  contains  sarcomatous  elements,  and  any  chondroma  may  become 
a  sarcoma.  Chondromata  are  notably  frequent  in  persons  who  had  rickets 
in  early  life.  Errhondroses,  which  are  "small  local  overgrowths  of  car- 
tilage"   {].    Bland    Sutton),    arise    from     articular    cartilages,   es])ecially    of 


Osteomata  253 

the  knee-joint,  and  from  the  cartilages  of  the  larynx  and  nose.  Loose  or 
floating  cartilages  in  the  joints  may  be  broken-off  ecchondroses  or  portions 
of  hyaline  cartilage  which  are  entirely  loose  or  are  held  by  a  narrow  stalk,  and 
which  arise  by  chondrification  of  villous  processes  of  the  synovial  membrane; 
only  one  or  vast  numbers  may  exist;  one  joint  may  be  involved,  or  several; 
they  may  produce  no  symptoms,  but  usually  produce  from  time  to  time  violent 
pain  and  immobility  by  acting  as  a  joint-wedge.  An  ecchondroma  may  arise 
within  the  medullary  canal  of  a  long  bone,  from  foci  of  dormant  cartilage,  and 
may  lead  to  the  de\'elopment  of  a  solitary  cyst  of  large  size  by  softening  of  the 
tumor.  The  femur  is  the  most  usual  site  of  disease.  It  begins  very  insidiously 
and  progresses  gradually.  There  are  slight  lameness,  trivial  pain,  tenderness 
below  the  level  of  the  trochanter,  apparent  shortening  and  some  bulging  of 
bone.  The  bone  may  bend  or  at  some  spot  may  thin  so  that  the  cyst  can  be 
felt.  Such  a  bone  fractures  from  slight  force,  and  after  a  fracture,  when  the 
effused  blood  and  inflammatory  exudate  have  been  absorbed,  a  tumor  can 
be  distinctly  detected.  A  solitary  cyst  of  a  long  bone  is  apt  to  be  regarded 
clinically  as  a  sarcoma  (Bergmann-Virchow). 

Treatment. — Remove  chondromata  whenever  possible,  for,  if  allowed 
to  remain  undisturbed,  they  are  apt  to  resent  this  hospitality  by  becoming 
sarcomatous.  Incise  the  capsule  and  take  away  the  growth,  using  chisels 
and  gouges  if  necessary.  Incomplete  removal  means  inevitable  recurrence. 
Amputation  is  very  rarely  demanded.  Loose  bodies  in  the  joints,  if  produc- 
tive of  much  anno\-ance,  are  to  be  removed,  the  joint  being  opened  with  the 
strictest  antiseptic  care.  Amputation  is  sometimes  performed  for  a  solitary 
cyst  of  a  long  bone,  the  surgeon  having  looked  upon  the  growth  as  sarcoma- 
tous. If  a  correct  diagnosis  is  arrived  at,  an  attempt  should  be  made  to 
remove  the  cyst  without  amputation.  Bergmann  succeeded  in  extirpating 
such  a  mass  from  the  femur. 

Osteomata. — Osteomata  are  tumors  which  are  composed  of  osseous 
tissue.  J.  Bland  Sutton  says  that  osteomata  are  ossifying  chondromata. 
Osteomata  take  origin  from  bone,  cartilage,  connective  tissue,  especially 
tissue  near  the  bone,  serous  membrane,  and  certain  glands  and  organs.  Com- 
pact osteomata,  which  are  identical  in  structure  with  the  compact  tissue  of 
bone,  arise  from  the  frontal  sinus,  mastoid  process,  external  auditorv  meatus, 
and  other  regions  in  those  beyond  middle  life;  they  are  small,  smooth,  round, 
densely  hard,  with  small  and  occasionally  cartilaginous  bases. 

Cancellous  osteomata,  which  comprise  the  great  majority  of  bone-tumors, 
are  similar  in  structure  to  cancellous  bone.  They  spring  from,  and  are  crusted 
with,  cartilage;  they  may  have  fibrous  capsules,  and  are  often  movable  when 
recent,  but  soon  become  fixed;  they  have  broad  bases,  are  angled,  nodular, 
firm  (but  not  so  hard  as  are  the  compact  osteomata),  painless  except  when 
pressed,  occur  particularh'  at  the  ends  of  long  bones,  may  grow  to  large  size, 
and  are  commonest  in  youth.  Osteomata  near  joints  become  overlaid  by 
bursas,  which  in  rare  instances  communicate  with  an  adjacent  joint. 

The  term  exostosis  has  been  used  as  being  synonymous  with  osteoma,  but 
wrongly  so,  as  an  exostosis  is  an  irregular,  local,  bony  growth  which  does  not 
tend  to  progress  without  limit,  and  which  is,  hence,  not  a  tumor.  A  true  exos- 
tosis is  seen  in  the  ossification  of  a  tendon-insertion,  in  a  limited  growth  from 
one  of  the  maxillary  bones,  and  in  a  local  growth  from  the  last  phalanx  of  the 


2  54  Tumors  or  Morbid   Growths 

big  toe,  which  latter  form  of  growth  is  known  as  a  subungual  exostosis.  Ex- 
ostoses 0/  the  retrocalcaneal  bursa  occasionally  arise  when  this  bursa  is  inflamed. 
Inflammation  of  this  bursa  is  known  as  Achillodynia  or  Albert's  disease.  The 
bonv  masses  sometimes  found  in  the  brain,  lungs,  testicle,  various  glands, 
and  tumors  are  not  true  osteomata.  Osteomata  do  not  tend  to  become 
malignant  and  do  not  recur  after  removal. 

Treatment. — Osteomata  which  are  non-productive  of  pain  or  trouble 
do  not  demand  removal.  If  they  produce  pain  by  pressure,  if  they  press  upon 
important  structures,  if  they  cause  annoving  deformities,  or  if  they  grow 
rapidlv,  then  remove  them  by  means  of  chisels,  gouges,  or  the  surgical  engine. 
Subungual  exostosis  should  always  be  removed.  The  nail  should  be  spHt 
and  part  of  it  taken  away,  and  the  bony  mass  be  gouged  away  or  be  cut  off 
with  forceps. 

Odontomata  *  are  tumors  composed  of  tooth-tissue.  They  spring  from 
the  germs  of  teeth  or  from  developing  teeth.  J.  Bland  Sutton  divides  them 
into  (i)  those  springing  from  the  follicle;  (2)  those  springing  from  the  papilla; 
and  (3)  those  springing  from  the  whole  germ. 

Epithelial  odontomes,  or  multilocular  cystic  tumors,  arise  from  the 
follicle,  occur  oftenest  in  the  lower  jaw,  dilate  the  bone,  have  capsules,  and 
are  made  up  of  masses  of  cysts  which  are  fiUed  with  brown  fluid.  These 
cysts  are  met  with  most  frequently  before  the  age  of  twenty.  Follicular  odon- 
tomes, or  dentigerous  cysts,  oftenest  spring  from  the  follicles  of  the  permanent 
molars.  In  a  dentigerous  cyst  there  exists  an  expanded  follicle  which  dis- 
tends the  bone,  the  follicle  being  filled  with  thick  fluid  and  containing  a  portion 
of  a  tooth.  A  fibrous  odontome  is  due  to  thickening  of  the  tooth-sac,  which 
prevents  eruption  of  the  tooth;  fibrous  odontomes  are  usually  multiple,  and 
are  apt  to  occur  in  rickety  children.  A  cementome  is  due  to  enlargement, 
thickening,  and  ossification  of  the  capsule,  the  developing  tooth  being  encased 
in  cement.  A  compound  jollicular  odontome  is  due  to  ossification  of  portions 
only  of  an  enlarged  and  thickened  capsule,  and  the  tumor  contains  bits  of 
cementum.  ]jortions  of  dentine,  or  small  misshapen  teeth.  A  radicular 
odontome  springs  from  the  papilla  and  arises  after  the  crown  of  the  tooth  is 
formed  and  while  the  roots  are  forming;  hence  it  contains  dentine  and  cement, 
but  no  enamel.  Composite  odontomes  are  formed  of  irregular,  shapeless 
masses  of  dentine,  cement,  and  enamel.  All  the  above  forms  occur  in  man. 
They  present  themselves  as  hard  tumors  associated  with  teeth  or  in  an  area 
where  teeth  have  not  erupted.  Occasionally  an  odontome  simulates  necrosis; 
it  is  surrounded  by  pus,  and  a  sinus  forms. 

Treatment. — The  diagnosis  is  scarcely  ever  made  until  after  an  incision; 
hence,  be  in  no  haste  to  excise  large  portions  of  bone  for  a  doubtful  growth ; 
inci.se  first  and  see  if  it  be  an  odontome,  which  requires  only  the  removal  of 
an  implicated  tooth,  curetting  with  a  sharp  s])oon  and  packing  with  iodo- 
form gauze. 

Myxomata  are  tumors  composed  of  mucous  tissue.  They  are  rare  as 
independent  growths,  although  myxomatous  change  is  frequent  in  the  stroma 
of  other  tumors.  The  tissue  type  of  these  tumors  is  found  in  the  vitreous 
humor  of  the  eye  and  in  the  perivascular  tissues  of  the  umbilical  cord  (Whar- 

*'riiis  section  is  aljiidged  from  J.  P.land  Sutton's  striking  chapter  \\\wn  odontomes  in 
his  recent  work  (jn  "Tumors." 


Myomata  255 

ton's  jelly).  Bowlby  states  that  myxomata  are  in  reality  soft  fibromata  whose 
intercellular  substance  has  been  replaced  by  mucin.  The  myxomatous  state 
may  be  a  stage  in  the  formation  of  a  fibroma,  a  stroma  not  having  developed. 
Myxomata  may  result  from  myxomatous  degeneration  of  cartilage,  of  muscle, 
or  of  fibrous  tissue.  These  tumors  are  soft,  elastic,  usually  pedunculated, 
tremulous,  and  vibratory.  The  stroma  is  very  delicate  and  carries  minute 
blood-vessels.  Cutting  into  a  myxoma  causes  a  straw-colored,  clear  jelly 
to  exude.  Myxomata  grow  slowly,  are  encapsuled,  have  but  little  circulation, 
and  the  diagnosis  may  be  impossible  before  removal  of  the  growth.  Some 
pathologists  place  my.xomata  among  the  malignant  tumors,  but  most  consider 
them  as  benign  tumors,  though  they  tend  strongly  to  become  sarcomatous 
(myxosarcomata) .     A  sarcoma  may  undergo  myxomatous  degeneration. 

Myxomata  may  arise  from  the  skin;  from  the  mucous  membrane  of  the 
nose,  the  frontal  sinus,  the  antrum,  the  womb,  the  auditory  meatus,  and  the 
tympanum  (gelatinous  polyps);  from  the  parotid  and  mammary  glands; 
from  the  subcutaneous  tissue,  the  nerve-sheaths,  the  intermuscular  septa, 
the  rectum,  and  the  bladder  (polyps).  They  may  be  congenital,  but  occur 
most  often  in  young  adults,  as  a  result  of  inflammation.  A  sudden  increase 
of  growth  indicates  beginning  malignancy  (sarcomatous  change).  When 
a  tumor  begins  to  undergo  myxomatous  transformation  we  give  to  it  a  com- 
pound name;  for  instance,  a  chondroma  undergoing  myxomatous  change  is 
a  chondromyxoma,  a  fibroma  undergoing  a  Hke  change  is  a  fibromyxoma,  etc. 
Mucous  polypi  grow  from  the  mucous  membrane  of  the  nose,  particularly 
from  the  outer  wall  near  the  middle  turbinated  bone,  and  often  from  the  roof 
of  the  nares.  Mucous  polypi  are  soft  and  jelly-like,  of  a  grayish  color,  and 
have  stems  or  pedicles;  they  may  be  seen  through  the  anterior  nares,  mav 
project  behind  the  veil  of  the  palate,  and  may  bulge  out  from  the  passages  of 
the  nose;  they  may  be,  and  usually  are,  multiple;  they  may  be  present  in  one 
nasal  fossa  or  in  both;  and  they  occur  most  commonly  in  youths  and  adults 
between  the  ages  of  fifteen  and  thirty-five  years. 

Hydatid  moles  of  pregnancy  are  due  to  myxomatous  changes  in  the  chorion. 

Treatment. — In  treating  myxomata,  remove  them  promptly  and  thor- 
oughly, because  of  the  danger  of  sarcomatous  change.  Polyps  of  the  bladder 
are  removed  by  means  of  cutting  forceps  after  suprapubic  cystotomy  has  been 
performed.  Nasal  polyps  may  usually  be  twisted  off  or  be  removed  by  the 
wire  snare  or  galvanocautery.  Occasionally  when  the  growths  are  numerous 
and  recur  rapidly  after  removal,  the  inferior  turbinated  bones  should  be  re- 
moved with  a  saw  (Rouge's  operation).  This  operation  secures  ready  access 
to  the  area  of  disease,  which  can  be  attacked  radically.  A  very  soft  myxoma 
breaks  up  when  removal  is  attempted,  and  the  base  must  be  cauterized. 

Myomata  are  tumors  composed  of  unstriped  muscle-fiber  mi.xed  often 
with  fibrous  tissue.  They  are  called  liomyomata.  Tumors  composed  of 
striated  muscle-fiber  and  spindle-cells  are  known  as  rhabdomyomata.  They 
are  very  rare  and  are  always  sarcomatous.  Liomyomata  are  found  in  the 
womb,  in  the  prostate  gland,  in  the  walls  of  the  gullet,  vagina,  stomach, 
bladder,  and  bowel,  in  the  broad  ligament,  ovary,  and  round  ligament,  in  the 
scrotum,  and  in  the  skin.  Myomata  usually  begin  during  or  after  middle 
age;  they  are  encapsuled,  they  grow  slowly,  they  are  firm  and  hard,  and 
produce  annoyance  by  their  size  and  weight  or  by  obstructing  a  viscus  or 


256  Tumors   or  Morbid   Growths 

channel.     A  homyoma  of  the  posterior  portion  of  the  middle  of  the  prostate 
gland  is  known  as  a  "  middle  lobe." 

The  so-called  uterine  fibroid  is  a  myoma  or  iibromyoma.  Uterine  niyo- 
mata  may  originate  within  the  walls  of  the  womb  (intramural  myomata), 
from  the  muscular  structure  of  the  mucous  lining  (submucous  myomata),  or 
from  the  muscular  tissue  of  the  serous  covering  (subserous  myomata).  Intra- 
mural uterine  myomata  may  be  single  or  multiple  and  may  grow  to  an  enor- 
mous size.  Submucous  myomata  project  into  the  cavity  of  the  womb  (fleshy 
polvps),  and  may  project  into  the  vagina.  They  distend  the  uterus  and  are 
often  accompanied  by  menorrhagia  or  metrorrhagia.  In  some  rare  cases  the 
projecting  tumor  is  detached  by  Nature  and  the  patient  is  cured ;  in  some  cases 
the  myoma  becomes  gangrenous.  A  fleshy  polyp  may  produce  inversion  of 
the  fundus  of  the  womb.  Subserous  uterine  myomata  cause  trouble  only  by 
the  inconvenience  of  weight  or  the  discomfort  of  pressure.  Uterine  myomata 
are  commonest  in  single  women,  and  arise  most  frequently  between  the  ages 
of  twenty-five  and  forty-five.  Negro  women  are  especially  prone  to  develop 
such  tumors.  They  may  never  produce  any  symptoms.  Some  of  these 
growths,  by  enlarging  until  they  ascend  above  the  pelvic  brim,  produce 
abdominal  distention;  some  become  jammed  or  impacted  in  the  pelvis,  and 
produce  by  pressure  retention  of  urine,  obstruction  to  the  passage  of  feces 
or  hydronephrosis.  Impaction  may  occur  temporarily  at  each  menstrual 
period.  Many  myomata  produce  uterine  hemorrhage;  some  cause  retro- 
version of  the  womb ;  some  protrude  from  the  cervical  canal ;  some  are  so  large 
that  they  cause  disastrous  pressure  upon  the  colon  (obstruction),  upon  the 
iliac  veins  (great  edema),  or  upon  the  ureters  (hydronephrosis).  Uterine 
myomata  usually  shrink  after  the  menopause.  Pregnancy  in  a  myomatous 
womb  usually  ends  in  abortion.  Uterine  myomata  may  undergo  fatty, 
calcareous,  or  myxomatous  change,  and  may  be  infected  by  septic  organisms 
as  a  result  of  the  use  of  a  uterine  sound  or  of  infection  of  the  pedicle  after 
oophorectomy.  Infection  of  a  uterine  myoma  causes  great  enlargement, 
elevated  temperature,  sweats,  and  exhaustion. 

The  symptoms  of  myomata  of  the  alimentary  canal  are  similar  to  or 
identical  with  the  symptoms  of  malignant  growths.  Myomata  of  the  skin 
are  rare  growths;  they  are  encapsuled,  firm  or  elastic,  and  painless. 

Treatment. — Cutaneous  myomata  are  removed  in  the  same  manner  as 
fibrous  tumors.  Uterine  myomata  are  treated  by  rest  and  the  administration 
of  ergot,  barium  chlorid,  and  dilute  sulphuric  acid.  If  this  treatment  fails 
to  arrest  serious  bleeding  due  to  a  flesh  polyp,  dilate  the  cervical  canal  and 
remove  the  growth.  If  there  be  dangerous  bleeding  in  a  woman  who  has 
some  years  to  wait  for  the  menopause  and  who  has  not  a  removable  polyp  as 
the  cause,  perform  oophorectomy  in  order  to  bring  on  an  artificial  menopause. 
When  a  myoma  becomes  impacted  at  each  menstrual  period, remove  the  ovaries 
and  Fallopian  tubes.  Subserous  myomata  may  be  removed  from  the  uterus 
after  abdominal  section,  the  resulting  wound  in  the  uterus  being  sutured. 
Hysterectomy  is  indicated  for  some  very  large  tumors,  for  tumors  that  grow 
after  the  menopause,  and  for  infected  myomata.  If  the  abdomen  be  opened 
to  perform  oophorectomy,  and  the  tubes  and  ovaries  are  found  .so  implicated 
in  the  growth  that  they  cannot  l)e  removed  completely,  or  the  broad  ligament 
is  found  so  drawn  out  that  a  safe  pedicle  cannot  be  secured,  |)erform  a  hyster- 


Neuromata  257 

ectomy.*  A  recent  suggestion  for  the  shrinkage  of  uterine  myomata  is  to 
ligate  both  the  uterine  and  ovarian  arteries.  If  a  myoma  of  the  prostate  causes 
severe  obstruction,  perform  a  suprapubic  cystotomy  and  remove  the  major 
portion  of  the  enlarged  gland;  or  make  both  a  suprapubic  and  a  perineal 
opening,  push  the  gland  into  the  perineum  and  shell  it  out  with  the  finger,  or 
make  permanent  suprapubic  drainage. 

Neuromata. — A  true  neuroma  springs  from  nerve-tissue  (brain,  cord,  or 
nerve-trunks) ;  it  is  composed  of  medullated  or  non-meduUated  nerve-fibers 
which  form  a  plexus  or  network,  and  which  are  not  continuous  with  the  fibers 
of  the  nerve-trunk  or  other  area  from  which  the  tumor  grows.  True  neuro- 
mata, which  are  rare  growths,  arise  during  middle  life;  they  are  small  in  size; 
are  due  to  injury  or  hereditary  tendency,  and  they  may  be  single  or  multiple. 
There  is  usually  around  the  tumor,  rather  than  in  it,  severe  neuralgic  pain, 
which  is  greatl}-  intensified  by  dampness,  by  blows,  or  by  rough  handling. 
The  parts  below  a  neuroma  are  cold,  swollen,  often  anesthetic,  and  frequently 
present  motor  paralysis  or  trophic  disorder.  A  false  neuroma  or  neurofibroma 
is  a  fibrous  tumor  growing  from  a  nerve-sheath,  and  is  identical  in  structure 
with  the  sheath.  False  neuromata  may  be  single,  but  they  are  often  multiple; 
they  may  be  as  small  as  peas  or  as  large  as  oranges;  they  are  smooth  and 
movable,  and  may  cause  great  pain  or  may  be  painful  only  when  pressed  or 
struck;  they  may  spring  from  roots,  trunks,  or  branches,  and  thev  may  be 
linked  with  the  disease  known  as  "' molhiscum  fibrosum.'"  In  plexijorm 
neuroma  some  branches  of  a  nerve  enlarge  and  lengthen  like  an  artery  in  a 
cirsoid  aneurysm ;  the  mass  feels  like  beads  or  like  a  bag  of  worms ;  it  is  mobile, 
and  no  pain  is  felt  on  moving  it;  and  it  is  generally  congenital.  In  plexiform 
neuroma  the  nerve-sheath  undergoes  myxomatous  change.  Malignant 
neuroma  is  a  primary  sarcoma  of  a  nerve-sheath,  though  any  neuroma  may 
become  sarcomatous. 

Traumatic  neuromata  are  false  neuromata  and  are  occasionally  well  ex- 
hibited after  nerve-section  or  amputation.  On  nerve-section  the  distal  end 
shrinks  and  atrophies,  the  proximal  end  enlarges  and  becomes  bulbous.  A 
traumatic  neuroma  is  composed  of  fibrous  tissue  which  contains  nerve-fibers. 
Such  a  growth  is  usually,  but  not  always,  painful  on  pressure  or  during  damp- 
ness, and  is  most  commonly  seen  in  a  stump  which  did  not  heal  by  first  inten- 
tion. In  performing  an  amputation  cut  the  nerves  high  up,  and  thus  keep 
them  out  of  the  scar,  permit  them  to  remain  mobile  in  their  sheaths,  and  so 
prevent  a  tender  stump.  A  tender  stump  may  be  due  to  anchoring  of  a  nerve 
in  a  scar,  the  nerve  ceasing  to  glide  when  the  individual  moves  the  extremity. 
The  condition  known  as  painful  subcutaneous  tubercle  was  discussed  on  page 
250. 

Treatment. — A  false  neuroma  is  to  be  removed,  if  possible,  without  de- 
stroying the  nerve-trunk.  If,  in  removing  a  neuroma,  it  is  necessary  to  exsect 
a  portion  of  a  nerve-trunk,  always  endeavor  to  suture  the  ends  of  the  di\'ided 
nerve  so  as  to  facilitate  restoration  of  function.  For  multiple  neuromata — at 
least  should  the  number  be  large  or  should  moUuscum  fibrosum  exist — surgery 
can  do  nothing.  Plexiform  neuromata  may  often  be  removed,  but  amputation 
may  be  required.     Painful  neuromata  in  stumps  should  be  excised. 

*  See  J.  Bland    Sutton's   admirable   article  on    "Uterine   Myomata"    in    his   work  on 
"Tumors." 
17 


258  Tumors  or   Morbid  Growths 

Qliomata. — These  tumors  develop  from  neurogha  and  more  often  from 
the  white  substance  than  from  the  gray.  They  are  usually  single,  and  arise 
in  the  brain,  rarely  in  the  cord,  and  \ery  rarely  in  the  cranial  nerves.  They 
may  take  origin  in  one  of  the  cerebral  hemispheres,  in  the  cerebellum,  in  the 
pons,  or  in  the  medulla.  Some  gliomata  are  soft  and  bear  a  close  relationship 
to  sarcoma ;  others  are  hard  and  resemble  fibroma. 

A  glioma  is  a  circumscribed  growth  in  contrast  to  a  gliosis,  which  is  a 
wide.spread  and  unlimited  hyperplasia  of  the  neuroglia.  Syringomyelia  is 
due  to  gliosis  of  the  spinal  cord. 

"A  glioma  consists  of  cells  containing  rounded  or  oval  nuclei  with  very 
little  protoplasm  and  fine  protoplasmic  extensions  which  interlace  and  form 
an  intercellular  reticulum"  (Stengel). 

A  glioma  passes  almost  insensibly  into  surrounding  tissue,  and  there  is  no 
distinct  edge;  hence,  because  of  the  slight  differentiation  from  brain  sub- 
stance, it  may  be  overlooked  during  exploration.  It  is  harder  than  the  sur- 
rounding tissue;  is  vascular  and  of  a  pink  or  red  color;  and  the  normal 
shape  of  the  part  is  often  very  little  altered,  although  the  tumor  may  reach 
the  size  of  a  lemon. 

Hemorrhage  may  take  place  into  a  glioma,  softening  may  occur,  cavities 
may  form,  or  the  growth  may  become  sarcomatous  or  psammomatous.  The 
symptoms  of  a  glioma  of  the  brain  depend  on  the  situation. 

Treatment. — When  the  growth  can  be  localized  it  is  justifiable  in  some 
cases  to  attempt  its  removal.     Even  a  partial  removal  may  be  of  benefit. 

.Angiomata  or  Hemangiomata. — An  angioma  is  a  tumor  composed 
largely  of  dilated  blood-vessels.  The  older  surgeons  called  such  growths 
erectile  tumors.  Some  of  the  so-called  angiomata  are  not  genuine  new  growths, 
but  are  due  to  dilatation  and  elongation  of  blood-vessels. 

Simple  or  capillary  angiomata,  nevi,  or  "mother's  marks,"  which 
affect  the  skin  or  subcutaneous  tissue,  are  composed  of  enlarged  and  twisted 
capillaries  and  of  anastomosing  vessels  surrounded  by  fat.  These  growths 
are  congenital  or  appear  in  the  first  few  weeks  of  life;  they  are  flat  and  sHghtly 
raised,  and  are  of  a  bright-pink  color  if  composed  chiefly  of  arterioles,  and 
are  bluish  if  composed  mainly  of  venules;  they  are  but  little  elevated;  they  can 
be  almost  completely  emptied  by  pressure;  they  occasionally  pass  away  spon- 
taneously, but  usually  grow  constantly  and  may  become  cavernous;  they  may 
ulcerate  and  occasion  violent  or  fatal  hemorrhage.  One  or  several  large 
vessels  connect  a  nevus  to  adjacent  blood-vessels.  Port-wine  or  claret 
stains  are  pink  or  blue  discolorations  due  to  superficial  nevi  of  the  skin;  they 
may  be  small  in  extent  or  they  may  involve  a  very  large  area,  are  not  elevated, 
and  do  not  usually  s[)read.  Te/anqiectasis  is  a  form  of  nevus  involving  the 
skin  and  subcutaneous  tissue  in  which  many  arterioles  and  venules  exist. 
Simple  angiomata  are  common  on  the  forehead,  the  scalp,  the  face,  the  neck, 
the  back,  and  the  extremities.  The\'  may  appear  on  the  labia,  the  tongue, 
or  the  lif)s. 

Cavernous  angiomata,  or  venous  nevi  (Fig.  85),  resemble  in  structure 
corpora  cavernosa  of  the  penis;  there  arc  large  endothelial  lined  .spaces  with 
thin  walls  carrying  blood,  and  there  may  be  distinct  vessels  as  well.  Arteries 
send  blood  into  the  spaces,  and  veins  receive  it  from  the  spaces.  These 
channels    and    sinuses    are    enormously    distended    capillaries.     Cavernous 


Treatment  of  Ancfiomata 


259 


Fig.  85. — Cavernous  angfioma  and  lymphangioma. 


angiomata  arise  in  the  skin  and  subcutaneous  tissues;  they  are  usually  con- 
genital, but  may  develop  from  simple  angiomata;  they  are  purple  or  blue  in 
color;  are  more  distinctly  elevated  than  the  capillary  nevi;  may  be  either 
cutaneous  or  subcutaneous;  swell  when  the  child  cries,  and  are  apt  to  pulsate; 
they  may  be  emptied  by  pressure, 
and  often  look  like  cysts  with  very 
thin  walls.  Cavernous  angiomata 
may  arise  in  the  breast,  the  tongue, 
the  lip,  the  cheek,  the  gums,  the 
subcutaneous  tissues,  or  the  mus- 
cles. If  an  angioma  contains  an 
excess  of  fat,  the  growth  is  called 
a  "nevoid  lipoma." 

Plexiform  angiomata  are 
known  as  "cirsoid  aneurysms" 
or  aneurysms  by  anastomosis 
(page  306). 

Angiomata  noticed  soon  after 
birth  may  disappear  completely 
or  may  enlarge  progressively. 

Treatment. — These  growths 
if  large  or  growing  must  be  treated. 
A  capillary  nevus  can  often  be 
quickly  cured  by  touching  it  with 

fuming  nitric  acid.  A  .second  application  of  acid  may  be  required.  The 
growth  may  be  destroyed  by  heat — "a  knitting-needle  at  a  dull-red  heat 
or  the  galvano-cautery"  (Wharton).      The  apphcation  of  ethylate  of  sodium 

or  the  employment  -of  electrolysis  will  de- 
stroy the  growth.  Astringent  injections 
are  dangerous  unless  the  base  of  the  nevus 
is  ligated,  because  they  may  lead  to  the 
formation  of  emboh. 

Small  port-wine  stains  may  be  removed 
by  electrolysis  or  multiple  incisions,  but 
extensive  stains  are  ineffaceable.  Small 
nevi  may  be  ligated  under  harelip  pins; 
larger  nevi  may  be  strangulated  in  sec- 
tions by  the  Erichsen  suture  (Fig.  86),  or 
may  be  completely  excised.  Excision  is 
usually  the  best  plan  for  the  cure  of  angio- 
mata. It  is  rapid,  thorough,  and  leaves 
but  a  trivial  scar.  Excision  should  always 
be  employed  if  we  feel  sure  that  the  edges 
of  the  wound  can  be  subsequently  approxi- 
mated and  that  there  will  not  be  a  danger- 
ous loss  of  blood.  It  is  sometimes  justifiable  to  excise  an  angioma  even  when 
approximation  of  the  wound  will  obviously  be  impossible.  In  such  a  case 
the  raw  surface  should  be  covered  with  Thiersch  grafts. 

Most  superficial  nevi  and  many  cavernous  angiomata  can  be  treated  by 


-Method  of  appl\  in 
ligature. 


26o  Tumors  or  Morbid   Growths 

excision.  Tlie  incisions  must  be  beyond  the  dilated  vessels.  In  large  angio- 
mata  involving  the  skin  and  also  deeper  parts,  or  involving  a  structure,  like 
the  lip.  which  it  is  undesirable  to  remove,  electrolysis  should  be  employed. 
The  operation  should  be  carried  out  with  aseptic  care,  and,  if  the  tumor  is 
large,  an  anesthetic  should  be  given. 

The  positive  pole  produces  a  firm  and  hard  clot.  One  or  more  needles 
connected  with  the  positive  pole  are  inserted  in  the  tumor,  and  these  needles 
are  insulated  to  within  about  a  quarter  of  an  inch  of  their  points.  A  flat 
moist  pad  is  placed  upon  the  skin  near  the  tumor  and  attached  to  the  negative 
pole,  and  the  pad  is  moved  from  time  to  time  during  the  operation. 

From  twenty-five  to  seventy-five  milliamperes  is  the  proper  strength,  and 
the  current  is  passed  for  ten  minutes.  The  current  is  increased  for  a  moment 
before  withdrawing  the  needles,  otherwise  they  will  stick  to  the  tissue  and 
cause  bleeding  when  torn  loose.  After  the  withdrawal  of  the  needles  the 
nevus  will  be  found  to  be  hard,  but  the  hardness  will  gradually  disappear. 
It  mav  be  necessary  to  repeat  the  operation  a  number  of  times  at  intervals  of 
ten  days.* 

Lymphangiomata  are  tumors  composed  of  dilated  lymph-vessels  and 
are  often,  though  not  invariably,  congenital.  A  lymphatic  nevus  is  a  color- 
less or  faintly  pink  elevation;  if  it  is  punctured  with  a  needle,  lymph  flows 
from  the  puncture.  One  or  several  nevi  may  be  present  in  the  same  in- 
dividual. The  dilatation  is  due  to  blocking  of  the  lymph-channels.  Local 
lymphangioma  of  the  tongue  is  manifested  by  a  cluster  of  papillary  projections 
containing  lymph.  Macroglossia  is  a  congenital  enlargement  of  the  anterior 
portion  of  the  tongue,  which  enlargement  grows  more  and  more  marked  until 
finally  the  tongue  is  forced  far  out  of  the  mouth.  This  condition  of  tongue 
enlargement  is  due  to  lymphangioma  of  the  mucous  membrane.  Lymph 
scrotum  is  due  to  a  similar  growth.  A  collection  of  these  warty-looking  dila- 
tations is  called  lymphangiectasis.  Just  as  cavernous  angiomata  constitute 
a  variety  of  blood-vessel  tumors,  so  cavernous  lymphangiomata  constitute  a 
varietv  of  lymph-vessel  tumors,  and  the  spaces  of  the  latter  are  filled  with 
lymph  instead  of  with  blood.  Areas  affected  with  lymphangiectasis  are  liable 
to  repeated  attacks  of  erysipelas-like  inflammation.  Whether  this  inflam- 
mation is  causative  or  secondary  is  not  known.  In  tropical  countries  blocking 
of  Ivmph-channels  may  be  brought  about  by  the  filaria  sanguinis  hominis,  a 
parasite  which  lurks  in  the  lymph-vessels  during  the  day  and  is  found  in  the 
blood  only  at  night-.  Lymphangiectasis  is  often  the  first  stage  of  an  ele- 
phantiasis. 

Treatment. — A  lymphatic  nevus  requires  excision.  In  macroglossia  the 
bulk  of  the  mass  should  be  removed  by  a  V-shaped, cut,  the  mucous  mem- 
brane being  sutured  so  as  to  cover  the  stump.  In  conditions  due  to  the  filaria, 
anilin-blue  has  been  given  internally. 

Malignant  Connective=tissue  Tumors,  or  Sarcomata.— The  sar- 
comata are  composed  of  embryonic  tissue-cells,  the  intercellular  substance 
being  very  scanty.  They  develop  from  connective  tis.sue,  rarely  have  a 
definite  stroma,  and  the  constituent  cells,  as  a  rule,  proliferate  with  great 
rapidity.  If  a  sarcoma  has  a  stroma  of  connective  tissue,  this  stroma  contains 
lymphatics  and  such  a  sarcoma  infects  adjacent  glands.  In  most  cases  there 
*  Cheyne  and  Burghard's  "Manual  of  Surgical  Treatment." 


Malignant  Connective-tissue  Tumors,  or  Sarcomata 


261 


is  no  connective-tissue  stroma  and  no  lymphatics.  In  a  sarcoma  without 
a  definite  stroma  the  blood-vessels  are  not  surrounded  by  lymph-spaces  and 
are  quickly  invaded  by  cells  (B.  H.  Buxton).  The  rapidly  growing  forms 
are  very  vascular,  the  blood  flowing  in  vessels  whose  walls  are  \'ery  thin  or 
running  in  canals  lined  by  endothelium  and  bounded  by  sarcomatous  cells. 
Such  a  tumor  may  pulsate  and  have  a  bruit,  and  hemorrhage  often  takes  place 
into  its  substance.  A  slow-growing  sarcoma  has  but  few  vessels.  Sarcoma 
tends  strongly  to  infiltrate  adjacent  parts.  The  growth  disseminates  by 
means  of  the  blood  and  the  vessel-walls,  particles  of  the  tumor  being  carried 
by  the  venous  blood  to  the  heart  and  from  this  organ  to  the  lungs,  where  they 
lodge  and  form  secondary  growths.  Emboli  from  these  secondary  foci  are 
sent  out  by  the  arterial  blood  to  various  portions  of  the  body,  as  the  bones, 
kidneys,  brain,  liver,  etc.  This  process  is  known  as  "metastasis."  In  some 
cases  sarcoma  is  disseminated  widely  throughout  the  body,  almost  all  the 
tissues  showing  minute  white  spots 
of  secondary  sarcoma  which  re 
semble  tubercles.  Such  widespread 
dissemination  is  called  sarcomato- 
sis.  Sarcoma  follows  the  vein- 
walls  for  considerable  distances 
and  builds  elongated  masses  of 
tumor-substance  inside  the  veins. 
The  tumor  may  possess  a  capsule 
when  it  is  in  an  early  stage,  but 
soon  loses  this  except  in  ver}'  slow- 
growing  varieties  or  in  mixed  forms 
growing  by  central  proliferation, 
but  secondary  sarcomata  are  often 
encapsuled.  Sarcomata  may  arise 
at  any  age  from  birth  to  extreme 
senility,  but  they  are  commonest 
during  youth  and  early  middle 
age.     They  are  not  hereditary,  and 

often  follow  traumatism  and  inflammation.  A  number  of  observers  main- 
tain that  they  are  due  to  parasites  (the  question  of  the  parasitic  origin 
of  malignant  disease  is  discussed  on  page  246).  A  sarcoma  may  be 
primary  or  may  arise  from  malignant  change  in  an  innocent  connec- 
tive-tissue growth  (chondrosarcoma,  fibrosarcoma,  etc.).  A  sarcoma  rarely 
affects  adjacent  lymphatic  glands  unless  it  contains  lymphatics,  and  the 
great  majority  of  sarcomata  do  not  contain  them.  Occasionally  sarcoma- 
cells  are  carried  to  adjacent  glands  by  the  vein-walls  rather  than  by  the  lymph- 
stream.  Sarcoma  of  the  tonsil,  sarcoma  of  the  testicle,  melanotic  sarcoma, 
and  lymphosarcoma  do  aft'ect  the  glands.  The  skin  over  the  tumor  may  give 
way,  a  bleeding  fungus-mass  protruding  (fungus  h?ematodes),  and  suppura- 
tion may  cause  septic  enlargement  of  adjacent  glands.  After  i-emoval  of  a 
sarcoma  the  growth  tends  to  recur,  and  the  recurrent  tumor  may  he  either 
more  or  less  malignant  than  its  predecessor,  the  degree  of  malignancy  being 
in  direct  ratio  to  the  number  and  smallness  of  the  cells.  A  sarcoma  is  malig- 
nant bv  local  tissue-infection  and  bv  dissemination.     Sarcomata  rareh'  cause 


Fio^.  ^7. — Sarcoma  of  the  aiilrum. 


262 


Tumors  or  Morbid   Growths 


pain  when  they  are  not  ulcerated.  They  are  commonest  in  the  skin  and  con- 
nective tissue  of  the  extremities,  but  they  arise  also  from  bone,  neuroglia, 
periosteum,  the  lymphatic  glands,  the  breast,  the  testicle,  the  eyeball,  the 
parotid,  and  other  parts.  Not  unusually  a  pigmented  mole  becomes  sarco- 
matous. Hemorrhages  into  a  sarcoma  often  occur,  with  the  result  of  sud- 
denly increasing  the  size  of  the  mass  and  forming  blood-cysts.  Sarcomata 
are  subject  to  partial  fatty  degeneration,  to  myomatous  changes  which 
produce  cavities  filled  with  fluid,  to  calcification,  and  occasionally  to  necrosis 
of  large  masses. 

Varieties  of  Sarcomata. — The  following  species  of  sarcomata  are  recog- 
nized : 

I.  Round-celled  Sarcoma. — A  tumor  composed  of  round  or  spherical  cells. 
The  intercellular  substance  is  scanty,  the  mass  is  soft  and  vascular,  and  grows 
with  great  rapidity.     It  often  softens,  and  may  become  cystic.     The  cells 


Fig.  SS. — Sniall-celled  sarcoma  of  the  neck. 


may  be  small  or  large.  The  smaller  the  cells  the  more  malignant  the  growth 
(Fig.  88).  A  growth  composed  of  small  round  cells  is  the  most  mahgnant 
form  of  sarcoma.  Lymphosarcoma  is  a  form  of  round-celled  sarcoma  which 
arises  from  lymphatic  glands,  lymphoid  tissues,  the  thymus  gland,  the  spleen, 
and  some  other  structures.  The  structure  of  a  lymphosarcoma  resembles  the 
structure  of  a  lymph-gland  in  the  fact  that  it  has  a  reticulum  which  looks 
like  lymphadenoid  structure.  Chloroma  is  a  form  of  lymphosarcoma  arising 
particularly  from  the  periosteum  of  the  bones  of  the  cranium  and  face.  The 
cells  contain  greenish  pigment,  hence  the  name.  What  is  known  as  glioma 
of  the  eyeball  is  not  a  true  glioma,  but  is  really  a  sarcoma  composed  of  small 
round  cells. 

2.  Spindle-celled  Sarcoma. — A  tumor  comj)osed  of  large  or  small  spindle- 
shaped  cells  lying  in  a  matri.x,  which  may  be  homogeneous,  but  which  may 
show  some  attempt  at  fi!)er-formation.     Angular  cells  and  stellate  cells  are 


Varieties   of   Sarcomata 


263 


often  present.  The  cells  may  be  placed  in  columns,  which  are  at  some  places 
nearly  parallel,  and  which  at  others  diverge  or  interlace.  Often  there  is  no 
orderly  arrangement.  Spindle-celled  sarcomata  are  usually  harder  than 
round-celled  growths,  but  are  sometimes  quite  .soft.  Cystic  changes  mav 
occur.  If  there  is  a  large  amount  of  intercellular  substance  the  growth  is 
known  as  a  fibrosarcoma.  A  rhabdomyoma  is  really  a  spindle-celled  sar- 
coma containing  striated  muscle-cells.  The  spindle-celled  sarcomata  often 
contain  cartilage.  Spindle-celled  growths  are  by  no  means  as  malignant  as 
round-celled  tumors.  Often  they  do  not  show  any  tendency  to  metastasis. 
The  greater  the  amount  of  intercellular  substance,  and  the  fewer  and  smaller 
the  cells,  the  less  the  malignancy.  Spindle-celled  growths  constitute  the 
majority  of  sarcomata  met  with  in  practice. 

3.  Giant-celled  or  myeloid  sarcoma  is  characterized  by  the  presence  of  very 
large  cells,  with  many  nuclei  looking  exactly  like  the  myeloplaques  of  bone- 


Fig.  Sq. — Melanotic  sarcoma. 


marrow.  The  remainder  of  the  growth  is  composed  of  spindle-cells,  of 
round-cells,  or  of  both  spindle-cells  and  round-cells.  Such  a  growth  is 
maroon-colored  on  section.  It  arises  most  usually  from  bone,  especialh' 
from  the  interior  of  a  long  bone,  hence  is  often  called  osteosarcoma.  It  mav, 
however,  arise  from  other  structures  than  bone.  It  is  the  least  malignant 
form  of  sarcoma.  Metastases  rarely  occur,  and  the  growth  often  admits  of 
complete  extirpation  and  cure. 

4.  Alveolar  Sarcoma. — A  tumor  containing  both  round-cells  and  spindle- 
cells,  and  characterized  by  the  formation  of  acini,  filled  with  round-cells  of 
large  size  resembling  epithelioid  cells.  The  walls  of  the  acini  are  formed  of 
spindle-cells  and  fibrous  tissue,  and  in  these  trabeculi  are  the  blood-vessels. 
The  collection  of  the  cells  into  the  alveoli  makes  the  structure  resemble  that 
of  a  cancer.     Such  growths  are  often  pigmented.     Alveolar  sarcomata  arise 


264  Tumors  or  Morbid  Growths 

particularly  from  moles  of  the  skin,  but  may  arise  from  lymphatic  glands, 
serous  membranes,  the  testicle,  and  other  parts.  Such  growths  are  very 
mahgnant. 

5.  Melanotic  or  Black  Sarcoma  (Fig.  89). — The  color  of  such  a  tumor  is  due 
to  pigment  in  the  cells  or  matrix.  These  growths  are  usually  composed  of 
round-cells,  but  may  consist  of  spindle-cells,  and  they  are  sometimes  alveolar. 
Melanotic  sarcomata  spring  from  parts  which  contain  pigment  (the  skin  and 
the  choroid  coat  of  the  eye);  they  are  apt  to  arise  from  pigmented  moles; 
they  are  very  malignant;  they  implicate  related  lymphatic  glands,  and  during 
their  existence  the  urine  contains  pigment. 

6.  Hemorrhagic  sarcoma  is  a  sarcoma  containing  blood-cysts  which  result 
from  parenchymatous  hemorrhages. 

7.  Angiosarcoma  takes  origin  from  the  outer  coat  of  a  blood-vessel.  The 
growth  is  often  very  vascular,  and  when  the  blood-vessels  are  notably  dilated 
the  tumor  is  called  a  telangiectatic  sarcoma.  The  ordinary  forms  of  angio- 
sarcoma are  only  moderately  malignant,  but  alveolar  and  melanotic  forms 
occur  which  are  highly  malignant.  Angiosarcoma  may  arise  in  the  skin,  in 
a  serous  membrane,  and  in  a  salivary  gland. 

8.  Cylindroma,  or  Plexijorm  Sarcoma. — In  this  variety  the  cells  adjacent 
to  vessels  have  undergone  hyaline  or  myxomatous  degeneration;  the  cells 
distant  from  vessels  are  unchanged.  Section  shows  the  normal  cells  appar- 
ently contained  in  spaces  with  hyaline  walls.  These  degenerative  changes 
occur  most  often  in  the  angiosarcomata.  Cylindromata  arise  from  the  brain, 
salivary  glands,  lachrymal  glands,  and  rarely  from  the  subcutaneous  tissue. 
The  growths  are  only  moderately  malignant.* 

9.  Mixed  tumors  consist  partly  of  mature  and  partly  of  embryonic  tissue, 
the  cellular  elements  exceeding  the  adult  elements  in  amount.  Among  these 
mixed  tumors  are  fibrosarcoma  or  the  recurrent  fibroid  tumor,  myxosarcoma, 
chondrosarcoma,  gliosarcoma,  and  osteosarcoma. 

10.  Endotheliomata  are  tumors  springing  from  endothelium,  and  the  name 
is  retained  no  matter  what  change  the  growth  ultimately  undergoes.  Many 
writers  include  under  the  term  endothelioma  psammoma,  myxosarcoma, 
angiosarcoma,  and  plexiform  sarcoma.  Others  consider  endothelioma  a 
.special  and  characteristic  form  of  sarcoma.  Some  would  not  consider  it  with 
the  sarcomata  at  all.  The  growth  may  take' origin  from  the  "endothe- 
lium of  the  blood-vessels  and  of  the  perivascular  lymph-spaces,  of  the  lymph- 
vessels,  and  of  the  great  serous  cavities  (peritoneum,  pleura,  meninges)."! 
The  characteristic  cell  is  the  endothelial  cell,  usually  known  as  the  epithe- 
lioid cell.  The  structure  of  these  tumors  is  very  variable  and  depends  upon 
the  origin.  Some  tumors  "recalling  the  original  vascular  network"  ("Amer- 
ican Text-Book  of  Pathology"),  others  being  distinctly  alveolar.  Many 
pathologists  consider  a  psammoma  of  the  dura  to  be  an  endothelioma  with  a 
fibrous  stroma.  A  psammoma  contains  calcareous  particles.  In  appear- 
ance an  endothelioma  strongly  resembles  cancer,  and  such  a  growth  is  often 
spoken  of  as  endothelial  cancer.  Such  growths  can  arise  in  many  different 
situations,  but  are  particularly  common  in  the  peritoneum,  pleural  mem- 
brane, membranes  of  the  brain,  ovary,  and  testicle.      T  have  removed  an 

*. Stengel,  "Text-book  of  Pathology." 

f  "  An  American  Text-Book  of  Pathology,"  edilefl  by  llektoen  .and  Reisman. 


Treatment  of  Sarcomata 


265 


endothelioma  of  the  tonsil,  and  also  one  of  the  mammary  gland.  The  pro- 
liferating endothelial  cells  lie  in  lymph-spaces.  Many  endotheliomata  grow 
rapidly,  secondary  growths  form,  and  metastases  are  apt  to  pass  to  the 
serous  membranes.  Certain  endotheliomata  grow  slowly,  do  not  infiltrate 
adjacent  structure,  and  do  not  produce  secondary  growths.  In  the  brain 
and  cord  endothelioma  may  produce  no  symptoms  for  a  long  time.  It  is 
not  as  yet  possible,  clinically,  to  distinctly  recognize  endotheliomata  from 
ordinary  sarcomata. 

II.  Mycosis  jitngo'ides  is  a   disease   which   resembles   sarcoma   in   many 


^S^^^^^^^^^^^^k 

V 

fl^l 

i 

w^ 

i 

'^^^^^B 

^^H^l^l 

p 

m 

'■■f^^^K^^^^t^^ 

9 

W 

,' j^^S^H^^H^^K' 

^m 

v^B 

<>lj^B| 

P 

'^^^^^^^^Mi 

Fig.  90. — Sarcoma  of  the  fibula. 


particulars  and  may  be  a  form  of  sarcoma.  It  attacks  the  skin  and  sub- 
cutaneous tissues.  The  skin  at  first  becomes  red  and  swollen;  numerous 
nodules  form;  the  nodules  become  distinct  tumors,  soften  at  their  centers, 
and  fungation  occurs.  Microscopically  the  tumor  resembles  a  lymphad- 
enoma.  Mycosis  fungoides  is  considered  by  some  pathologists  to  be  multiple 
cutaneous  sarcoma. 

Treatment  of  Sarcomata. — Remove  a  sarcoma  at  once  if  it  is  in  an 
accessible  spot.  Never  delay  removal.  Cut  well  clear  of  it.  If  affecting  a 
part  where  amputation  is  impossible,  the  rapidly  growing  sarcomata  will 
almost  inevitablv  return,  and  the  verv  malignant  varietv,  if  uninterfered  with, 


266  Tumors  or  Morbid  Growths 

may  terminate  life  in  six  months;  but  even  in  such  case  operation  postpones 
the  evil  day  and  renders  it  possible  that  death  will  occur  from  metastatic 
growth  in  an  organ,  and  that  the  patient  will  escape  the  horrors  of  ulceration 
and  hemorrhage  from  the  original  tumor.  Slowly  growing  and  hard  tumors 
offer  some  prospects  of  cure.  The  mixed  tumor  (as  a  recurrent  fibroid)  may 
repeatedlv  recur,  and  yet  the  patient  may  be  cured  at  last  by  a  sixth,  an 
eighth,  or  a  tenth  operation.  In  a  case  of  spindle-celled  sarcoma  of  the  breast 
the  vounger  Gross  performed  22  operations  in  the  course  of  four  years,  and 
eleven  years  later  the  woman  was  well.  In  sarcoma  of  a  long  bone  amputa- 
tion should.,  as  a  rule,  be  performed,  though  in  .some  cases  of  giant-celled 
sarcoma  of  the  radius,  ulna,  or  fibula  excision  may  be  employed.  In  sarcoma 
of  either  jaw-bone,  excision;  of  the  eye,  enucleation;  and  of  the  testicle, 
castration,  is  demanded.  Sarcoma  of  the  ovary  in  adults  demands  removal, 
but  in  children  the  operation  is  generally  useless.  Sarcoma  of  the  kidney 
in  adults  calls  for  nephrectomy,  but  in  children  the  operation  is  usually  of 
little  avail.  In  my  experience,  in  the  cases  of  sarcoma  of  the  kidney  which 
survived  operation,  the  growth  always  appeared  in  the  other  kidney.  In 
melanotic  sarcoma  remove  the  growth  and  adjacent  lymph-glands,  or  in 
some  cases  amputate.  Removal  of  a  sarcoma  when  there  is  no  hope 
of  a  cure  is  often  justifiable  to  prolong  life,  to  relieve  the  patient  of  a 
foul,  offensive,  bleeding  mass,  and  to  permit  of  an  easier  road  to  death  by 
means  of  metastasis  to  an  internal  organ.  In  an  inoperable  case  the  ligation 
of  the  vessel  of  supply  may  do  good.  In  sarcoma  of  the  tonsil  Dawbarn 
advises  the  extirpation  of  the  external  carotid  artery  and  the  ligation  of  its 
branches.  The  operation  is  performed  first  on  one  side  of  the  tumor  and  in  a 
week  or  so  on  the  other  side.  I  employed  it  in  3  cases  with  distinct  benefit. 
Occasionally,  though  very  rarely,  suppuration  cures  a  sarcoma.  Wyeth,  of 
New  York,  reported  a  case  of  sarcoma  of  the  abdominal  wall.  It  was  found 
possible  to  remove  only  part  of  the  growth;  suppuration  followed  and  the 
tumor  disappeared,  and  ten  years  later  had  not  returned.  A  study  of  statistics 
seems  to  indicate  that  more  cases  of  sarcoma  are  cured  after  operation  if  the 
wound  suppurates  than  if  it  remains  aseptic,  and  it  has  been  proposed  to 
deliberately  infect  the  wound  with  pus  germs  to  lessen  the  danger  of  recur- 
rence.    This  proceeding,  however,  is  dangerous  to  life. 

It  has  been  observed  that  an  attack  of  erysipelas  occasionally  greatly 
benefits  a  sarcoma,  causing  large  masses  of  the  growth  to  soften  or  to  slough 
and  exposing  a  granulating  surface.  Busch  noticed  this  in  1866,  but  the  fact 
had  been  observed  in  the  seventeenth  century.  Interest  was  decidedly 
awakened  by  Billroth's  case  of  sarcoma  of  the  pharynx  which  was  cured  by 
an  attack  of  facial  erysipelas.  It  was  suggested  that  in  inoperable  cases  of 
sarcoma  erysipelas  might  be  estabhshed  artificially.  Fehleisen  inoculated 
tumors  with  cultures  of  erysipelas.  Lassar,  in  1891,  employed  the  toxins 
(cultures  rendered  sterile  by  heat  and  filtration).  In  [892  Coley  began  his 
observations.  The  first  plan  was  as  follows:  a  bouillon  culture  is  made  of 
the  streptococci;  this  culture  is  filtered  through  porcelain  and  an  injection  is 
given  once  a  day  into  and  about  the  sarcoma.  The  first  dose  is  ^,x,  and  it  is 
progressively  increased;  it  should  cause  a  febrile  reaction,  and  sometimes 
establishes  softening  or  suppuration.  Coley's  present  method  is  as  follows: 
make  cultures  of  erysipelas  cocci  in  cacao  broth;  after  three  weeks  inoculate 


Papillomata,  or  Warts  267 

them  with  the  bacillus  prodigiosus,  and  cultivate  the  mixed  growth  for  four 
weeks.  The  mixed  cultures  are  maintained  at  a  temperature  of  136°  F.  until 
they  become  sterile.  This  sterile  fluid  contains  the  toxins.  The  dose  is 
from  I  to  8  minims.  The  material  is  very  powerful  and  may  cause  high  fever. 
Begin  with  a  small  dose  and  gradually  increase  until  the  proper  amount  of 
reaction  ensues  (io3°-io4°  F.).  The  injection  may  be  about  the  sarcoma 
or  at  a  distant  point.  It  seems  definitely  proved  that  cases  are  occasionally 
cured  by  Coley's  fluid.  Spindle-celled  sarcomata  are  influenced  most  favor- 
ably. Round-celled  sarcomata  are  very  refractory  and  so  are  cancers.  The 
method  is  not  entirely  free  from  danger.  It  seems  of  value  in  post-operative 
cases  to  prevent  recurrence.  For  this  purpose  it  is  applied  twice  a  week  for 
several  months.  Emmerich  and  SchoU  claim  good  results  from  the  injection 
of  erysipelas  serum.  A  sheep  is  injected  with  cultures  of  erysipelas,  the  blood 
is  drawn,  the  serum  separated,  filtered  to  remove  cocci,  and  injected  about 
the  sarcoma.  Results  are  not  definite.  Among  other  agents  which  have  been 
used  to  inject  inoperable  sarcomata  we  may  mention  alcohol,  chlorid  of  zinc, 
arsenic,  corrosive  sublimate,  thiosinamin,  pepsin,  alkahes,  etc.  The  injection 
of  anilin  products  into  the  sarcoma,  which  has  received  a  qualified  commenda- 
tion from  some  observers,  has  been  abandoned  by  most  surgeons.  The 
.v-rays  are  sometimes  of  benefit,  but  are  not  so  serviceable  as  in  carcinoma. 

Adrenal  Tumors. — Some  of  these  tumors  bear  a  strong  resemblance 
to  adenomata  and  carcinomata.  Some  adrenal  tumors  are  benign,  and 
among  such  tumors  we  note  fatty  growth,  fibrous  growth,  and  a  growth  re- 
sembling glioma.  Another  benign  growth  imitates  the  structure  of  the  cortex 
of  the  adrenal.  Malignant  tumors  occur,  and  many  of  them  are  identical  or 
almost  identical  with  sarcoma.  One  form  is  composed  of  epithelioid  cells 
and  resembles  endothelioma. 

Accessory  adrenals  are  common.  They  are  known  as  adrenal  rests. 
"They  are  found  oftenest  in  the  connective  tissue  about  the  main  adrenals, 
but  also  in  the  kidneys,  the  right  lobe  of  the  liver,  along  the  renal  vessels  and 
spermatic  veins,  in  the  inguinal  canals,  and  in  the  broad  ligaments"  ("Amer- 
ican Text-Book  of  Pathology").     Tumors  may  take  origin  from  adrenal  rests. 

Innocent  Epithelial  Tumors. — These  growths  imitate  an  epithe- 
lial tissue  of  the  mature  and  healthy  organism. 

Papillomata,  or  Warts. — Papillomata  are  formed  upon  the  type  of 
cutaneous  and  mucous  papilla?.  A  papilloma  consists  of  a  fibrous  stroma 
which  contains  blood-vessels  and  lymphatics  and  is  covered  with  epithelium 
of  the  variety  appertaining  to  the  diseased  part.  Papillomata  grow  from 
the  skin  and  from  mucous  membranes;  they  may  be  single  or  multiple;  many 
may  form  in  one  region  or  various  distant  parts  may  be  aft'ected ;  they  may  be 
painless  or  may  be  ulcerated  or  bleeding;  they  \ar}-  in  color  from  light  pink 
to  deep  brown  or  black.  Papillomata  of  the  skin  are  usually  hard;  papillo- 
mata of  mucous  membranes  are  soft.  A  skin-wart  may  be  smooth  and 
rounded,  or  may  look  like  a  cauliflower,  the  epidermis  upon  it  being  very 
rough.  A  papilloma  of  a  mucous  membrane  looks  hke  a  cauliflower.  Papil- 
lomatous masses  may  gather  around  the  anus,  the  vagina,  or  the  penis  during 
the  existence  of  a  filthy  discharge  {venereal  warts)  (Fig.  91),  and  crops  of  warts 
may  appear  on  the  hands  of  those  who  work  in  irritant  material  (as  petroleum). 
Papillomata  are  apt  to  arise  in  mucous  membranes  about  carcinomata  or 


268 


Tumors  or  Morbid  Growths 


chronic  ulcerations.  A  large  crop  of  warts  may  disappear  in  a  single  night; 
hence  the  popular  belief  in  the  elBcacy  of  charms.  Warts  are  particularly 
common  on  the  skin  of  the  back  of  the  hands  and  fingers,  the  skin  of  the  back, 
and  the  skin  of  the  neck  and  scalp.  A  single  skin-wart  may  reach  the  size 
of  a  walnut  and  become  pigmented.  The  squamous  epithelium  covering 
a  skin-wart  may  become  horny  (a  wart-horn).  Other  cutaneous  horns  arise 
from  the  nails,  from  the  scars  of  burns,  or  from  ruptured  sebaceous  cysts. 

Villous  papillomata  grow  chiefly  from  the  bladder,  but  they  may  also  grow 
from  the  stomach  and  intestine.  A  papilloma  of  mucous  membrane  covered 
with  squamous  epithelium  looks  like  a  wart  of  the  skin.  Papillomata  of  the 
larynx  are  formed  of  squamous  epithelium.  Villous  papillomata  form  tufts 
like  the  villous  processes  of  the  chorion;  they  may  be  single  or  multiple,  and 
may  be  sessile  or  pedunculated;  they  are  very  vascular,  and  are  apt  to  bleed 
freely.     Papillomata  may  arise  in  cysts  of  the  paroophoron,  in  cysts  of  the 


Fig.  91. — Venereal  warts. 


mammary  gland,  from  the  choroid  plexuses  of  the  ventricles  of  the  brain, 
and  from  the  spinal  membranes.  Papillomata  may  give  rise  to  hemorrhage 
or  may  impair  the  function  of  a  part.  Any  papilloma  may  become  a  cancer. 
Treatment. — Venereal  warts  are  treated  by  repeatedly  washing  with 
peroxid  of  hydrogen,  drying  with  cotton,  and  dusting  with  a  powder  composed 
of  borated  talcum  or  of  equal  parts  of  calomel  and  subnitrate  of  bismuth,  or 
of  oxid  of  zinc  and  iodoform.  If  the\'  do  not  soon  dry  up,  cut  them  off  with 
scissors  and  burn  with  the  Paquelin  cautery.  Ordinary  warts  may  usually 
be  destroyed  in  a  short  time  by  daily  ap})lications  of  lactic  or  chromic  acid. 
In  multiple  warts  of  the  face  Kaposi  applies  daily  for  several  days  a  portion 
of  the  following  combination:  sublimed  sulphur,  .^v;  glycerin,  .5iss;  acetic 
acid,  .^iiss.  Keeping  a  wart  constantly  moist  with  castor  oil  will  usually  cause 
it  to  drop  off.  Warts,  and  even  extensive  callosities,  may  be  removed  by 
y)ainting  once  a  day  for  five  days  with  pure  carbolic  acid  and  covering  with 


Malignant  Epithelial  Tumors,  Carcinomata,  or  Cancers       269 

lint  kept  wet  with  boric  acid.  A  convenient  plan  is  to  paint  a  wart  daily  with 
a  solution  containing  i  part  of  corrosive  sublimate  to  30  parts  of  collodion 
(hydrarg.  chlor.  corros.,  3ss;  collodion,  oxv).  Large  warts  should  be 
excised.  Villous  papillomata  of  the  bladder  demand  the  performance  of  a 
suprapubic  cystotomy  in  order  to  remove  them.  A  papilloma  of  the  larynx 
may  be  removed  with  the  cautery  loop  or  may  be  destroyed  with  the  cautery. 

Adenomata. — Adenomata  are  tumors  corresponding  in  structure  to 
normal  epithelial  glands.  The\'  ha\e  a  framework  of  vascular  connective 
tissue,  and  they  may  contain  acini  and  ducts  like  racemose  glands  or  tubes 
like  tubular  glands.  The  acini  or  tubules  contain  epithelium  of  either  the 
cylindrical  or  polyhedral  variet}'.  Adenomata  grow  from  secreting  glands, 
but  cannot  produce  the  secretion  of  the  glands  from  which  they  spring;  or, 
if  they  do  secrete,  the  fluid  is  retained,  and  not  discharged  by  the  gland-ducts. 
Adenomata  occur  in  the  mammary  gland,  the  parotid,  the  ovary,  the  thyroid 
gland,  the  liver,  the  sweat-glands,  the  sebaceous  glands,  the  kidney,  the 
pylorus,  and  the  prostate;  and  they  may  spring  as  pedunculated  growths 
from  the  mucous  lining  of  the  intestine  and  uterus.  They  are  encapsuled, 
are  usually  single,  but  may  be  multiple,  are  of  slow  growth,  but  may  attain  a. 
great  size;  they  do  not  tend  to  recur  after  thorough  removal,  do  not  invoh'e 
adjacent  glands,  and  do  not  disseminate;  they  are  firm  to  the  touch;  they 
tend  to  become  cystic  (especially  in  the  thyroid  gland),  the  fluid  which  dis- 
tends the  ducts  being  due  to  mucoid  liquefaction  of  the  proliferating  epithe- 
lium. If  cysts  form,  the  growth  is  spoken  of  as  a  cystic  adenoma.  If  the 
framework  of  an  adenoma  contains  considerable  fibrous  tissue,  the  tumor 
is  named  a  fibro-adenoma.  Adenomata  are  particularly  liable  to  become 
carcinomatous. 

In  the  breast  a  fibro-adenoma  has  a  distinct  capsule;  it  is  elastic  and 
movable,  is  usually  superficial,  and  one  occasionally  exists  in  each  gland. 
They  are  most  common  before  the  age  of  thirty,  and  are  often  painful,  espe- 
cially during  menstruation.  Cystic  adenomata  of  the  breast  attain  a  large 
size;  they  are  encapsuled  and  grow  slowly,  are  most  common  after  the  thirtieth 
year,  and  are  rarely  painful.  Both  fibro-adenoma  and  cystic  adenoma  may 
arise  in  the  male  breast.  Young  unmarried  women  not  unusually  develop 
in  the  breast  small,  very  tender,  and  painful  bodies,  most  usually  around 
the  edge  of  the  areola,  which  bodies  increase  in  size  and  become  more  tender 
during  menstruation;  they  are  only  cysts  of  the  mammary  tissue. 

Adenomata  of  the  thyroid  gland  usuall}-  begin  before  the  fifteenth  }-ear. 
Adenomata  may  arise  in  the  prostate  if  that  gland  be  already  the  seat  of  senile 
hypertrophy.  Adenomata  of  mucous  glands  may  arise  in  the  young  or 
middle-aged.  Adenomata  of  mucous  membranes  often  cause  hemorrhage 
and  interfere  with  function. 

Treatment. — Adenomata  should  be  extirpated.  To  let  them  alone  ex- 
poses the  patient  to  the  danger  of  cancerous  change.  By  confusing  adeno- 
mata of  the  mammary  gland  with  small  cysts  of  that  structure  an  erroneous 
belief  has  arisen  that  the  former,  as  well  as  the  latter,  may  sometimes  be 
cured  by  the  local  use  of  iodin,  mercury,  ichthyol,  and  the  internal  use  of  iodid 
of  potassium.     The  treatment  in  the  breast,  as  elsewhere,  is  excision. 

Malignant    Epithelial    Tumors,   Carcinomata,   or    Cancers.— 

Cancers  are  tumors  growing  from  epithelial  surfaces,  and  are  composed  of 


70 


Tumors  or  Morbid  Growths 


embryonic  epithelial  cells  which  are  clustered  in  spaces,  nests,  or  alveoH  of 
fibrous  tissue,  and  which  proliferate  enormousl}-,  extending  beyond  normal 
anatomical  boundaries  and  as  an  invading  host  entering  into  connective  tissue. 
This  unrestrained  and  unlimited  reproduction  of  epithehal  cells  is  the  char- 
acteristic of  cancer.  The  cells  of  a  cluster  are  not  separated  by  any  stroma, 
and  the  walls  of  the  alveoli  carry  blood-vessels  and  lymphatics.  The  growth 
may  be  cancerous  from  the  start,  or  may  have  begun  as  an  innocent  epithelial 
tumor.  Cancers  are  always  derived  from  epithelium  (of  glands,  of  skin,  of 
mucous  membrane,  etc.),  and  if  found  in  a  non-epithelial  tissue  must  be 
secondary,  or  must  have  arisen  from  a  depot  of  embryonal  epithelial  cells  of 
prenatal  origin  lying  in  the  midst  of  a  non-epithelial  tissue.  Carcinomata 
have  no  capsules,  rapidly  infiltrate  surrounding  tissues,  and  are  firmly  anchored 
and  immovable.     In  the  beginning  a  cancer  is  a  local  lesion ;  but  it  soon  attacks 

related  lymph-glands  and  by  means  of 
•  ^'^    "  '■■[      the  lymph  is  carried  to  other  structures, 

producing  secondary  tumors  and  dis- 
eases and  enlargement  of  adjacent  and 
finally  of  more  distant  lymph-glands. 
When  lymphatic  vessels  are  obstructed, 
lymph  filled  with  cancer-cells  may  flow 
in  a  direction  the  reverse  of  that  pur- 
sued in  health.  Secondary  growths 
are  identical  with  the  parent  growth. 
Widespread  or  general  dissemination  is 
due  to  carcinomatous  thrombosis  of  a 
vein  or  perforation  of  the  wall  of  a  vein, 
multiple  emboli  forming.  Strange  to 
say,  emboli  of  cancer-cells  may  be  sur- 
rounded with  blood-corpuscles  and 
move  against  the  blood-current.  A 
metastatic  focus  consists  of  cells  ident- 
ical in  character  with  those  of  the  pri- 
mary focus.  For  instance,  the  cells  of 
a  primary  carcinoma  of  the  liver  may 
secrete  bile,  and  the  cells  of  a  metastatic  area  may  do  the  same.  Fiit- 
terer  has  reported  a  case  of  carcinoma  of  the  thyroid  with  pulmonary 
metastases  which  secreted  colloid.  Metastases  from  a  columnar-celled 
rectal  cancer  are  composed  of  columnar  cells.  Metastases  from  a  squa- 
mous-celled  epithelioma  are  composed  of  squamous  cells.  Cancer  is  rare 
before  the  age  of  forty,  and  ne\'er  occurs  before  puberty;  and  is  sometimes 
linked  with  continued  irritation  as  a  cause  (cancer  of  the  penis  in  phimosis; 
cancer  of  the  lip  from  the  hot  stem  of  a  clay  \n])e;  chimney-sweeps'  cancer 
from  soot  in  the  scrotal  folds;  cancer  of  the  gall-bladder  when  gall-stones  e.xist). 
Dennis  says  that  all  clinical  evidence  points  strongly  to  the  view  that  inflam- 
matory changes  following  irritation  are  responsible  for  cancer.  Hereditary 
influence  seems  in  some  instances  to  faxor  the  development  of  carcinoma. 
That  cancer  is  due  to  parasitic  influence  is  warmly  advocated  by  many  pathol- 
ogists and  surgeons.  It  is  true  that  transplantation  has  taken  place,  but 
only  by  autoinfcM  tion  or  Ijy  transplantation  to  an  animal  of  the  same  species. 


Fig.  92.— Secondary  carcinoma  of  the  sub- 
mental and  submaxillary  lymphatic  glands  fol- 
lowing carcinoma  of  the  lip  (SeniO- 


Malignant  Epithelial  Tumors,   Carcinomata,  or  Cancers       271 

The  facts  that  transplantation  can  be  sometimes  carried  out,  and  that  conta- 
gion is  a  possible  occurrence  under  exceptional  circumstances,  do  not  prove 
that  cancer  is  a  parasitic  disease,  but  simply  prove  that  it  can  be  transplanted. 
It  is  not  that  the  cancer  carries  a  parasite  which  will  cause  the  disease  in  sound 
tissues,  but  rather  that  the  cells  of  the  cancer  may  themselves  take  root  and 
grow  in  sound  tissues  (page  246).  The  parasitic  theory  arose  from  observa- 
tion of  the  metastasis  which  occurs  during  the  progress  of  the  disease,  and 
received  support  from  the  fact  that  inoculation  of  another  part  of  an  indi- 
vidual suffering  from  cancer  may  be  followed  by  the  development  of  a 
tumor  like  the  original  growth,  f'or  instance,  if  a  cancer  is  growing  upon 
the  lower  lip,  the  upper  lip  may  be  inoculated  {contact  cancer).  It  has  also 
been  pointed  out  that  carcinoma  is  especially  common  in  regions  predis- 
posed b\-  their  situation  to  injury  and  infection,  and  that,  "among  the 
lower  animals  at  least,  tumors  resembling  carcinomas  have  been  transplanted 
from  one  to  another"  ("Recent  Studies  upon  the  Etiology  of  Carcinoma," 
by  Joseph  Sailer,  "Phila.  Med.  Jour.,"  June  7,  1902).  Roswell  Park  believes 
that  Gaylord  has  really  produced  adenocarcinoma  in  a  number  of  animals. 
But  there  is  great  doubt  as  to  the  cancerous  nature  of  some  of  the  tumors 
which  have  been  successfully  transplanted  from  one  animal  to  another. 

In  successful  transplantations  there  is  as  yet  no  proof  that  epithelial  cells 
were  not  transferred  with  the  supposed  parasites,  and  if  they  were  transferred 
the  success  of  the  experiment  does  not  prove  that  cancer  is  due  to  parasites, 
but  simpl}'  proves  again  what  we  knew  before — that  epithelial  cells  can  be 
transplanted.  Many  parasites  have  been  regarded  as  causative  by  different 
observers.  Bacteria,  yeast-cells,  and  protozoa  have  been  found  by  different 
experimenters.  It  is  not  thought  that  bacteria  are  causative.  Yeasts  are 
regarded  as  causative  by  some.  It  is  certain  that  they  may  exist  in  cancer, 
but  it  is  by  no  means  certain  that  they  cause  the  disease.  They  may  be  only 
a  contamination.  Gaylord  and  others  regard  the  protozoa  as  causative,  but 
this  statement  does  not  seem  to  be  proved.  Many  of  the  supposed  parasites 
of  cancer  have  been  shown  to  be  cell-degenerations  or  contaminations.  V\t 
are  justified  in  concluding  that  the  parasitic  origin  is  not  as  yet  proved,  and  we 
agree  with  the  elder  Senn  that  it  is  improbable.  A  carcinoma  is  often  the 
seat  of  pricking  pain;  the  growth  tends  strongly  to  recur  after  removal;  is 
prone  to  ulcerate,  causing  pain,  hemorrhage,  and  cachexia;  makes  rapid 
progress,  and  is  often  fatal  in  from  one  to  two  and  a  half  years.  It  is  more 
common  in  women  than  in  men,  and  rarely  exists  in  association  with  tubercle. 
After  a  cancer  has  existed  for  a  time  in  an  important  structure,  or  after  a 
superficial  cancer  has  ulcerated  and  become  hemorrhagic,  there  are  noted  in 
the  individual  evidences  of  illness  and  exhaustion.  \\'e  speak  of  this  condi- 
tion as  the  cancerous  cachexia,  and  in  it  the  muscles  are  wasted,  the  body- 
weight  is  constantly  diminishing,  the  complexion  is  sallow,  the  face  is  sunken, 
pearly  white  conjunctivjc  contrast  strongly  with  the  yellow  skin,  the  pulse  is 
weak  and  rapid,  and  night-sweats  add  to  the  exhaustion.  The  above  condi- 
tion is  due  to  the  absorption  of  toxic  products  from  the  diseased  tissues,  and 
also  to  pain,  loss  of  sleep,  bleeding,  deprivation  of  exercise,  and  malassimilation 
of  food.  Mental  depression  is  not  a  cause  of  recurrence,  but  is  simply  ex- 
pressive of  a  condition  of  nutritive  failure  which  may  favor  recurrence  (J. 
D.  Bryant).     Recurrence  after  operation  is  due  to  the  gnnvth  of  cells  which 


272  Tumors  or  Morbid  Growths 

were  not  removed.  Cancer  may  kill  b}-  obstructing  a  canal,  by  destroying 
the  functions  of  a  viscus  or  organ,  by  hemorrhage,  by  anemia,  by  sepsis,  or 
by  exhaustion. 

The  Alleged  Increase  of  Carcinoma. — Is  cancer  increasing?  The 
apparent  death-rate  from  cancer  increases  year  by  year.  It  is  pointed  out 
by  W.  Roger  Williams  that  in  England  and  Wales  the  mortality  from  cancer 
has  increased  from  i  to  5646  in  1840,  to  i  to  1306  in  1896,  and  the  proportion 
to  deaths  from  other  causes  has  risen  from  i  to  129  in  1840,  to  i  to  22  in  1896.* 
Roswell  Park  comments  on  the  increasing  number  of  deaths  from  cancer  in 
New  York  State,  and  says  if  it  continues  for  the  next  ten  years  the  disease 
will  kill  more  persons  annually  than  phthisis,  smallpox,  and  typhoid  com- 
bined. Such  statements  are  truly  alarming,  and  yet  the  reality  of  this  apparent 
increase  is  doubtful.  A  part  of  the  apparent  increase  is  due  to  the  greater 
frequency  of  exploratory  operations  for  diagnostic  purposes,  to  the  greater 
frequency  of  post-mortem  examinations,  and  to  more  correct  diagnoses  of 
obscure  internal  conditions.  x\gain,  death  certificates  are  filled  in  more 
accurately  than  was  once  the  case.  Neusholme  says  that  just  as  deaths 
certified  as  due  to  old  age  grow  apparently  fewer  every  year,  so  other  non- 
specific certifications  grow  fewer,  and  cancer  gains  as  they  lose.  The  expe- 
rience of  most  practical  surgeons  is  that  there  is  a  real  increase  in  cancer,  but 
the  extent  of  the  increase  cannot  be  ascertained  with  any  accuracy. 

Classification  of  Carcinomata. — Carcinomata  are  classified  as  follows: 
(i)  Epithelioma;  (2)  rodent  ulcer,  or  Jacob's  ulcer;  (3)  spheroidal-celled 
cancer;  (a)  scirrhous;  (h)  encephaloid;  (r)  colloid;  and  (4)  cyhndrical-celled 
cancer.  Clinically  we  speak  of  ciiirass  cancer,  a  condition  sometimes  arising 
when  the  mammary  gland  is  cancerous  and  due  to  the  infiltration  of  the 
cutaneous  lymphatics  with  cancer-cells;  chiriiney-sweeps'  cancer  and  paraffl^n 
workers^  cancer,  if  either  of  these  occupations  seems  to  have  been  causative; 
cancer  a  deux,  a  phrase  used  in  France  to  signify  that  carcinoma  has  occurred 
in  two  persons  of  a  household  who  are  not  blood  relations,  but  have  been  in 
close  contact;  contact  ca)icer  whtw  it  follows  close  contact — for  instance,  when 
a  cancer  of  the  upper  lip  follows  a  malignant  growth  of  the  lower  lip;  when 
a  carcinoma  of  the  face  follows  a  like  growth  of  the  hand;  when  a  cancer 
appears  on  the  penis  of  a  husband  whose  wife  has  cancer  of  cervix  uteri  or 
vagina.  A  mela7iotic  carcinoma  is  a  form  of  encephaloid  in  which  the  cells 
contain  melanin.  Scirrhous  cancer  contains  much  fibrous  tissue  and  is 
densely  hard.  An  encephaloid  is  very  soft  or  brain-like.  Marjolin^s  ulcer 
is  an  epithelioma  which  arises  from  the  epithelial  edge  of  a  chronic  ulcer,  a 
scar,  or  a  sinus. 

Epitheliomata. — An  epithelioma  arises  from  surface  epithelium,  and  may 
arise  from  squamous  cells  or  cyhndrical  cells,  according  to  the  location. 

Squanioiis-celled  epithelioma  takes  origin  from  the  skin  or  from  a  mucous 
membrane  covered  with  pavement  epithelium.  It  is  especially  apt  to  appear 
at  the  junctions  of  skin  and  mucous  membrane  (as  the  hps)  or  the  point  of 
juxtaposition  of  different  kinds  of  epithelium.  Such  a  growth  may  arise  in  the 
anus,  vagina,  penis,  scrotum,  lips,  tongue,  mouth,  nose,  skin,  and  other  situa- 
tions. There  is  an  ingrowth  of  surface  ej)ithelium  into  the  subepithelial  con- 
nective tissue,  colonies  of  cells  growing  inward  and  forming  epithelial  nests. 

*  Lancet,  Aug.  20,  1898. 


Classification  of    Carcinomata  273 

It  may  arise  without  discoverable  cause,  it  may  follow  prolonged  irritation,  or 
it  may  arise  in  a  wart  or  fissure.  In  the  nipple  it  is  not  very  unusually,  and 
in  the  scrotum  and  nose  it  is  occasionally,  preceded  by  a  persistent  eczema, 
due  possibly  to  psorosperms,  and  known  as  PageVs  disease.  Paget's  disease 
is  not  true  eczema,  but  is  rather  malignant  dermatitis.  A  crust  gathers  on 
the  part,  and  beneath  this  crust  is  a  raw,  red,  and  moist  surface,  the  edge  of 
which  is  slightly  elevated  and  somewhat  indurated.  In  the  beginning  there 
is  a  strong  resemblance  to  eczema.  The  nipple  is  apt  to  retract.  The  parts 
are  the  seat  of  a  constant  itching  and  scalding  sensation.  The  area  may 
become  cancerous  in  a  few  weeks,  but  may  not  for  years.  Squamous  ej)ithe- 
lioma  generally  begins  as  a  warty  protuberance  which  soon  ulcerates.  A  malig- 
nant or  true  cancerous  ulcer  has  a  hard,  irregular  base,  uneven  edges,  a  foul, 
fungus-hke  bottom,  and  gives  off  a  sanious  or  ichorous  discharge.  This  ulcer 
is  the  seat  of  sharp,  pricking  pain,  sometimes  bleeds,  and  extends  over  a 
considerable  area,  embracing  and  destroying  every  structure.  Epithelioma 
usually  affects  lymphatic  glands  early,  but  such  infection  may  be  delayed 
for  eight  or  ten  months.  Epitheliomatous  glands  break  down  in  ulcera- 
tion, making  frightful  gaps  and  often  causing  fatal  hemorrhage.  Dissemi- 
nation is  not  nearly  so  common  as  in  other  forms  of  cancer,  but  it  does  some- 
times occur. 

Cylindrical-ceUed  Epitlielioma. — This  form  of  growth  takes  origin  from 
structures  covered  with  or  containing  cyhndrical  epithehum,  and  it  contains 
cylindrical  or  columnar  cells.  It  is  composed  of  a  stroma  of  fibers  between 
which  he  tubular  glands  fined  with  columnar  epithelium  and  containing 
masses  of  epithelial  cells.  Such  tumors  are  found  in  the  uterus  and  gastro- 
intestinal tract,  and  may  begin  from  the  surface  epitheHum  or  from  the  cells 
of  tubular  glands.  In  these  tumors  there  is  an  acinus-like  structure  and  the 
spaces  are  filled  with  proliferating  epithelium.  Cylindrical-celled  cancers 
also  arise  from  the  mammary  gland,  liver,  and  kidney.  One  of  the  most 
common  seats  of  cylindrical  cancer  is  the  rectum.  Cancer  of  the  rectum 
may  occur  at  an  earlier  age  than  cancer  elsewhere,  being  not  uncommon 
between  the  ages  of  twenty-eight  and  forty.  Cylindrical-celled  epitheliomata 
are  at  first  covered  with  mucous  membrane,  but  they  soon  ulcerate  and  in- 
volve the  submucous  and  muscular  coats  in  the  growth.  They  grow  rather 
slowly,  usually,  but  not  always,  cause  lymphatic  involvement,  and  finally 
disseminate  widely.  They  require  often  from  five  to  six  years  to  cause 
death. 

.A.  rodent  or  Jacob's  ulcer  is  scarcely  ever  met  with  except  upon  the  face, 
though  Jonathan  Hutchinson  saw  one  upon  the  forearm,  and  James  Berry 
met  with  one  upon  the  arm.  It  is  especially  common  upon  the  nose  and 
forehead.  It  begins  after  the  age  of  forty  as  a  little  warty  prominence  which 
ulcerates  in  the  center,  the  ulceration  progressing  at  a  rate  equal  to  the  new 
growth.  The  ulcer  becomes  deep;  it  is  not  crusted;  its  edges  are  irregular, 
hard,  and  everted;  the  floor  is  smooth  and  of  a  grayish  color;  the  discharge 
is  thin  and  acrid;  and  the  parts  about  the  sore  contain  numbers  of  visible 
vessels.  Jacob's  ulcer  grows  slowly,  may  last  for  years,  does  not  involve  the 
lymphatics,  produces  no  constitutional  cachexia,  and  is  rarely  fatal.  A 
rodent  ulcer  is  usually  considered  to  be  a  malignant  epithelial  growth  which 
springs  from  a  sweat-gland,  a  sebaceous  gland,  or  a  hair-follicle,  but  Kanthack 
'18 


274 


Tumors  or  Morbid  Growths 


asserts  that  before  ulceration  the  rete  and  the  sweat-glands  are  normal,  but 
the  sebaceous  glands  are  destroyed.  The  base  and  edges  of  the  ulcer  are 
hard,  which  differentiates  it  from  lupus ;  and,  further,  the  bacilli  of  tubercle 
may  sometimes  be  cultivated  from  the  discharge  of  an  area  of  lupus  (page 
i8o).  Rodent  ulcer  begins  below  the  skin,  ordinary  epithelioma  begins  in 
the  skin,  and  a  rodent  ulcer  contains  no  cell-nests.  A  rodent  ulcer  very 
rarely  undergoes  cicatrization,  a  fact  which  differentiates  it  from  lupus. 
Occasionally,  but  very  rarely,  a  small  portion  of  the  growth  sloughs  out  and 
a  temporary  scar  forms  at  this  point. 

Glandular  Carcinoma. — Glandular  carcinomata  in  structure  resemble 
racemose  glands.  They  consist  of  a  stroma  of  connective  tissue  and  alveoli 
filled  with  proliferating  epithelial  cells.  If  the  proportion  between  the  fibrous 
stroma  and  the  cellular  elements  is  about  the  same  as  in  a  normal  gland,  the 
growth  is  called  simple.  When  the  cellular  element  is  in  excess  the  growth  is 
soft  (medullary),  and  when  the  fibrous  stroma  is  in  excess  the  growth  is  hard 
(scirrhous) . 

1.  Scirrhous  carcinoma  is  a  white  and  fibrous  mass  which  has  no  capsule, 
which  infiltrates  tissues,  and  which  draws  in  toward  it,  by  the  contraction  of 
its  outlying  fibrous  processes,  adjacent  soft  parts,  thus  producing  dimpling, 
or,  as  in  the  breast,  retraction  of  the  nipple.  It  is  composed  of  spheroidal 
cells  in  alveoli  formed  of  connective-tissue  bands.  The  commonest  seat  of 
scirrhus  is  the  female  breast.  It  occurs  also  in  the  skin,  vagina,  rectum, 
prostate,  uterus,  stomach,  and  esophagus.  It  is  most  frequent  in  women 
after  forty.  It  begins  as  a  hard  lump  which  is  at  first  painless,  but  which 
after  a  time  becomes  the  seat  of  an  acute,  localized,  pricking  pain.  This 
lump  grows  and  becomes  irregular  and  adherent,  causing  puckering  of  the 
soft  parts.  After  the  skin  or  mucous  membrane  above  it  has  become  infil- 
trated ulceration  takes  place  and  a  fungous  mass  protrudes  which  bleeds 
and  suppurates.  The  adjacent  lymphatic  glands  usually  become  cancerous, 
the  time  occupied  being  from  six  to  ten  weeks,  and  constitutional  involvement 
is  rapid  and  certain. 

2.  Medullary  or  encephaloid  carcinoma  is  a  soft  gray  or  brain-like  mass. 
It  is  a  rare  growth,  it  has  no  capsule,  and  it  may  appear  in  the  kidney,  liver, 
ovary,  testicle,  mammary  gland,  stomach,  bladder,  and  maxillary  antrum. 
An  encephaloid  cancer  often  contains  cavities  filled  with  blood,  and  this 
variety  is  known  as  a  "hematoid"  or  a  "telangiectatic"  carcinoma.  These 
growths  are  soft  and  semi-fluctuating,  they  infiltrate  rapidly  and  soon  fungate, 
and  they  terminate  life  in  from  a  year  to  a  year  and  a  half.  If  the  cells  of 
encephaloid  become  filled  with  melanin,  the  condition  is  called  "melanosis" 
or  "  melanotic  cancer." 

3.  Colloid  cancer  is  extremely  rare.  It  arises  from  either  a  scirrhus  or  an 
encephaloid,  when  the  cells  or  the  stroma  of  such  a  growth  undergo  colloidal 
degeneration.  On  section  there  will  be  seen  in  the  center  of  the  growth  a 
series  of  cavities  filled  with  a  material  resembling  honey  or  jelly;  the  periphery 
is  frequently  an  ordinary  .scirrhus  or  encephaloid  cancer.  Colloid  degenera- 
tion is  most  prone  to  attack  carcinomata  of  the  stomach,  mammary  gland, 
and  intestine.  The  name  colloid  cancer  is  often  given  to  glistening,  gelatinous, 
malignant  growths  springing  from  the  ovary,  testicle,  mammary  gland,  or 
gastro-intestinal  tract.     The  condition  is  due  to  mucous  degeneration  of  the 


Treatment  of  Carcinoma  275 

connective  tissue  or  of  the  epithelial  tissue  of  a  carcinoma.  Only  a  portion 
of  the  tumor  may  degenerate  or  the  entire  mass  may  become  gelatinous. 

Syncytioma  Malignum. — By  this  name  is  meant  a  malignant  epithelial 
growth  arising  from  the  site  of  the  placenta  during  pregnancy  or  the  puerperal 
state.  It  resembles  placenta  in  appearance  and  rapidly  causes  metastases 
by  way  of  the  blood-vessels.     It  is  quickly  fatal. 

Treatment. — Carcinomata  demand  early  and  free  excision,  with  removal 
of  implicated  glands.  Anatomically  related  lymph-nodes  must  be  removed 
even  if  they  show  no  evidence  of  involvement.  If  operation  is  early  and  thor- 
ough, and  if  certain  regions  are  involved,  a  considerable  proportion  of  cases 
can  be  cured.  Carcinomata  of  the  lip,  the  skin,  and  the  mammary  gland 
can  often  be  cured.  A  recurrent  growth  may  be  removed  as  a  paUiative 
measure,  to  lessen  pain  and  to  relieve  the  patient  from  ulceration  and  hemor- 
rhage, but  such  an  operation  is  rarely  curative.  If  a  growth  does  not  recur 
within  five  years  after  removal,  a  cure  has  probably  been  attained;  in  fact, 
if  there  is  no  recurrence  within  three  years,  the  case  is  probably  cured.  The 
three-year  limit  has  been  usually  accepted  since  Volkmann's  paper  on  the 
subject.  A  rodent  ulcer  should  be  excised  or  else  be  curetted  and  cauterized 
with  the  hot  iron  or  the  Paquehn  cautery.  In  cancer  of  the  lower  Up,  remove 
the  growth  by  Grant's  operation  {q.  v.),  or  by  a  V-shaped  incision,  or 
cut  away  the  entire  lip.  In  every  case  remove  the  glands  beneath  the  jaw. 
In  cancer  of  the  tongue,  excise  this  organ  and  also  the  lymph-nodes  from 
beneath  the  jaw  and  in  the  anterior  carotid  triangles.  In  cancer  of  the 
breast,  remove  the  breast,  the  pectoral  fascia,  and  the  great  pectoral  muscle, 
and  take  away  the  fat  and  glands  of  the  axilla.  In  cancer  of  the  rectum,  if 
near  the  surface,  excise  the  rectum  from  below;  if  above  five  inches  from  the 
anus,  do  the  sacral  resection  of  Kraske  and  then  remove  the  growth.  In 
cancer  of  the  esophagus,  perform  gastrostomy;  in  cancer  of  the  pylorus,  per- 
form pylorectomy  or  gastro-enterostom}- ;  in  cancer  of  the  bowel,  do  resection 
with  end-to-end  approximation,  side-track  the  diseased  area  by  an  ana.'ito- 
mosis,  or  make  an  artificial  anus;  in  cancer  of  the  penis,  amputate  and  remove 
the  glands  of  the  groin.  Erysipelas  toxins  and  erysipelas  serum  have  been 
tried  in  inoperable  carcinoma,  but  without  any  positive  benefit.  \'on  Leyden 
and  Blumenthal  ('Deutsche  medicinische  Wochenschrift,"  Sept.  4,  1902) 
report  benefit  to  human  beings  suffering  from  cancer  by  the  injection  of  serum 
expressed  from  carcinomatous  tumors.  Such  observations  require  many 
confirmatory  studies  before  we  can  assume  that  a  remedy  has  been  found. 
The  same  is  true  of  the  employment  of  pyoktanin,  thiosinamin,  and  of  all 
other  drugs  that  have  been  suggested.  The  .v-rays  are  t)f  distinct  value  in 
certain  cases  of  carcinoma.  Surface  growths  may  be  apparenth-  cured, 
although  unfortunately  they  are  apt  to  return  even  after  total  disappearance. 
Deeper  growths  are  apparently  not  benefited.  In  some  cases  ligation 
of  the  artery  of  supply  or  extirpation  of  the  artery,  as  suggested  bv  Daw- 
barn,  notably  retards  growth.  I  have  been  able  to  confirm  this  state- 
ment. In  cancer  of  the  breast,  oophorectomy  occasionallv  produces  benefit  or 
even  cure  (Beatson's  operation).  In  inoperable  cases  palliative  operations  may 
be  justifiable  to  relieve  some  urgent  discomfort  or  get  rid  of  a  foul  or  bleeding 
mass.  Gastro-enterostomy,  gastrostomy,  and  colostomy  are  palliative  opera- 
tions.    In   a  malignant  growth  of  the   nasopharynx  tracheotomy    max    be 


2/6  Tumors  or  Morbid  Growths 

required,  and  in  a  malignant  growth  of  the  bladder  it  may  be  advisable  to 
perform  suprapubic  cystotomy.  In  an  inoperable  case  relieve  the  pain  by 
opium,  giving  as  much  as  may  be  required  to  secure  ease.  Opium  so  used 
seems  not  only  to  relieve  pain,  but  to  retard  the  growth  of  the  tumor  and  to 
favor  the  development  of  fibrous  tissue  in  the  stroma. 

Cystomata. — A  cystoma  is  a  benign  cystic  tumor  in  which  the  cells 
of  the  cyst-wall  constitute  the  new  growth.  The  cyst  contents  are  derived 
from  the  cells  of  the  wall.  The  tumor  is  the  cyst-wall;  the  cells  of  this  wall 
are  derived  from  the  epiblast,  the  hypoblast,  or  the  mesoblast,  and  are  either 
epithelial  or  endothelial.  The  cells  of  the  cyst-wall  adhere  to  connective 
tissue  which  seems  to  constitute  a  part  of  the  wall.  A  thick  wall  contains 
much  connective  tissue,  a  thin  wall  very  httle.  The  nature  of  the  contents 
is  dependent  on  the  character  of  the  cells  which  constitute  the  tumor.  Cysts 
lined  by  endothelium  contain  serous  tluid;  a  cyst  of  the  thyroid  gland  usually 
contains  colloid  material;  a  cyst  lined  by  flat  epithelial  cells  contains  matter 
resulting  from  fatty  degeneration,  etc. 

Cystomata  may  be  congenital  or  acquired,  and  an  acquired  cystoma  may 
arise  after  injury  or  follow  inflammation.  The  cyst  may  increase  in  size 
progressively  or  its  growth  may  be  halted.  The  wall  may  become  calcareous 
or  even  bony.  When  a  cyst  has  one  cavity,  we  call  it  monolocular;  when 
there  are  several  or  many  cavities,  it  is  called  multilocular. 

Varieties  of  Cystomata. — The  chief  varieties  are:  Traumatic  epithelial; 
atheromatous;  mucous;  mesoblastic. 

Traumatic  Epithelial  Cystomata, — These  growths  have  been  called 
traumatic  dermoids.  Such  a  growth  may  arise  after  an  injury  which  carries 
and  deposits  epithelial  cells  or  a  bit  of  skin  deep  into  the  connective  tissue. 
For  instance,  a  punctured  wound  of  the  hand  may  be  followed  by  an  epithelial 
cystoma.  It  may  arise  after  a  scalp  wound  or  in  the  scar  of  a  burn.  The 
cyst  grows  only  to  a  certain  size  and  then  remains  stationary.  It  is  hned  by 
pavement  epithelium  and  it  contains  products  of  the  fatty  degeneration  of 
epithelial  cells. 

Treatment. — Extirpation  of  the  wall. 

Atheromatous  Cystomata. — These  growths,  according  to  Senn,  are 
met  with  particularly  in  the  ovaries,  in  the  orbital  region,  and  at  the  base  of 
the  tongue,  but  they  can  arise  almost  anywhere.  They  may  remain  small 
or  may  attain  a  great  size.  Such  a  cystoma  contains  epithelial  cells  which 
have  undergone  fatty  degeneration  and  sometimes  contains  oil.  An  athero- 
matous cystoma  is  deep  seated  and  is  not  connected  with  the  skin,  in  contrast 
to  a  sebaceous  cyst,  which  is  superficial  and  is  a  part  of  the  skin.  An  athero- 
matous cystoma  is  lined  with  epithelium,  but  not  with  skin.  A  dermoid  cyst  is 
lined  with  skin  or  other  definite  structures.  An  atheroma  is  due  to  the  dis- 
placement of  a  mass  of  epithelial  cells,  which  mass  was  the  matrix  of  the  cys- 
toma. "  The  displacement  of  the  matrix  of  an  atheroma  occurred  at  a  time 
prior  to  the  differentiation  of  the  epiblastic  cells  into  the  organs  representing 
the  appendages  of  the  skin,  while  the  matrix  of  a  dermoid  cyst  points  to 
a  later  displacement  rjf  the  matrix"  ("Pathology  and  Surgical  Treatment  of 
Tumors,"  by  Nicholas  Senn).  Atheromatous  cystomata  may  be  congenital, 
but  may  not  appear  until  y)uberty  or  even  much  later. 

Treatment. — Extirjjation  of  the  wall  of  the  cystoma. 


Teratomata  277 

Mucous  Cystomata. — A  mucous  cystoma,  like  an  atheromatous  cystoma, 
is  due  to  the  displacement  of  epithelium,  but  in  the  former  condition  it  is  pave- 
ment epithelium  and  in  the  latter  it  is  columnar  epithelium.  The  one  is 
filled  with  fatty  debris  and  the  other  with  a  mucoid  material.  Such  a  mucous 
cystoma  must  not  be  confused  with  a  retention-cyst  of  a  mucous  membrane. 
Mucous  cystomata  are  found  particularly  about  the  lips,  mouth,  and  pharynx. 
They  rarely  attain  any  considerable  size.  Cystomata  lined  with  ciliated 
epithehum  may  arise  in  the  testicle,  the  liver,  and  the  brain. 

Treatment. — Incise,  cauterize,  and  drain.  The  wall  is  so  delicate  that 
excision  is  rarely  possible. 

Mesoblastic  Cystomata. — They  are  lined  with  endothehal  cells.  They 
contain  serous  fluid,  often  grow  to  a  large  size,  and  sometimes  disappear 
spontaneously.  Mesoblastic  cystomata  are  probably  distended  lymph-spaces. 
They  are  congenital  and  are  most  common  in  the  neck,  axilla,  and  perineum. 
In  one  case  seen  by  the  author  such  a  cystoma  of  the  neck  appeared  late  in 
life,  but  it  is  probable  that  it  had  existed  in  childhood,  and  after  disappearing 
for  a  long  time  had  reappeared.  The  most  common  form  of  mesoblastic 
cyst  is  known  as  hydrocele  of  the  neck. 

Treatment. — Excision  is  very  difficult.  In  one  case  in  which  I  assisted 
Professor  Keen  it  was  successfully  accomphshed.  The  usual  treatment  is 
to  tap  frequently,  after  each  tapping  washing  out  with  carbolic  acid  (2  to  5 
per  cent.),  and  applying  pressure. 

Cystomata  of  bone,  of  the  thyroid  gland,  of  the  mammary  gland,  etc.,  are 
considered  in  the  sections  on  Regional  Surgery. 

Teratomata. — The  teratomata  contain  tissues  or  higher  structures 
derived  from  two  or  all  of  the  blastodermic  layers.  The  tumors  we  previously 
considered  are  derived  from  only  one  of  these  layers.  The  elder  Senn,  in  his 
work  on  "Tumors,"  thus  defines  a  teratoma:  "A  teratoma  is  a  tumor  com- 
posed of  various  tissues,  organs,  or  systems  of  organs  which  do  not  normally 
exist  at  the  place  where  the  tumor  grows.  The  highest  type  of  a  teratoma 
is  a  foetus  in  foetu.  In  the  simpler  varieties  the  tumor  is  composed  of  hetero- 
topic tissue,  such  as  bone,  teeth,  skin,  mucous  membrane,  etc.  All  teratoid 
tumors  are  congenital;  that  is,  the  tumor  either  exists  at  the  time  of  birth  or 
the  patient  is  born  with  the  essential  tumor  matrix.  A  teratoma  never  springs 
from  a  matrix  of  post-natal  origin."  Any  human  structure  may  be  found  in 
a  teratoma.  Various  fetal  malformations  belong  to  this  group,  as  do  also 
double  monsters,  in  which  one  of  the  embryos  is  rudimentary.  The  members 
of  this  group  most  often  seen  by  the  surgeon  are  branchial  cysts  and  dermoid 
cysts. 

Branchial  Cysts. — When  a  branchial  cleft  fails  to  become  completely 
obliterated,  a  branchial  cyst  may  form.  The  branchial  clefts  are  the  analogues 
of  the  gill-shts  of  a  fish.  There  are  four  of  these  clefts  on  each  side  of  the 
neck.  They  are  called  clefts,  but  they  are  really  grooves,  and  each  groove 
on  the  skin  has  its  counterpart  in  the  mucous  membrane  of  the  pharynx. 
Each  pharyngeal  groove  is  covered  with  hypoblastic  epithelium;  each  cuta- 
neous groove  is  covered  with  epiblastic  epithelium,  and  the  two  grooves  are 
separated  by  mesoblastic  structures.  When  the  sides  of  a  cleft  do  not  unite 
and  an  opening  forms  in  the  mucous  membrane,  a  complete  branchial  fistula 
results.     When  the  sides  of  a  cleft  fail  to  unite,  and,  although  the  mucous 


2/8  Tumors  or  Morbid  Growths 

membrane  is  not  perforated,  the  skin  does  not  cover  the  cleft,  an  incomplete 
branchial  pstiila  resuks.  When  the  sides  of  a  cleft  toward  the  pharynx  fail 
to  coalesce,  a  pharyngeal  diverticulimi  is  produced.  When  the  pharyngeal 
surface  and  the  cutaneous  surface  both  close,  but  the  deeper  part  of  a  cleft 
remains  open  and  epithelial  cells  are  caught  in  mesoblastic  elements,  a 
branchial  cyst  is  formed. 

The  essential  cellular  element  of  such  a  cyst  is  epithelium,  either  from 
the  skin  or  pharynx;  hence  the  branchial  cyst  is  not  a  dermoid,  because  its 
histological  elements  are  derived  from  onl}-  one  of  the  blastodermic  layers. 
Branchial  cysts  are  most  common  in  the  triangle  of  election  of  the  left  side. 
They  are  round,  smooth,  often  fluctuating,  and  are  very  deeply  situated,  being 
in  close  relation  with  the  great  vessels.  Some  cysts  contain  mucus,  others 
serous  fluid,  others  fatty  debris. 

Treatment. — In  old  children  and  in  adults  it  may  be  possible  to  extirpate, 
although  this  is  very  difficult  and  often  impossible.  Other  methods  employed 
are  incision,  cauterization  with  the  Paquehn  cautery,  and  packing  with  gauze; 
frequent  tapping  and  injection  with  iodin;  incision  and  drainage,  every  anti- 
septic care  being  observed.  In  all  young  children  and  in  some  older  persons 
with  deep  cysts,  the  latter  plan  is  the  only  one  advised,  and  it  will  often  fail, 
but  will  sometimes  produce  a  cure. 

Dermoid  Cysts. — These  cysts  were  first  studied  and  described  by  Lebert. 
The  name  dermoid  implies  that  the  cyst  contains  skin,  and  it  does  contain 
skin  or  mucous  membrane,  the  chief  mass  of  the  tumor  being  derived  from 
proliferation  of  the  cells  of  a  portion  of  displaced  epiblast  or  hypoblast.  A 
superficial  dermoid  is  formed  by  the  inclusion  in  mesoblastic  tissues  of  a  por- 
tion of  the  epidermis  or  mucous  membrane.  Superficial  dermoids  are  situated 
in  the  region  of  fetal  fissures  which  have  closed.  A  deep  dermoid  is  formed 
from  a  collection  of  epithelial  cells  completely  separated  from  the  epiblastic 
tissue  from  which  they  originated.  When  a  cyst  originates  from  epiblastic 
cells  so  immature  that  the  skin  appendages  have  not  as  yet  been  formed,  it 
will  contain  only  atheromatous  material  like  that  found  in  a  sebaceous  cyst. 
When  a  cyst  arises  from  epiblastic  cells  after  they  have  so  matured  that  the 
appendages  of  the  skin  have  been  formed,  it  will  contain  atheromatous  matter, 
sweat,  sebaceous  matter,  and  hair.  The  first  form  is  known  as  an  athero- 
matous cystoma;  the  second,  as  a  dermoid.  A  deep-seated  dermoid  may 
contain  also  such  structures  as  prove  it  must  have  taken  origin  from  "  a  dis- 
placed matrix  representing  different  tissues  and  organs"  (Senn).  Such  a 
dermoid  may  contain  portions  of  organs,  bone,  cartilage,  and  teeth. 

Dermoid  cysts  are  mo.st  commonly  found  in  the  ovary  and  in  regions 
where,  during  bodily  development,  the  blastodermic  layers  come  in  contact; 
for  instance,  in  the  neck,  the  eyelids,  the  orbital  angles,  the  region  of  the  coccyx, 
the  root  of  the  nose,  and  the  floor  of  the  mouth.  Such  cysts  are  also  found  in 
the  ovary,  testicle,  brain,  eye,  mediastinum,  lung,  omentum,  mesentery,  and 
carotid  sheath.  A  dermoid  cyst  may  be  defined  as  a  heterotopic  cyst,  the  wall 
of  which  is  composed  of  connective  tissue  lined  with  epithelium,  and  con- 
taining material  formed  by  the  proliferation  of  epithelium  and  often  hair, 
teeth,  or  even  bone. 

Sarcoma  may  form  fnjm  the  connective-tissue  elements  of  the  wall  of  a 
dermoid  cyst.     A  dermoid  cyst  may  become  cancerous,  or  innocent  epithelial 


Cysts  279 

tumors  may  originate  from  the  cyst  lining.  The  epithelial  cells  may  become 
fatty,  and  an  oil-cyst  may  actually  form.  If  the  cyst  epithelium  was  derived 
from  mucous  membrane,  mucus  may  gather  in  the  sac.  A  dermoid  cyst 
may  inflame  or  even  suppurate.  A  dermoid  cyst  is  free  from  pain  unless  it 
suppurates,  inflames,  or  develops  into  a  malignant  tumor;  it  grows  slowly  and 
rarely  attains  any  considerable  size  unless  it  arises  in  the  ovary.  Such  cysts 
tend  to  appear  in  particular  regions.  A  subcutaneous  dermoid  may  or  may 
not  fluctuate.  It  is  not  in  the  skin  as  is  a  sebaceous  cyst,  but  the  skin  can 
be  moved  over  it.  A  sebaceous  cyst  moves  with  the  skin.  Subcutaneous 
dermoids  about  the  orbit  are  adherent  to  the  underlying  periosteum.  A  sacral 
dermoid  bears  a  striking  likeness  to  a  spina  bifida.  The  matrix  of  a  dermoid 
is  congenital,  but  the  cyst  often  does  not  appear  until  pubertv  or  later. 

Treatment. — Complete  extirpation.  If  any  of  the  epithelium  of  the  cyst- 
wall  is  left,  the  cyst  will  re-form.  A  superficial  dermoid  is  removed  in  the 
same  manner  as  a  sebaceous  cyst,  and  if  it  is  adherent  to  underlying  perios- 
teum the  portion  of  this  membrane  to  which  it  adheres  is  also  removed.  A 
deep  dermoid  is  removed  as  a  tumor  would  be  if  operation  is  feasible. 

Cysts. — A  cyst  is  a  cavity,  abnormal  or  pathological  in  character,  lined 
by  a  membrane  and  containing  material  usually  fluid  or  semi-fluid.  It  is 
necessary  to  bear  in  mind  the  distinction  between  a  cystoma  and  a  cyst. 
Hektoen  and  Riesman,  in  "An  American  Text-Book  of  Pathology,"  insist 
on  this  distinction.  They  say:  "A  cystoma  is  a  true  tumor,  arising  from 
active  proliferation  of  a  matrix  destined  to  form  cvstic  spaces;  whereas  a  cyst 
is  a  secondary  formation  not  primarily  due  to  tissue  proliferation."  Cysts 
are  divided  into  the  following  classes:  Retention-cysts;  cysts  from  softening; 
tubulo-cysts;  and  parasitic  cysts  ("American  Text-Book  of  Pathology"). 

Retention-cysts. — A  retention-cyst  is  formed  by  blocking  of  the  duct  of 
a  gland  or  by  a  failure  in  the  absorption  of  the  proper  amount  of  the  secretion 
of  a  ductless  gland.  A  few  characteristic  forms  of  retention-cysts  will  be 
described. 

Sebaceous  Cysts. — These  arise  when  the  excretor_\-  duct  of  a  sebaceous 
gland  is  blocked  by  dirt  or  occluded  by  inflammation.  The  oriiice  of  the  duct 
is  often  visible  as  a  black  speck  o\-er  the  center  of  the  cyst.  They  are  very 
common  in  the  scalp,  being  known  as  wens,  and  upon  the  face,  neck,  shoulders, 
and  back.  x'Vrising  in  the  skin,  and  not  under  it,  the  skin  cannot  be  freely 
moved  over  a  sebaceous  cyst.  A  sebaceous  cyst  is  lined  with  epithelium 
and  is  filled  with  foul-smelling  sebaceous  material.  A  sebaceous  cyst  mav 
suppurate.  \Mien  a  cyst  ruptures  and  the  contents  become  hard,  a  horn  is 
formed.  Another  form  of  horn  has  been  previously  alluded  to  as  due  to 
horny  transformation  of  a  wart. 

Treatment. — To  treat  a  sebaceous  cyst,  incise  the  portion  of  skin  above 
it,  and  dissect  the  sac  entirely  away  with  scissors  or  a  dissector,  trving  not  to 
rupture  the  dehcate  wall.  If  even  a  small  particle  of  the  wall  is  left,  the  cyst 
will  re  form.  If  it  ruptures  during  removal  and  it  is  feared  that  some  portion 
may  remain,  paint  the  interior  of  the  wound  with  pure  carbolic  acid.  If  acid 
is  not  used,  close  without  drainage;  but  if  acid  is  used,  drain  for  twenty-four 
hours.  If  an  abscess  forms  in  a  sebaceous  cyst,  open  it,  grasp  the  edges  of 
the  cyst-lining  with  forceps,  dissect  out  this  lining  with  scissors  curved  on  the 
flat,  cauterize  with  pure  carbolic  acid,  and  drain  for  twenty-four  hours. 


28o  Tumors  or  Morbid  Growths 

Mucous  Cysts. — A  mucous  cyst  is  due  to  the  blocking  of  a  mucous  gland 
or  a  mucous  crypt.  Mucous  cysts  occur  particularly  in  the  mucous  membrane 
of  the  mouth  and  genito-urinary  organs,  and  are  filled  with  thick,  adhesive 
mucus  containing  numerous  epithelial  cells.  Such  a  cyst  is  of  spherical 
outHne,  and  the  epithehal  membrane  which  lines  it  is  strongly  adherent  to 
tissues  beyond. 

Treatment :  Incision,  curetment,  cauterization  with  pure  carbohc  acid, 
and  packing  or  extirpation  of  a  considerable  part  of  the  cyst,  and  curetment 
and  cauterization  of  the  part  remaining. 

Oil  Cysts. — x^n  oil  cyst  is  due  to  fatty  degeneration  of  epithelium  lining  a 
sebaceous  cyst,  or  a  milk  cyst  of  the  breast.  As  previously  noted,  a  dermoid 
may  result  in  an  oil  cyst. 

Treatment :  Extirpation,  as  for  sebaceous  cysts. 

Salivary  Cysts. — A  retention-cyst  of  a  salivary  gland  is  known  as  a  ranula 
(q.  v.).  These  cysts  are  most  common  in  the  submaxillary  or  sublingual 
gland. 

Lacteal  or  Milk  Cysts. — Such  a  cyst  occasionally  arises  in  the  mammary 
gland  during  lactation,  and  is  the  result  of  blocking  of  a  lactiferous  duct  (see 
Cysts  of  Mammary  Gland). 

Among  other  forms  of  retention-cysts,  most  of  which  are  discussed  in 
special  sections  of  this  book,  we  mention  hydrosalpinx,  a  cyst  due  to  blocking 
of  a  Fallopian  tube;  cysts  due  to  obstruction  of  the  bile-ducts  (the  most  com- 
mon form  is  known  as  a  cholecyst,  which  is  a  dilated  gall-bladder  the  result 
of  obstruction);  cyst  of  the  thyroid  gland;  cyst  of  the  pancreas;  and 
hydronephrosis,  a  condition  produced  by  obstruction  of  the  ureter. 

Cysts  from  Softening. — These  cysts  are  formed  by  the  disintegration 
of  degenerated  tissues.  For  instance,  after  a  hemorrhage  into  the  brain, 
softening  may  follow  and  a  cyst  arise.  Cystic  changes  of  this  sort  are  fre- 
quently observed  in  sarcomata  and  carcinomata.  A  cyst  from  softening  has 
a  wall  of  connective  tissue,  but  there  is  no  endothehal  or  epithelial  layer. 

Tubulo-cysts. — This  name  was  given  by  J.  Bland  Sutton  to  cysts  formed 
in  certain  remains  of  embryonal  ducts,  which  vestiges  in  the  developed  body 
ought  to  have  been  destroyed.  A  small  cavity  is  left  unobliterated,  and  in 
this  space  fluid  gathers.  The  source  of  the  fluid  is  usually  the  lining  cells 
of  the  cavity.  Branchial  cysts  are  frequently  considered  under  this  head- 
ing. Two  of  the  commoner  tubulo-cysts  are  cysts  of  the  vitello-intestinal 
duct  and  cysts  of  the  urachus. 

Cysts  of  the  Vitello-intestinal  Duct. — Such  a  cyst  presents  itself  as  a  small, 
bright  red,  globular  mass,  which  appears  to  arise  from  the  umbilicus  of  a 
baby  or  a  young  child,  and  which  usually  has  a  distinct  pedicle,  but  may  be 
sessile.  A  cyst  of  this  character  forms  when  the  vitello-intestinal  duct 
atrophies  from  the  gut  toward  the  umbihcus,  but  a  remnant  at  the  umbilicus 
escapes  obliteration,  and  from  this  remnant  a  cyst  forms.  The  wall  of  such 
a  cyst  contains  unstriped  muscular  fiber  and  is  lined  with  mucous  membrane. 
Occasionally  the  duct  in  the  process  of  involution  is  not  destroyed, — its  caliber 
is  simply  lessened, — and  the  duct  remains  open  in  the  navel  and  feces  come 
from  it.  If  the  duct  fails  of  obliteration  at  the  intestinal  end,  a  diverticulum 
remains  at  this  point  (Meckel's  diverticulum). 

Treatment:  A  pedunculated  cyst  at  the  navel  is  treated  by  ligating  its  base 


Parasitic  Cysts  281 

and  cutting  the  stalk  beyond  the  ligature.  A  cyst  with  a  thick  base  is  dissected 
out.  The  surgeon  must  be  careful  to  avoid  confounding  an  umbilical  her- 
nia with  a  cyst  of  the  navel. 

Urachal  Cysts. — The  urachus  is  the  obliterated  allantois  and  is  a  cord 
running  from  the  summit  of  the  bladder  to  the  umbilicus.  This  structure 
is  in  the  middle  line  of  the  abdomen  and  in  front  of  the  peritoneum.  A  por- 
tion of  the  allantois  may  not  be  obliterated  at  birth,  and  in  consequence  of 
this  failure  a  cyst  forms.  It  grows  to  a  considerable  size,  may  push  the  peri- 
toneum away  and  reach  the  pelvis,  may  communicate  with  the  bladder,  may 
break  through  the  umbilicus  or  grow  backward  toward  the  spine. 

Treatment:  Extirpation  of  the  lining  membrane,  partial  closure  of  the 
cavity  by  suture,  and  packing  the  unobhterated  part. 

Parasitic  Cysts, — Parasitic  cysts  are  due  to  the  development  of  certain 
parasites  in  the  tissues.  The  form  most  often  encountered  is  known  as 
hydatid  disease. 

Hydatid  cysts  are  especially  common  in  Iceland,  and  are  frequent  in 
Australia  and  South  America,  but  are  very  rare  in  the  United  States.  In 
the  United  States  91  per  cent,  of  cases  occur  in  foreigners  (Lyon).  They  are 
due  to  echinococci.  The  adult  echinococcus  is  the  tapeworm  of  the  dog 
(taenia  echinococcus),  and  its  ova  or  larvae  gain  access  to  man's  body  by 
accompanying  the  food  he  eats  and  passing  into  the  alimentary  canal,  from 
which  situation  they  are  transported  to  various  organs  by  the  blood.  Osier 
says  the  embryo  (which  has  six  booklets)  burrows  through  the  wall  of  the 
bowel  and  enters  the  peritoneal  cavity  or  muscles;  it  may  enter  the  portal 
vessels  and  reach  the  liver,  or  may  enter  the  systemic  circulation  and  pass 
to  distant  parts.  The  danger  depends  on  two  factors:  "the  situation  and 
the  liability  of  the  cyst  to  suppurate"  (Sidney  Coupland).  The  organs  most 
usually  attacked  are  the  liver  and  lung.  In  60  per  cent,  of  cases  the  liver 
suffers,  and  in  12  per  cent,  the  lung  (Thomas).  Lyon  estimates  that  the  liver 
is  the  seat  of  disease  in  73  per  cent,  of  cases.  Cysts  sometimes  arise  in  the 
intestine,  genito-urinary  passages,  brain,  or  spinal  canal.  When  the  embryo 
lodges,  the  booklets  disappear  and  a  cyst  is  formed.  This  cyst  is  composed 
of  two  layers,  an  outer  capsule  (cuticular  membrane)  and  an  inner  layer 
(endocyst).  The  cyst  contains  clear  saline  fluid.  As  the  cyst  grows,  daughter- 
cysts  bud  out  from  the  wall  of  the  mother-cysts,  the  structure  of  the  daughter- 
cysts  being  identical  with  that  of  the  mother-cysts.  From  the  lining  mem- 
brane of  all  the  cysts,  after  a  time,  growths  arise  known  as  scolices,  which 
represent  the  head  of  the  echinococcus  and  exhibit  four  sucking  disks  and  a 
row  of  booklets  (Osier). 

The  fluid  is  not  albuminous,  is  occasionally  saccharine,  is  thin  and  clear, 
and  may  contain  scolices  or  booklets. 

A  hydatid  cyst  may  calcify,  may  rupture,  or  may  suppurate.  These 
cysts  are  very  firm,  but  usually  fluctuate.  Palpation  with  one  hand  while 
percussion  is  practised  with  the  other  gives  a  persistent  tremor  {hydatid 
jremitiis).  If  the  cyst  can  be  safely  reached,  some  fluid  should  be  drawn 
and  examined  for  diagnostic  purposes.  When  a  cyst  suppurates,  positive 
constitutional  and  local  symptoms  arise.  Hydatid  cysts  of  the  brain  and 
cord  tend  to  produce  death  in  the  same  manner  as  do  tumors.  In  the  liver 
a  cyst  may  rupture  into  the  pleural  sac,  into  the  belly  cavity,  into  the  stomach, 


282  Tumors  or  Morbid  Growths 

or  into  the  bowel,  producing  shock,  hemorrhage,  and  probably  death.  In 
rare  cases  hydatid  cysts  rupture  into  the  pericardium  or  into  a  great  ab- 
dominal blood-vessel,  or  externally.  Rupture  into  the  bile-passages  is  usu- 
ally followed  by  suppuration  of  the  cyst.  Suppuration  of  a  cyst  may  follow 
uncleanly  tapping.  It  has  been  recently  pointed  out  that  eosinophilia  is 
noted  in  most  persons  suffering  from  hydatid  disease. 

Treatment:  An  unruptured  hydatid  cyst  of  a  superficial  structure  should 
be  incised  and  the  sac-wall  should  be  dissected  out.  Hydatids  of  the  brain 
have  been  successfully  removed  in  AustraHa.  A  cyst  of  the  kidney  is 
removed  through  a  lumbar  incision.  Omental  cysts  should  be  radi- 
cally removed  if  possible;  if  this  is  not  possible,  open  the  abdomen,  sur- 
round the  cyst  with  gauze,  evacuate  through  a  trocar,  stitch  the  cyst-wall 
to  the  wound,  incise,  irrigate,  and  drain  with  gauze.  Bond  advocated 
evacuating  the  cyst,  closing  it  with  sutures,  and  dropping  it  back  in  the  abdo- 
men. Gardner  says  tapping  is  dangerous,  as  it  may  cause  rupture  of  the 
cyst.  In  a  hydatid  of  the  liver  the  abdomen  should  be  opened,  the  cyst  should 
be  surrounded  with  gauze  pads,  and  tapped  with  a  trocar  and  cannula. 
When  the  cyst  is  emptied  of  fluid  it  is  grasped  with  forceps  and  pulled  to  the 
incision  in  the  abdominal  wall;  it  is  sutured  to  this  incision,  the  trocar  opening 
is  enlarged,  and  the  endocyst  is  removed  by  irrigation.*  This  operation  is 
called  marsupialization.  If  the  cyst  is  on  the  summit  of  the  liver,  it  may  be 
reached  by  a  transpleural  hepatotomy.  If  aspiration  is  performed  to  settle 
a  diagnosis,  operate  at  once  after  doing  it,  because  of  fear  that  the  cyst  may 
leak  and  disseminate  the  disease  throughout  the  peritoneal  cavity.  If  hydatid 
fluid  is  disseminated  throughout  the  peritoneal  cavity,  it  may  or  may  not  lead 
to  the  development  of  new  cysts,  but  it  is  almost  certain  to  cause  a  febrile 
condition  known  as  hydatid  toxemia. 

*  John  O'Conor,  of  Buenos  Ayres,  in  Annals  of  Surgery,  May,  1897. 


Wounds  of  the  Pericardium  and  Heart  283 


XVIII.   DISEASES  AND   INJURIES  OF  THE   HEART  AND 

VESSELS. 

Heart  and  Pericardium. — In  acute  pulmonary  congestion  the  venous 
side  of  the  heart  is  overdistended  with  blood,  and  the  surgeon  in  desperate 
cases  may  tap  the  right  auricle  (see  Paracentesis  Auriculi).  Pericardial  effu- 
sion, if  severe,  calls  for  aspiration  or  incision,  and  purulent  pericarditis 
demands  incision  and  drainage. 

Rupture,  Wounds  and  Injuries.— Rupture.— The  heart  may  rupture 
and  cause  instant  death,  but  rupture  may  not  be  instantly  fatal.  Curtin 
reported  a  case  in  which  death  did  not  occur  for  over  twenty-four  hours. 
Eisner  reported  a  case  of  rupture  in  which  life  was  prolonged  for  ten  days. 
One  case  lived  eleven  days.  In  cases  in  which  death  does  not  occur 
rapidly  the  rupture  must  be  so  small  that  very  httle  blood  escapes.  Rupture 
occurs  in  a  damaged  heart,  a  heart  in  which  the  muscular  fiber  is  fatty,  is 
fibroid,  or  is  necrotic  from  suppuration.  It  may  be  traumatic,  resulting  from 
a  fall  or  a  blow  upon  the  chest,  or  non-traumatic,  following  a  great  effort  or 
strain.  If  death  does  not  at  once  take  place  the  pulse  becomes  very  rapid, 
there  is  precordial  pain,  dyspnea,  cyanosis,  feeble  heart-sounds,  rapid  respira- 
tion, great  restlessness,  collapse,  and  syncope,  and  the  development  of  a  tri- 
angular area  of  dulness.  Positive  diagnosis  is  impossible.  Meyer  collected 
36  cases  of  rupture  of  heart  reported  since  1870.  Death  occurs  from  accu- 
mulation of  blood  in  the  pericardium.  Aspiration  is  useless,  as  fresh  blood 
replaces  what  is  withdrawn.  Suturing  must  fail  in  non-traumatic  cases 
because  of  the  badly  diseased  myocardium.  In  traumatic  cases  it  may 
possibly  succeed. 

Wounds  of  the  Pericardium  and  Heart.— Severe  wounds  usually, 
though  not  always,  produce  death,  but  slight  wounds  may  not  prove  fatal. 
It  is  a  popular  impression  that  the  expression  "  stabbed  to  the  heart"  is  another 
way  of  saying  that  instant  death  has  occurred.  This  view  was  accepted  even 
by  surgeons  during  many  centuries.  During  the  sixteenth  century  sportsmen 
found  now  and  then  bullets  and  arrow-tips  healed  in  the  heart-walls  of  animals 
they  had  slain.  At  this  time  the  famous  case  of  a  duelist  was  published  by 
Pare.  This  man  received  a  sword  thrust  in  the  heart,  but  was  able  to  run 
after  his  opponent  many  hundred  feet  before  falling  down  in  death.  (See 
"An  Experimental  Investigation  of  the  Treatment  of  A\'ounds  of  the  Heart," 
by  Charles  A.  Elsberg,  in  "The  Journal  of  Experimental  Medicine,"  Sept. 
and  Nov.,  1899.)  From  Pare's  time  until  our  own  it  has  been  recognized 
by  surgeons  that  a  wound  of  the  heart  does  not  of  necessitv  produce  immediate 
death  and  may  even  be  recovered  from. 

In  1867  G.  Fisher  published  a  study  of  452  cases  of  wound  of  the  heart, 
and  pointed  out  the  surprising  fact  that  from  7  to  10  per  cent,  of  such  cases 
recover.  In  recent  years  Rosenthal,  Block,  Del  Vechio,  and  others  have 
proved  by  animal  experimentation  not  only  that  cardiac  wounds  are  not  of 
necessity  instantly  fatal,  and  that  in  some  cases  they  may  be  recovered  from, 
but  that  the  suturing  of  such  wounds  is  possible  and  greatly  enhances  the 
chance  of  recovery.  L.  L.  Hill  ("Med.  Record,"  Nov.  29,  1902)  shows  that 
although  90  per  cent,  of  heart-wounds  are  penetrating,  only  19  per  cent,  are 


284  Diseases  and  Injuries  of  the  Heart  and  Vessels 

immediately  fatal.  Sudden  death  occurs  when  Kronecker's  coordination 
center  is  damaged.  Several  times  during  post-mortem  examinations  on  human 
beings  healed  scars  have  been  found  upon  the  heart.  The  heart  has  been 
punctured  a  number  of  times  accidentally  or  intentionally,  and  death  has  not 
ensued.  John  B.  Roberts,*  of  Philadelphia,  suggested  in  1881  that  it  would 
be  proper  to  try  to  suture  wounds  of  the  heart. 

Symptoms. — A  wound  of  the  heart  causes  hemorrhage,  usually  copious; 
but  owing  to  the  interlocking  of  muscular  fibers  the  hemorrhage  is  often  slight. 
Bleeding  mav  take  place  into  the  pericardial  sac  in  some  cases  where  the 
pericardium  has  been  injured  and  the  heart  has  escaped.  Such  an  injury 
is  occasionally  inflicted  by  the  sharp  end  of  a  fractured  rib.  The  wound  is 
rarely  at  or  near  the  apex  of  the  sac.  In  most  cases  the  pleural  cavity  is 
opened  and  severe  hemothorax  occurs.  The  lung  may  or  may  not  be  injured. 
A  wound  of  the  pericardium  or  heart  causes  profound  shock,  irregular  or 
very  weak  pulse,  sighing  respiration,  dyspnea,  and,  it  may  be,  the  signs  of 
hemopericardium  or  hemothorax.  There  may  or  may  not  be  serious  external 
bleeding.  Fatal  concealed  hemorrhage  may  occur.  Pain  is  constant,  and 
attacks  of  syncope  are  the  rule.  Death  is  apt  to  occur  suddenly  from  shock, 
hemorrhage,  and  inability  of  the  heart  to  contract  because  of  the  severed 
fibers,  or  inability  of  the  heart  to  dilate  because  of  the  pressure  of  blood  in  the 
pericardial  sac.  If  a  wound  of  the  pericardium  or  heart  does  not  cause  death 
during  the  first  day  or  two,  inflammation  follows  (traumatic  pericarditis  or 
carditis). 

Treatment. — Wounds  of  the  pericardium  and  heart  should  be  sutured. 
The  cutaneous  surface  should  be  rapidly  disinfected,  and  every  effort  must 
be  made  to  antagonize  shock  during  the  operation.  The  patient  should  be 
wrapped  in  hot  blankets  and  surrounded  with  hot  bottles  or  hot  water-bags, 
or  should  be  placed  upon  a  table  composed  of  pipes  in  which  hot  water  circu- 
lates. The  foot  of  the  bed  should  be  raised.  Hot  saline  fluid  should  be 
infused  into  a  vein.  Adrenalin  chlorid  may  prove  of  service.  The  extremi- 
ties, except  the  one  selected  to  infuse  salt  solution  in,  should  be  ban- 
daged (auto-transfusion),  an  enema  of  hot  coffee  and  whiskey  should  be 
given,  and  atropin  should  be  given  hypodermatically.  It  is  rarely  proper  to 
give  an  anesthetic.  If  there  has  been  a  wound  of  the  cardiac  region  and 
the  symptoms  are  threatening  to  life,  at  once  do  an  exploratory  operation 
(G.  T.  Vaughan,  "Med.  News,"  Dec.  7,  1901).  The  heart  is  exposed  by 
resecting  several  ribs,  and  usually  the  pleural  .sac  is  opened.  Parrozzani 
makes  a  trap-door  in  the  chest,  the  hinges  of  the  door  being  the  rib-car- 
tilages. The  heart  is  exposed,  clots  are  removed  from  the  pericardial 
sac,  and  the  sac  is  irrigated  with  hot  saline  fluid.  The  bleeding  may  be 
furious.  A  non-penetrating  wound  of  the  ventricle  may  bleed  so  profusely 
during  systole  as  to  resemole  a  penetrating  wound  (Sherman).  A  pene- 
trating wound  may  bleed  most  during  diastole.  The  motion  of  the  chest 
makes  manipulation  difficult.  It  is  wise  to  in.sert  two  traction  sutures  in 
order  to  lift  the  heart  toward  the  operator.  A  wound  in  the  heart  is  sutured 
with  interrupted  sutures  of  silk,  which  are  passed  by  means  of  a  round, 
curved  needle,  and  if  a  cavity  of  the  heart  is  open,  each  .suture  includes  the 
whole  thickness  of  the  heart-wall  except  the  endocardium.     If  pos.sible,  the 

*The  author,  in  Progressive  Medicine,  vol.  i,  1899. 


Treatment  of  Wounds  of  Pericardium  and   Heart  285 

sutures  should  be  tied  during  diastole,  otherwise  they  are  apt  to  cut  out.  The 
pericardium  is  sutured  with  silk,  or,  as  was  done  in  one  successful  case,  the 
sac  is  packed  with  iodoform  gauze  (Rehn's  case).  It  is  not  absolutely  necessary 
to  drain  the  pericardial  sac.  Clots  are  removed  from  the  pleural  sac  by  irri- 
gation with  hot  saline  solution,  pulmonary  bleeding  is  arrested  by  the  suture 
or  bv  packing,  and  a  wound  in  the  lung,  especially  if  it  communicates  with 
the  air-passages,  is  sutured  if  the  patient's  condition  justifies  prolonging 
the  operation.* 

After  such  an  operation  the  patient  is  in  great  danger,  and  every  effort 
should  be  made  to  save  him  from  shock.  In  performing  operations  upon  the 
heart  the  pleura  may  be  opened  by  design  or  by  accident.  When  the  pleura 
is  opened,  there  is  always  danger  of  pneumothorax,  pulmonary  collapse,  and 
overwhelming  shock.  It  is  a  great  advantage  in  such  cases  to  have  at 
hand  the  Fell-0'Dwyer  apparatus,  which  will  prevent  or  amend  pulmonary 
collapse. 

Dalton  has  sutured  the  pericardium.  Rehn  sutured  a  wound  of  the  heart 
and  packed  the  pericardium  with  gauze,  and  the  patient  recovered.  Parroz- 
zani  successfully  sutured  a  wound  of  the  ventricle.  Williams  reports  recovery 
after  a  stab-wound  of  the  heart,  the  pericardium  having  been  sutured.  Fareni 
sutured  a  stab-wound  of  the  left  ventricle,  and  the  patient  lived  several  days. 
Cappelan  sutured  a  wound  of  the  heart,  and  the  patient  lived  two  and  one-half 
days.  Sherman,  in  the  address  on  Surgery  delivered  before  the  American 
JMedical  Association  in  1902  (''Jour.  Am.  Med.  Assoc,"  June  14,  1902), 
gave  a  table  containing  34  cases  of  heart  suture  since  1896.  Only  2  of  these 
were  bullet-wounds,  32  were  incised  or  lacerated  wounds.  In  32  cases  the 
ventricle  was  injured;  in  2,  the  auricle.  The  left  ventricle  suffered  17  times 
and  the  right  ventricle  13  times.  In  7  cases  it  was  necessary  to  drain  the 
pericardial  and  the  pleural  cavity  after  suturing;  in  4  the  pleura  only  was 
drained;  the  other  cases  were  not  drained.  Five  died  during  the  operation; 
10  died  soon  afterward.  In  19  the  suturing  was  successfully  carried  out,  and 
although  6  died  later  of  infection,  secondary  hemorrhage  did  not  occur. 
Thirteen  recovered  and  4  of  these  recovered  in  spite  of  infection.  L.  L.  Hill, 
of  Montgomery,  Alabama  ("Med.  Record,"  Nov.  29,  1902),  reports  the  suc- 
cessful suturing  of  a  stab-w'ound  of  the  left  ventricle  of  a  boy  thirteen  years  of 
age.  The  operation  was  performed  eight  hours  after  the  stabbing.  Hill  pub- 
lishes a  table  of  39  cases  with  14  recoveries,  and  concludes  that:  The  right 
ventricle  is  most  often,  the  left  auricle  least  often,  injured ;  wound  of  the  auricle 
is  more  dangerous  than  wound  of  the  ventricle;  and  wound  of  the  apex  is  less 
dangerous  than  either.  A  needle  puncture  rarely  causes  serious  bleeding  from 
a  ventricle,  but  is  very  apt  to  cause  severe  bleeding  from  an  auricle.  A  wound 
recei\-ed  during  diastole  is  less  dangerous  than  one  received  during  systole. 
Wounds  of  the  right  heart  bleed  more  than  wounds  of  the  left  heart.  If 
operation  is  performed,  the  mortality  is  about  63  per  cent.;  otherwise  it  is 
90  per  cent. 

If  there  is  suspicion  of  a  heart-wound,  perform  an  exploratorv  operation. 
The  immediate  dangers  of  the  operation  are  hemorrhage,  shock,  and  the  en- 
trance of  air.  The  late  dangers  are  pericarditis,  empyema,  and  pneumonia 
(\'aughan).  Traumatic  carditis  or  pericarditis  is  treated  in  the  same  wav  as 
*  The  author,  on  "  Sutuie  of  tlie  Heart,"  in  Progressive  Medicine,  vol.  i,  1899. 


286  Diseases  and  Injuries  of  the  Heart  and  Vessels 

idiopathic  cases.  Pus  in  the  pericardial  sac  should  be  evacuated  by  resection 
of  the  fourth  left  costal  cartilage  and  incision  of  the  pericardium  (von  Eisel- 
berg's  case). 

Pericarditis. — Pericarditis  is  an  infectious  condition  that  may  be 
traumatic  or  non-traumatic.  If  pericarditis  follows  an  open  wound,  it  is 
obvious  how  the  infection  must  have  entered ;  if  it  follows  a  bruise  or  a  con- 
tusion, the  injury  has  rendered  the  pericardium  a  point  of  least  resistance. 
In  some  few  cases,  which  are  known  as  primary  pericarditis,  it  is  impossible 
to  determine  how  the  micro-organisms  gained  entrance.  The  ordinary 
form  appears  as  a  complication  of  certain  infectious  diseases,  such  as  sep- 
ticemia, pneumonia,  rheumatism,  and  tuberculosis.  It  may  be  secondary  to 
some  adjacent  infection,  such  as  an  empyema.  A  tuberculous  abscess  may 
break'  into  the  pericardium,  and  an  abscess  even  from  a  distant  point  may 
burrow  into  it.  A  great  variety  of  bacteria  may  be  responsible  for  pericar- 
ditis. The  discharge  may  be  serofibrinous;  this  is  an  evidence  of  its  being 
a  mild  infection,  and  such  a  discharge  may  undergo  absorption.  On  the 
other  hand,  the  discharge  may  be  purulent,  and  in  such  a  case  cure  will 
never  follow  absorption.  In  pericarditis  there  is  usually  some  pain  in  the 
region  of  the  heart,  and  this  pain  is  apt  to  extend  into  the  left  arm.  The 
heart  is  overacting,  the  heart-sounds  are  indistinct,  the  pulse  is  strong  and 
very  rapid,  there  is  an  increased  area  of  cardiac  dulness,  and  the  patient 
complains  of  dyspnea.  The  temperature  is  elevated,  and  a  double  friction- 
sound  may  be  made  out  upon  auscultation. 

Treatment. — Ordinary  pericarditis,  without  pus-formation  or  extensive 
effusion,  is  managed  by  the  physician;  but  when  there  is  extensive  effusion, 
it  may  be  necessary  to  open  the  pericardium,  and  if  there  is  purulent  effusion 
the  pericardium  must  be  opened.  The  procedure  usually  practised  in  the 
past  to  relieve  pericarditis  with  marked  effusion  was  aspiration.  This,  how- 
ever, is  extremely  dangerous.  The  heart  is  not  pushed  back  by  the  pericar- 
dial effusion,  but  is  lifted  upward  and  forward;  and  it  is  impossible  to  select 
any  place  for  aspiration  that  assures  us  that  there  will  be  no  danger  of  punc- 
turing the  heart.  In  cases  of  extensive  pericardial  effusion,  and  also  in  cases 
of  suppuration  within  the  pericardium,  an  inch  or  more  of  the  cartilage 
of  the  fourth  rib  of  the  left  side  should  be  removed  or  two  inches  of  the 
fourth  rib  itself,  and  the  pericardial  sac  should  be  formally  incised.  In  this 
operation  it  may  be  necessary  to  tie  the  internal  mammary  artery.  The 
pericardial  sac  is  cleared  of  purulent  material  and  fibrinous  masses  by  irriga- 
tion, and  the  edges  of  the  pericardial  wound  are  sutured  to  the  edges  of 
the  superficial  wound  and  gauze  drainage  is  introduced.  Incision  is  safer 
and  more  certainly  curative  than  aspiration;  for  whereas  aspiration  might 
be  curative  in  pericardial  effusion,  it  cannot  be  so  if  the  effusion  is  purulent. 

Phlebitis,  or  Inflammation  of  a  Vein. — Acute  Phlebitis. — 
Phlebitis  may  be  plaslic  or  it  may  be  injeclive.  Plastic  phlebitis,  while  occa- 
sionally due  to  rheumatism,  to  gout,  to  advanced  phthisis,  to  a  febrile  malady, 
or  to  some  other  constitutional  condition,  usually  takes  its  origin  from  a  wound 
or  other  injury,  from  the  extension  to  the  vein  of  a  perivascular  inflammation, 
or,  in  the  portal  region,  from  an  embolus.  Varicose  veins  are  particularly 
liable  to  phlebitis.  When  phlebitis  begins  a  thrombus  usually  forms  because 
of  the  destruction  of  the  endothelial  coat  of  the  vessel,  and  this  clot  may  give 


Varicose  Veins  ;   Phlebectasis,  Phlebectasia,  or  Varix  287 

rise  to  emboli,  may  be  absorbed,  or  may  be  organized.  An  aseptic  clot 
organizes  and  the  vein  becomes  permanently  narrowed  or  blocked.  A  septic 
clot  is  apt  to  soften  and  break  up.  In  the  lower  extremities  paraphlebitis  is 
common  with  slight  involvement  of  coats,  and  no  clot  may  form.  Clot- 
formation  causes  edema.  Infective  phlebitis  is  a  suppurative  inflammation 
of  a  vein,  arising  by  infection  from  suppurating  perivascular  tissues  (infective 
thrombophlebitis).  If  is  not  unusually  met  with  in  cellulitis  or  phlegmonous 
erysipelas,  may  arise  in  the  lateral  sinus  as  a  result  of  mastoid  suppuration,  or 
in  the  liver  from  appendicitis  or  phlebitis  of  the  rectal  veins.  A  -thrombus 
forms,  the  vein-wall  suppurates,  is  softened  and  in  part  destroyed,  and  the 
infected  clot  softens  and  gives  rise  to  emboli.  No  bleeding  occurs  when  the 
vein  ruptures,  as  a  barrier  of  clot  keeps  back  the  blood-stream.  The  clot 
of  suppurative  phlebitis  cannot  be  absorbed  and  cannot  organize.  Septic 
phlebitis  causes  pyemia,  and  the  infected  clots  of  pyemia  cause  phlebitis 
at  the  points  of  lodgment. 

Phlebitis  of  the  iliac  vein  may  follow  an  abdominal  operation  when  there 
is  no  evidence  of  infection.  Strange  to  say,  it  is  most  apt  to  attack  the  left 
iliac  vein;  it  matters  not  upon  which  side  the  operation  was  performed.  It 
may  be  due  to  toxins  damaging  the  inner  coat  of  the  vein,  but  feeble  circu- 
lation is  a  powerful  factor  in  its  production.  Vandeveer  reported  4  cases  in 
which  sepsis  was  positively  absent  ("American  Medicine,"  July  13,  1901).  I 
have  seen  it  occur  in  the  left  iliac  vein  after  an  interval  operation  for  appen- 
dicitis. Phlebitis  may  arise  in  the  vein  of  one  extremity,  a  clot  may  form, 
and  this  may  be  absorbed  or  may  organize.  Another  extremity  may  be  in- 
volved afterward  or  simultaneously. 

Symptoms. — The  symptoms  of  plastic  phlebitis  are  pain,  tenderness  in 
and  around  a  vein,  discoloration  over  it,  and  edema  below  the  seat  of  the 
disease.  Suppurative  phlebitis,  besides  these  conditions,  causes  the  con- 
stitutional symptoms  of  pyemia  (page  164). 

Treatment. — The  treatment  of  phlebitis  of  an  extremity  comprises  rest 
in  bed  for  from  four  to  six  weeks,  slight  elevation  of  the  part,  the  use  of  cold 
for  the  first  twenty-four  hours,  and  then  the  application  of  external  heat  and  a 
flannel  bandage.  If  the  patient  is  gouty  or  rheumatic  appropriate  remedies 
should  be  given.  A  clot  does  not  always  form  in  a  vein,  but  if  one  forms 
there  is  danger  of  embolism;  hence  massage  and  both  active  and  passive 
movement  are  dangerous  until  the  clot  becomes  firm.  When  a  vein  is 
involved  in  a  suppurative  process  and  septic  thrombophlebitis  exists,  ligate 
the  vein,  if  possible,  above  and  below  the  clot,  open  the  vessel,  and  wash 
out  the  infected  clot,  or,  if  dealing  with  an  accessible  vein,  extirpate  the 
involved  portion.  This  plan  of  treatment  is  always  to  be  applied  in  in- 
fective thrombophlebitis  of  the  lateral  sinus  and  of  the  internal  saphenous 
vein.     The  constitutional  treatment  is  that  of  pyemia. 

Chronic  Phlebitis, — This  rare  condition  is  known  as  phlebosclerosis 
and  it  is  a  chronic  inflammation  of  the  wall  of  a  vein,  producing  a  fibrous 
change  in  the  vascular  coatS.  It  may  arise  in  a  part  the  seat  of  chronic  venous 
engorgement,  but  its  most  frequent  cause  is  syphilis. 

Varicose  Veins;  Phlebectasis,  Phlebectasia,  or  Varix.— 
Definition  and  Causes. — Varicose  veins  are  unnatural,  irregular,  and  per- 
manently dilated  veins  which  are  elongated  and  pursue  a  tortuous  course. 


288 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


This  condition  is  very  common,  and  20  per  cent,  of  adults  exhibit  it  in  some 
degree  in  one  region  or  another.  Some  facts  indicate  hereditary  predisposi- 
tion. In  over  80  per  cent,  of  cases  the  trouble  begins  before  the  age  of 
twenty-five.  The  causes  of  varicose  veins  are  said  to  be  obstruction  to 
venous  return  and  weakness  of  cardiac  action,  which  lessens  the  propulsion 
of  the  blood-stream.  A.  Pearce  Gould  says  obstruction  is  not  a  cause,  be- 
cause in  pregnancy  varicose  veins  may  be  seen  early,  before  the  womb  is 
much  enlarged.  The  real  cause  is  probably  a  predisposition  to  the  growth 
of  vein-tissue,  which  leads  to  valve  failure  and  a  regurgitation  of  blood  from 
the  deep  veins  into  the  superficial  venous  channels  (A.  Pearce  Gould,  in 
"Lancet,"  March  i  and  15  and  June  7,  1902).  As  Billroth  said  over  thirty 
years    ago,    sudden   obstruction    causes  edema   and   gradual   obstruction  a 


Fig-  93- — Varicose  veins. 


free  collateral  circulation.  Neither  sudden  nor  gradual  obstruction  can 
cause  varicosity  unless  the  veins  are  predisposed  by  a  tendency  hereditary 
or  acquired. 

Varicose  veins  may  occur  in  any  portion  of  the  body,  but  are  chiefly  met 
with  on  the  inner  side  of  the  lower  e.xtremity,  in  the  spermatic  cord,  and  in 
the  rectum.  Varix  in  the  leg  is  met  with  during  and  after  pregnancy  and  in 
persons  who  stand  upon  their  feet  for  long  periods.  It  is  especially  common 
in  the  long  saphenous  vein,  which,  being  subciftaneous,  has  no  muscular 
aid  in  supporting  the  blood-column  and  in  urging  it  on.  The  deep  as  well 
as  the  superficial  veins  may  become  varicose.  Verneuil  maintained  that  varix 
of  the  superficial  veins  is  almost  always  secondary  to  varix  of  the  deep  veins, 
a  radical  view  which  .seems  improbable.     It  is  certain,  however,  that  after 


Varicose  Veins  ;  Phlebectasis,   Phlebectasia,  or  Varix         289 

contusions  of  the  leg  it  is  not  unusual  for  the  deep  veins  to  become  fiUed  with 
clot  and  for  the  superficial  veins  to  dilate  notably.  By  the  term  "caput 
medusae"  is  meant  dilated  veins  radiating  from  the  umbilicus.  The  veins 
of  the  esophagus  may  become  varicose,  and  this  malady  is  commonly  un- 
recognized clinically.  \'aricose  veins  are  in  rare  instances  congenital;  but 
the\'  are  most  often  seen  in  the  aged,  and  usually  begin  between  the  ages  of 
twentv  and  forty.  They  are  more  common  in  women  than  in  men,  owing, 
it  is  believed,  to  the  influence  of  pregnancy. 

Varix  of  the  spermatic  cord  is  known  as  "  varicocele."  It  is  apt  to  appear 
about  the  time  of  puberty,  and  most  adult  men  have  at  least  a  slight  varico- 
cele. Varix  is  more  likely  to  appear  in  the  left  spermatic  vein  than  in  the 
vein  of  the  right  side,  because  the  left  spermatic  vein  has  no  valves  (Brinton). 

\"aricose  tumors  of  the  rectum  constitute  "hemorrhoids"  or  "piles." 
Piles  are  caused  by  obstruction  to  the  upward  flow  in  the  hemorrhoidal  veins, 
either  by  obstructive  liver  disease,  enlargement  of  the  uterus  or  prostate,  or 
the  presence  in  the  rectum  of  fecal  masses  in  a  person  habitually  constipated. 

A  vein  under  pressure  may  dilate  more  at  one  spot  than  at  another, 
the  distention  being  greatest  back  of  a  valve  or  near  the  mouth  of  a  tributary. 
The  valves  become  incompetent  and  the  dilatation  becomes  still  greater. 
Callender  has  pointed  out  that  varix  is  apt  to  begin  where  the  deep  vessels 
join  the  superficial  veins.  At  this  point  Treves  says  three  forces  meet:  the 
blood-column  above,  the  valve  below,  and  the  force  of  the  blood-current. 
At  the  spot  where  the  pressure  is  greatest  the  vein-wall  dilates,  and  from 
this  dilatation  the  blood-current  is  deflected  and  causes  another  dilatation 
higher  up  and  on  the  opposite  side  of  the  vessel.  The  blood  is  again  de- 
flected and  causes  another  dilatation,  and  so  on  (Agnew).  The  vein-wall 
may  become  fibrous,  but  usually  it  is  thin  and  sometimes  it  ruptures.  The 
veins  not  only  dilate,  but  they  also  become  longer,  and  hence  do  not 
remain  straight,  but  twist  and  assume  a  characteristic  form.  It  seems 
probable  that  the  first  step  in  the  process  is  a  growth  of  new  venous  tissue 
(A.  Pcarce  Gould)  and  then  follow  lengthening,  tortuosity,  incompetence  of 
the  valves,  and  dilatation  of  the  vessel. 

Delbet  *  points  out  that  varicose  veins  of  the  leg,  which  begin  in  the 
thigh,  result  from  valvular  incompetence,  and  ulcers  arise  from  variations 
of  pressure  due  to  valvular  incompetence.  This  incompetence  of  the  valves 
does  harm  by  allowing  the  intravenous  pressure  to  equal  the  pressure  in  the 
arterioles,  a  condition  which  arrests  capillary  circulation,  causes  conges- 
tion, and  greatly  lowers  tissue-resistance.  Incompetent  valves  also  favor 
ulceration  by  developing  a  vicious  \enous  circle  first  described  by  Trendelen- 
burg. Blood  passing  through  this  circle  loses  nutritive  elements.  Tren- 
delenburg has  described  the  vicious  circle  as  follows:  Blood  in  the  saphenous 
vein  flows  toward  the  periphery  instead  of  toward  the  center,  it  passes  into 
the  veins  which  connect  the  superficial  veins  with  the  deep  veins  and  then 
enters  the  tibial  and  peroneal  veins.  It  passes  from  the  tibial  and  peroneal 
into  the  popliteal  and  femoral  veins,  and  some  of  it  leaves  the  femoral  vein 
and  again  enters  the  saphenous. 

The  skin  over  varicose  veins  in  the  leg  is  often  discolored  by  pigmentation 
due  to  the  red  blood-cells  having  escaped  from  the  vessel  and  broken  up. 

*  Sem.  med.,  Oct.  13,  1897. 
19 


290  Diseases  and  Injuries  of  the  Heart  and  Vessels 

The  tissues  around  a  varicose  vein  become  atrophied  from  pressure,  and  it 
is  not  unusual  to  meet  with  a  very  large  vein  whose  thin  walls  are  in  close 
contact  with  skin.  In  this  condition  rupture  and  hemorrhage  are  probable. 
When  the  vein-wall  forms  a  pouch-like  dilatation  the  condition  is  spoken 
of  as  a  cyst.  \^aricose  veins  are  apt  to  inflame,  and  thrombosis  frequently 
occurs.  When  a  thrombus  forms,  especially  if  the  patient  walks  about, 
emboli  may  be  broken  off  and  carried  into  the  circulation,  but  embolic  forma- 
tion is  not  nearly  so  common  as  a  result  of  thrombosis  in  a  varicose  vein  as 
in  thrombosis  in  an  undistended  and  unelongated  vessel.  In  varicose  veins 
of  the  thigh,  however,  the  chance  of  embolism  following  thrombosis  is  much 
greater  than  when  the  veins  of  the  leg  alone  are  invohed.  In  some  elderly 
people  thrombus  actually  effects  spontaneous  cure.  When  a  thrombus 
organizes,  more  or  less  calcification  is  apt  to  ensue,  and  a  vein-stone  or 
phlebolith  is  formed.  After  middle  life  many  varicosities  remain  stationary 
or  cease  to  give  trouble.  The  chief  complications  of  varicose  veins  of  an 
e.xtremity  are  thrombosis,  edema,  violent  hemorrhage  from  rupture,  phlebitis, 
eczema,  and  chronic  ulceration. 

Treatment. — The  treatment  of  varix  may  be  palliaiivc  or  curative,  but 
whichever  plan  is  followed,  the  surgeon  should  endeavor  first  of  all  to  remove 
the  exciting  cause.  An  essential  part  of  palliative  treatment  is  to  attend  to 
the  general  health,  to  keep  up  the  force  and  activity  of  the  circulation,  and  to 
prevent  constipation.  The  patient  should  exercise  in  the  open  air  and  should 
lie  down  for  a  time,  if  possible,  every  afternoon.  Instead  of  lying  down  for  a 
time  during  each  day,  he  may  sit  down  and  elevate  the  legs,  resting  them  on 
a  table,  and  thus  assuming  a  position  supposed  to  be  peculiarly  American. 
Locally,  in  varix  of  the  leg,  use  a  flannel  roller  or  Martin's  rubber  bandage 
to  support  the  veins  and  drive  the  blood  into  the  deeper  vessels  which  have 
muscular  support.  The  use  of  a  rubber  pad  filled  with  glycerin  and  applied 
over  the  saphenous  vein  so  as  to  support  the  blood-column  and  act  as  a  valve, 
has  been  recommended.  Locally,  in  varicocele,  pour  cold  water  upon  the 
scrotum  twice  a  day  and  order  the  patient  to  wear  a  suspensory  bandage. 
Locally,  in  hemorrhoids,  use  injections  of  ice-water  and  astringent  supposi- 
tories. A  purely  local  varix  should  be  excised,  because  there  is  always  danger 
of  injury,  and  consequently  of  hemorrhage  or  thrombosis.  If  the  superficial 
veins  have  dilated  becau.se  of  thrombosis  of  the  deep  veins  and  edema  exists, 
operation  is  contraindicated,  as  its  performance  might  lead  to  permanent 
edema.  If  the  disease  involves  the  leg  only,  operative  treatment  is  rarely 
required  and  may  even  do  harm.  Such  cases  are  operated  uyjon  if  there  are 
cyst-like  dilatations,  if  thrombi  form,  and,  as  Bennett  ])oints  out,  if  a  thin- 
walled  vein  crosses  the  tibia,  and  is  thus  exposed  to  the  danger  of  injury 
and  thrombosis.* 

If  the  leg  is  involved  in  the  f)rocess,  and  the  sa[)hena  in  the  thigh  is  also 
varicose,  ojjeration  should  be  j)erformed. 

If  a  thrombus  forms  in  a  varicose  vein,  tie  the  vein  above  and  below  the 
clot,  divide  the  vessel  in  two  places,  and  remove  the  vein  and  the  clot  within 
it.  Thrombosis  of  a  varicose  \ein  is  not  so  apt  to  lead  to  emboli  as  throm- 
bosis in  a  non-varicose  \ein,  but  it  may  do  so,  ;infl  the  condition  is 
dangerous. 

■^- \V.  H.   llciiiiiil,   Lniicct.  Oci.  15,   1898. 


Arteritis 


291 


If  edema  is  marked,  and  increases  in  spite  of  properly  applied  bandages, 
etc.,  it  probably  signifies  clot-formation,  and  the  patient  should  remain  in 
bed  until  this  question  is  determined.  Hemorrhage  from  a  ruptured  varicose 
vein  of  an  extremity  is  usually  readily  arrested  by  compression  and  elevation. 

The  radical  treatment  of  varix  of  the  leg  often  does  good,  often  relieves 
some  annoying  condition,  but  rarely  absolutely  cures  (W.  H.  Bennett). 
There  are  several  methods  of  operation:  ligation  with  excision  of  part  of  the 
vein,  exposure  and  ligation  of  the  vein  below  the  saphenous  opening,  or  cir- 
cular incision  around  the  leg  (see  Operations  upon  Vessels). 

Nevus. — (See  Tumors.) 

Arteritis,  or  inflammation  of  an  artery,  is  acute  or  chronic. 

Acute  Arteritis. — Slight  inflammation  is  by  no  means  unusual,  but 
severe  arteritis  is  decidedly  rare.  It  may  follow  direct  injury  or  arise  secon- 
darily to  a  perivascular  inflammation.  An  artery  is  very  resistant  to  the 
spread  of  inflammation,  but  we  sometimes  encounter  suppurative  arteritis 
in  a  suppurating  area.  Arteritis  may  arise  in  the  course  of  an  infective 
malady,  being  produced  by  germs,  but  it  is  also  found  in  intoxications, 
and  is  then  due  purely  to  toxins.  It  may  occur  in  the  eruptive  fevers, 
in  influenza,  typhoid  fever,  acute  rheumatism,  gout,  syphilis,  and  diphtheria, 
septicemia  and  septic  intoxication.  Ford  points  out  that  acute  arteritis  devel- 
oping during  acute  or  chronic  infections  is  particularly  apt  to  arise  in  the 
lower  extremities  (Ford,  "  These  de  Paris,"  1901).  Toxins  or  bacteria  usually 
reach  the  artery  in  the  main  blood-stream,  but  may  be  lodged  in  the  vessel- 
wall  by  the  lymph  or  the  flow  in  the  vasa  vasorum.  The  inner  coat  of  the  artery 
becomes  lined  with  inflammatory  exudate  and  the  coats  are  infiltrated  with 
small  cells.  Often  parietal  thrombi  form.  Sometimes,  though  rarelv,  the 
vessel  is  completely  blocked  by  thrombosis.  In  acute  suppurati\e  arteritis 
pus  accumulates  in  the  arterial  wall,  a  clot  forms  in  the  lumen,  and  the  coats 
of  the  vessel  undergo  necrosis  and  give  way.  \'iolent  hemorrhage  may  thus 
arise,  but  often,  in  thrombo-arteritis  as  in  thrombophlebitis,  rupture  does  not 
cause  hemorrhage.  Acute  arteritis,  if  non-bacterial  in  origin,  is  u.sually 
recovered  from  with  slight  structural  change.  Infective  arteritis  is  recovered 
from  if  the  causative  germ  is  not  very  virulent  or  if  the  toxin  is  not  ])resent  in 
excessive  c}uantity.  Acute  arteritis  may  terminate  in  arterial  obstruction 
with  or  without  gangrene,  permanent  dilatation,  arterial  ru])ture,  or  chronic 
arteritis. 

Symptoms. — The  symptoms  ma\'  l)c  merged  with  those  of  an  acute  or 
chronic  intoxication  or  infection,  or  with  those  of  a  local  perivascular  inflam- 
mation. In  arteritis  arising  during  infections  the  symptoms  appear  abru])tly 
and  the  onset  is  marked  by  great  pain.  Ford  studied  18  cases  in  influenza. 
He  says  it  attacks  ])articularly  persons  over  thirty  years  of  age,  occurs  in  one 
leg  or  both,  usuallv  arises  during  convalescence,  but  mav  not  begin  until 
the  individual  is  apparently  well.  There  is  pain  and  tenderness  (>\er  the 
vessels,  low  surface  temperature,  paresthesia,  and  mottled  skin  (Ford,  "These 
(ie  Paris,"  igor).  The  arter\'  mav  be  obstructed,  and  if  a  large  vessel  is 
blocked,  the  ]julse  below  the  clot  is  lost.  The  block  may  l)e  temporary  or 
persistent.  Gangrene  may  follow.  Ford  points  out  that  if  the  artery  only 
is  blocked,  the  gangrene  is  dry;  but  if  the  vein  also  is  occluded,  it  may  be 
moist.     I  have  seen  two  cases  of  dry  gangrene  following  influenza. 


292  Diseases  and  Injuries  of  the  Heart  and  Vessels 

Treatment. — Secure  rest  in  bed;  elevate  the  extremity  sHghtly,  relax  it, 
smear  the  skin  over  the  inflamed  vessel  with  ichthyol  ointment,  or  mercurial 
ointment,  or  follow  Ford's  advice  and  use  methyl  salicylate  or  an  ointment 
of  salicyUc  acid,  turpentine,  and  belladonna.  Wrap  the  part  in  cotton  and 
surround  it  with  bottles  or  bags  filled  with  warm  water.  If  a  patient  is  very 
restless,  a  splint  must  be  used.  It  may  be  necessary  to  give  morphin  for  pain, 
and  any  infection  or  toxemia  must  be  combated  with  appropriate  remedies. 

If  gout,  rheumatism,  or  sj^hilis  is  regarded  as  causative,  proper  remedies 
must  be  given.  It  is  most  important  to  maintain  the  secretion  of  the  kidneys. 
If  abscesses  form  in  a  septic  case,  they  must  be  opened  and  drained.  If  a 
large  artery  of  an  extremity  become  occluded,  raise  the  foot  about  two  inches 
from  the  bed,  wrap  the  foot  and  leg  in  cotton  wool,  apply  a  flannel  bandage 
from  the  toes  up,  and  surround  the  limb  with  bags  of  warm  water — not  hot 
water.  Hot  water  would  take  more  blood  to  the  region  of  the  block  than 
could  be  distributed.     If  gangrene  occurs,  amputation  is  necessary. 

Chronic  Endarteritis  (Arteriosclerosis,  Atheroma,  Arteriocapil- 
lary  Fibrosis). — By  these  terms  we  mean  thickening  of  the  walls  of  the 
arteries,  limited  in  area  or  widespread,  due  to  inflammation  or  degeneration 
of  the  middle  coats.  Atheroma  is  used  to  designate  the  disease  when  it 
attacks  the  large  vessels  and  is  characterized  by  advanced  degeneration. 
Chronic  endarteritis  is  due  to  increase  of  blood-pressure.  Increase  of  blood- 
pressure  may  be  brought  about  by  kidney  disease,  hard  work,  violent  strains, 
heart  disease,  care  and  anxiety,  worry  and  mental  strain,  habitual  gluttony, 
syphilis,  gout,  rheumatism,  lead-poisoning,  diabetes,  and  acute  infections  like 
typhoid  fever  and  influenza.  It  may  arise  in  an  old  man  who  has  not  suffered 
particularly  from  any  of  the  above-named  causes,  or  may  occur  prematurely 
from  heredity.  It  is  a  true  saying  of  Cazalis  that  "A  man  is  as  old  as  his 
arteries,"  and  a  young  man  dilapidated  by  syphilitic  disease  or  alcohol  may 
have  diseased  arteries,  and  hence  be  really  older  than  a  healthy  man  of  sixty. 
The  aorta,  of  all  vessels,  is  most  prone  to  suffer.  The  large  vessels  are  more 
apt  to  be  diseased  than  the  small,  but  even  the  capillaries  can  be  involved. 
The  arteries  of  the  stomach,  liver,  and  mesentery  are  rarely  sclerotic.  In 
arteriosclerosis  connective  tissue  is  substituted  for  the  normal  elements  of  the 
vascular  wall  and  this  tissue  undergoes  hyperplasia  and  subsequent  contrac- 
tion and  induration.  If  the  mass  of  proliferating  fibroblasts  undergoes  fatty 
degeneration,  atheroma  is  said  to  exist,  and  an  atheromatous  vessel  may  be 
calcified  by  deposition  (^f  lime  salts.  When  fatty  degeneration  occurs,  the 
endothelium  ib  aestroyed,  the  vessel-wall  is  damaged,  and  the  blood  may 
obtain  access  to  the  deeper  coats.  Calcareous  change  may  follow  fatty  de- 
generation. 

A  sclerosed  artery  is  rigid,  non-contractile,  and  inelastic,  and  the  parts  it 
supplies  are  cold,  congested,  and  ill-nourished,  and  often  edematous.  The 
heart  at  first  hyjjertrophies  and  then  dilates.  Atheroma  is  a  frequent  cause 
of  thrombosis,  aneurysm,  senile  gangrene,  and  apoplexy.  If  a  hypertrophied 
heart  exists  with  diseased  arteries,  apoplexy  or  aneurysm  is  apt  to  occur 
(Nammack,  "Med.  Record,"  Oct.  26,  1901).  Syphilitic  arteritis  is  char- 
acterized by  an  enormous  growth  of  granulation  tis.sue  from  the  inner  coats 
of  arteries  of  small  size  Cobliterative  endarteritis).  Calcification  of  an  artery 
may  be  secondary  to  fatty  change,  or  may  occur  primarily  from  deposit  of 


Aneurysm  293 

lime  salts  in  the  middle  coat.  Periarteritis  is  inflammation  of  the  sheath 
and  outer  coat.  An  acute  arteritis  is  always  local,  but  a  chronic  arteritis 
may  be  general. 

Treatment  oj  Chronic  Arteritis. — In  treating  chronic  arteritis,  endeavor  to 
antagonize  the  dangers  to  which  the  patient  is  obviously  liable.  Forbid 
alcohol  as  a  beverage,  though  a  little  whiskey  may  be  taken  at  meals  to  aid 
digestion.  Maintain  the  activity  of  the  skin  by  daily  baths,  and  of  the  kidneys 
by  diuretic  waters.  A  cfeily  bowel  movement  should  be  secured.  The  diet 
is  to  be  plain  and  is  to  contain  a  minimum  of  nitrogen.  If  syphilis  has  existed, 
occasional  courses  of  iodid  of  potassium  are  to  be  given.  If  the  arterial 
tension  at  any  time  becomes  inordinately  high,  administer  nitroglycerin. 
One  danger  to  which  the  patient  is  liable  is  apoplexy;  hence  excitement  and 
violent  exercise  are  to  be  avoided.  Another  danger  is  senile  gangrene;  hence 
the  patient  should  wear  woolen  stockings,  put  a  bottle  or  bag  of  warm  water 
to  his  feet  at  night,  and  be  careful  to  avoid  injuring  his  toes  or  feet,  especially 
when  cutting  his  corns.  A  bag  of  very  warm  water  is  dangerous  and  may 
actually  excite  gangrene.  When  a  patient  with  atheroma  has  dyspnea  and 
is  of  a  livid  color,  or  when  the  arterial  tension  is  very  high,  a  moderate  blood- 
letting (sixteen  to  eighteen  ounces)  does  good,  and  may  prevent  or  arrest 
edema  of  the  lungs.  Still  another  danger  is  aneurysm,  which  may  appear 
suddenly  from  rupture  or  gradually  from  progressive  distention. 

Aneurysm. — An  aneurysm  is  a  pulsating  sac  containing  blood  and  com- 
municating with  the  cavity  of  an  artery,  and  formed  partly  or  entirely  by  the 
arterial  walls  or  a  fusiform  dilatation  of  an  artery.  Some  restrict  the  term 
"true  aneurysm"  to  a  condition  of  dilatation  involving  all  the  coats  of  the 
vessel.  We  shall  consider,  with  Heath,  a  true  aneurysm  to  be  one  in  which 
the  blood  is  included  in  one  or  more  of  the  arterial  coats,  and  a  false  aneurysm 
to  be  a  condition  in  which  the  vessel  has  ruptured  or  has  atrophied  and  the 
aneurysmal  wall  is  formed  by  a  condensation  of  the  perivascular  tissues. 

Forms  of  Aneurysm. — The  following  forms  of  aneurysm  are  recognized: 

1.  True  aneurysm — one  whose  sac  is  formed  of  one  or  more  arterial  coats. 

2.  False  aneurysm — one  whose  sac  is  formed  of  condensed  perivascular 
tissues  and  contains  no  arterial  coat. 

3.  Traumatic  aneurysm — a  false  aneurysm  due  to  traumatic  rupture  some 
time  before,  the  blood  being  in  a  sac  of  condensed  tissue  and  any  wound 
being  healed.  A  traumatic  aneurysm  may  follow  a  puncture  or  an  incised 
wound  of  an  artery,  the  injury  causing  the  aneurysm  directly.  It  may  follow 
an  effort  or  a  strain,  the  injury  indirectly  causing  the  aneurysm  by  acting 
on  a  diseased  vessel. 

4.  Fusiform  aneurysm — a  variety  of  true  aneurysm,  the  sac  being  s|)indle- 
shaped. 

5.  Consecutive  aneurysm — a  sacculated  aneurysm  diffused  by  rupture,  or 
a  false  aneurysm  due  to  gradual  destruction  or  atrophy  of  a  true  aneurysmal 
sac  or  to  vascular  rupture. 

6.  Sacculated  aneurysm — a  common  form  of  aneurysm,  in  which  the 
dilatation  is  Hke  a  pouch,  arising  from  a  part  of  the  arterial  circumference 
and  joining  the  lumen  of  the  vessel  by  an  aperture. 

7.  Dissecting  aneurysm  (Shekelton's  aneurysm) — a  pouch-like  dilatation 
of  an  artery  due  to  the  blood  which  has  gained  access  to  the  middle  coat  through 


294  Diseases  and  Injuries  of  the  Heart  and  Vessels 

an  atheromatous  ulcer  or  a  minute  rupture  of  the  inner  coat.  It  used  to  be 
taught  that  the  blood  flows  between  the  media  and  adventitia;  we  now  know 
that  it  flows  between  the  layers  of  the  middle  coat.  The  outer  wall  of  the 
aneurysm  consists  of  adventitia  and  a  portion  of  the  middle  coat.  It  may 
or  may  not  Join  the  lumen  of  the  artery  at  another  point  by  a  fresh  aperture 
in  the  intima.  Dissecting  aneurysm  is  practically  only  met  with  in  the  aorta. 
It  is  most  common  in  the  thoracic  aorta.  About  eighty  cases  have  been 
reported.* 

8.  Arteriovenous  aneurysm,  which  is  divided  into  aneurysmal  varix,  or 
Pott's  aneurysm,  where  there  is  direct  communication  between  a  vein  and 
an  artery;  and  varicose  aneurysm,  where  there  is  communication  between  an 
arterv  and  a  vein  by  means  of  an  interposed  sac. 

g.  Acute  aneurysm — a  cavity  in  the  walls  of  the  heart,  which  cavity  com- 
municates with  the  interior  of  this  organ,  and  which  is  due  to  suppuration 
in  the  course  of  acute  endocarditis  or  myocarditis. 

10.  Aneurysm  by  anastomosis  (see  Angiomata). 

11.  Aneurysm  of  bone — an  inaccurate  clinical  term  used  to  designate  a 
pulsatile  tumor  of  bone. 

12.  Circumscribed  aneurysm — when  the  blood  is  circumscribed  by  distinct 
walls. 

13.  Circoid  aneurysm — a  mass  of  dilated  and  elongated  arteries  shaped 
like  varicose  veins  and  pulsating  with  each  heart-beat. 

14.  C ylindrical  aneurysm — a  dilatation  which  maintains  the  same  dimen- 
sions for  a  considerable  space. 

15.  Embolic  or  capillary  aneurysm — dilatation  of  terminal  arteries  due  to 
emboli. 

16.  Spontaneous  aneurysm — non-traumatic  in  origin. 

17.  Miliary  aneurysm — a  minute  dilatation  of  an  arteriole. 

18.  Secondary  aneurysm — one  which,  after  apparent  cure,  again  pulsates, 
the  blood  entering  by  means  of  the  anastomotic  circulation. 

19.  Verminous  aneurysm — one  containing  a  parasite.  This  form  of 
aneurysm  is  met  with  in  the  mesenteric  arterv  of  the  horse. 

The  sac  of  a  sacculated  aneurysm  is  at  first  composed  of  at  least  two  of  the 
arterial  coats,  reinforced  by  the  sheath  and  perivascular  tissues.  After  a 
time  the  blood-pressure  distends  the  sac,  and  the  inner  and  middle  coats  either 
stretch  with  interstitial  growth  or — what  is  more  common — are  worn  away 
and  lost.  When  all  the  coats  are  lost,  and  the  blood  is  sustained  only  by  the 
sheath  and  .surrounding  tissue,  a  true  aneurysm  becomes  a  false,  diffuse,  or 
consecutive  aneurysm,  the  limiting  tissues  and  sheath  being  condensed, 
thickened,  and  glued  together.  This  limiting  process  is  deficient  in  the  brain; 
hence  cerebral  aneurysms  break  soon  after  their  formation.  When  all  the 
arterial  coats  are  lost,  the  blood-pressure,  acting  on  the  tissues,  finds  some 
.spots  less  resistant  than  others,  the  blood  follows  the  lines  of  least  resistance, 
the  aneurysm  grows  with  great  rapidity,  and  soon  ruptures  externally  or  into 
a  cavity. 

An  aneurysm  may  rupture  into  a  cavity  (pleural,  pericardial,  or  peritoneal), 
into  the  perivascular  tissues,  or  through  the  skin.  Rupture  into  the  tissues 
may  produce  pressure-gangrene.     When  rupture  occurs  through  the  skin  the 

*  Coleman,  in  Dublin  Jour.  Med.  Sciences,  Aug.,  1898. 


Causes  of  Ancui-\sin  295 

hemorrhage  is  not  often  instantly  fatal,  but  during  several  days  recurs  again 
and  again  in  larger  and  larger  amounts.  The  pressure  of  an  aneurysm  causes 
atrophy  of  tissues,  hard  and  soft,  bones  and  cartilages  being  as  easily  destroyed 
as  muscles  and  fat.  Sometimes  the  perivascular  tissues  inflame  and  suppurate, 
and  the  sac  is  opened  rapidly  by  sloughing.  An  aneurysm  usuallv  progresses 
toward  rupture,  the  slowest  in  this  progression  being  the  fusiform  dilatation, 
which  may  exist  for  many  years,  but  which  finall}-  is  converted  into  the  sac- 
culated variety. 

In  some  rare  instances  there  takes  place  spontaneous  cure,  which  mav 
result  from  laminated  fibrin  being  deposited  upon  the  walls  of  the  sac  as  the 
blood  circulates  through  it.  This  laminated  fibrin  is  known  as  an  "active 
clot,"  and  eventually  fills  the  sac.  The  weaker  and  slower  the  blood-stream, 
the  greater  is  the  tendency  to  the  formation  of  an  active  clot;  hence  any  agent 
impeding,  but  not  abolishing,  the  circulation  aids  in  the  deposition.  This 
weakening  and  slowing  of  circulation  may  be  brought  about  by  great  activity 
of  the  collateral  circulation  diverting  most  of  the  blood  from  the  area  of 
disease.  Sometimes  a  clot  breaks  off  from  the  sac-wall  and  plugs  the  artery 
beyond  the  aneurysm,  and  the  anastomotic  vessels,  enlarging,  diAert  the 
blood-stream.  A  large  aneury.sm,  falling  over  by  its  own  weight  upon  the 
vessel  above  the  mouth  of  the  sac,  may,  in  very  unusual  cases,  diminish  the 
blood-stream.  The  development  of  another  aneurysm  upon  the  same  vessel 
nearer  to  the  heart  weakens  the  circulation  in  and  may  cure  the  older  one. 
Inflammation  occasionally  forms  a  clot.  The  tissues  about  an  aneurysm 
tend  to  contract  when  arterial  force  is  lessened;  hence  tissue-pressure  may 
more  than  counteract  blood-pressure  when  the  circulation  is  feeble.  Clotting 
of  the  blood  contained  within  a  sac,  circulation  through  the  aneurysm  having 
ceased,  causes  a  "passive  clot."  A  passive  clot,  which  occasionally  induces 
cure,  may  arise  from  a  twist  of  the  neck  of  the  sac  preventing  the  passage  of 
blood;  from  the  lodgment  of  a  clot  in  the  mouth  of  the  sac;  and  from  inflam- 
mation.    Spontaneous  cure  is,  unfortunately,  very  rare. 

Causes  of  Aneurysm. — Gradual  distention  of  arterial  coats  which  are  in 
a  condition  of  arterial  sclerosis,  or  of  coats  whose  resisting  power  is  lowered 
because  of  atheroma,  may  cause  aneurysm.  Hence  the  causes  of  sclerosis 
and  atheroma  are  also  causes  of  aneurysm.  The  principal  cause  of  aneurysm 
is  increased  blood-pressure.  This  increase  may  be  brought  about  bv  .severe 
labor;  by  sudden  strains,  as  in  lifting;  by  violent  efforts,  as  in  rowing  in  a 
boat-race;  by  chronic  interstitial  nephritis;  by  hypertrophy  of  the  heart; 
by  alcoholic  excess;  and  by  syphilis.  Arterial  disease  is  commonest  in 
the  larger  vessels,  and  in  the  aged,  but  it  may  occur  in  youth,  \yhen  an 
aneurysm  follows  a  strain,  it  may  be  due  to  laceration  of  the  media  and  loss 
of  resistance  at  a  narrow  point.  The  intima  may  lacerate,  permitting  the 
blood  to  come  in  contact  with  the  media  or  causing  blood  to  diffuse  between 
the  coats  (dissecting  aneurysm).  When  an  embolus  lodges  in  an  artery  the 
vessels  may  become  aneurysmal  on  the  proximal  side  of  the  clot.  The  em- 
bolus, if  infective,  causes  softening,  and  if  calcareous  causes  laceration  (Osier). 
Colonies  of  micrococci  may  cause  aneurysm.*  The  parasite  strongy/iis  arma- 
tus  causes  aneurysm  of  the  mesenteric  arteries  in  horses.  Suppuration  around 
a  vessel  weakens  its  coats  and  tends  to  aneurysm  by  inducing  acute  arteritis 

*See  Osier  on  "Malignant  Endocaiditi.s." 


296  Diseases  and  Injuries  of  the  Heart  and  Vessels 

and  softening.  Sometimes  an  individual  develops  multiple  aneurysms  the 
origins  of  which  are  absolutely  unknown.  A  cut  or  puncture  of  a  healthy 
artery  may  lead,  after  the  surface  wound  heals,  to  the  development  of  an 
aneurysm.  Such  an  aneurysm  does  not  differ  in  symptoms  or  treatment 
from  the  other  form. 

The  constituent  parts  oj  an  aneurysm  are  (i)  the  wall  of  the  sac;  (2)  the 
cavitv;  (3)  the  mouth;  and  (4)  the  contents. 

Symptoms  of  Aneurysm. — The  formation  of  an  aneurysm,  when  sudden, 
is  occasionally,  though  rarely,  appreciated  by  the  patient,  and  is  described 
by  him  as  a  feehng  of  something  having  given  way.  In  most  instances  the 
feeling  of  beating  and  the  discovery  of  the  lump  are  the  first  intimations  that 
anything  is  wrong.  An  oval  or  globular,  soft,  elastic,  and  pulsatile  protrusion 
develops  in  the  line  of  an  artery.  It  is  usually  quite  evident  to  the  touch  that 
the  sac  contains  fluid,  but  sometimes  in  old  aneurysms  the  sac  feels  firm  or 
even  hard,  because  of  the  deposit  of  fibrin  upon  its  inner  surface.  In  a  par- 
tially consolidated  aneurysm  pulsation  may  be  slight  or  even  inappreciable. 
The  protrusion  instantly  ceases  to  pulsate  and  almost  disappears  on  making 
firm  pressure  on  the  artery  above.     On  relaxing  the  pressure  the  pulsatile 


Fig.  94. — Radial  pulse-tracings  in  aneurysm  of  right  brachial  artery  :   i,  Left  radial  pulse;  2,  right 
radial  pulse  (after  Mahomed). 

enlargement  at  once  reappears.  Direct  pressure  upon  the  tumor  may  cause 
it  to  almost  disappear.  Pressure  upon  the  artery  below  causes  the  tumor 
to  enlarge.  The  pulsation  is  expansile — that  is,  the  sac  expands  in  all  direc- 
tions during  ever_v  cardiac  contraction — and  if  an  index-finger  be  laid  on  each 
side  of  the  tumor  so  that  the  points  nearly  touch,  each  pulsation  not  only  lifts 
the  fingers,  but  it  also  separates  them.  On  placing  a  stethoscope  over  the 
aneurysm  or  over  the  vessel  below  the  aneurysm  there  is  imparted  to  the  ear 
a  distinct  bruit  which  travels  in  the  direction  of  the  blood-stream,  is  systolic  in 
time,  and  is  usually  blowing  in  character.  In  some  cases  bruit  is  absent 
(when  a  sacculated  aneurysm  has  a  very  small  mouth,  when  the  circulation 
is  tranquil,  or  when  the  sac  is  full  of  blood  and  clot).  When  bruit  is  absent 
it  may  sometimes  be  developed  by  muscular  exerci.se  or  raising  the  affected 
limb  (Holloway).  In  rare  cases  there  may  be  a  double  bruit.  Occasionally 
in  fusiform  aortic  aneurysm  linked  with  aortic  regurgitation  a  diastolic  bruit 
exists.  A  bruit  is  arrested  by  pressing  upon  the  artery  between  the  aneurysm 
and  the  heart.*  A  patient  who  has  an  aneurysm  of  an  extremity  com- 
plains of  a  sensation  of  beating,  of  weakness  or  stiffness  of  the  limb,  frequently 
of  pain  in  a  nerve,  a  feeling  of  fatigue  in  the  muscles,  and  edema  and  dilated 
veins  are  apt  to  develop  because  of  pressure  upon  large  veins  and  lo.ss  of  vis  a 

*  Holloway  on  "  Aneurysm,"  in  Park's  "  Surgery  by  American  Authors." 


Treatment  of  Aneurysm  297 

tergo  in  the  circulation.  The  skin  over  an  aneurysm  may  be  normal,  may  be 
discolored,  may  ulcerate,  or  even  slough.  The  pulse  below  an  aneurysm  is 
weaker  than  the  pulse  of  a  corresponding  part  of  the  opposite  limb.  This  is 
well  shown  by  sphygmographic  tracings  (Fig.  94).  The  tracings  taken  below 
an  aneurysm  are  rounded  without  a  sudden  rise  or  an  abrupt  fall.  In  inter- 
nal aneurysms  pressure-symptoms  are  marked.  Thoracic  aneurysm  causes 
intercostal  pain;  iliac  aneurysm  causes  pain  in  the  thigh.  Aneurysm  of  the 
thoracic  aorta  pressing  upon  the  pneumogastric  nerve  causes  spasmodic 
dyspnea,  and  upon  the  recurrent  laryngeal,  causes  hoarseness,  which  may 
be  associated  with  loss  of  voice,  cough,  and  laryngeal  spasm,  and  is  due  to 
unilateral  abductor  paralysis.  Pressure  upon  a  bronchus  or  the  trachea 
causes  dyspnea  from  obstruction,  dysphagia,  and  cough  from  laryngeal 
spasm.  Pressure  upon  the  cervical  sympathetic  first  causes  dilatation  and 
later  contraction  of  the  pupil  of  the  same  side.  An  aneurysm  in  the  neck 
may  interfere  with  the  cerebral  circulation  and  produce  vertigo  and  even 
attacks  of  unconsciousness.  The  evidences  of  rupture  of  an  aneurysm  of 
an  extremity  into  the  tissues  are  loss  of  distinctness  of  outline  and  increase 
in  area  of  the  tumor,  weakening  or  disappearance  of  both  bruit  and  pulsation, 
absence  of  pulse  below  the  aneurysm,  severe  pain,  edema  and  coldness  of 
the  surface,  shock,  and  possibly  syncope.  External  hemorrhage  may 
arise;  the  tissues  may  become  extensively  infiltrated  with  blood;  sloughing 
or  gangrene  may  ensue.  Death  is  frequent,  and  only  in  very  rare  cases  does 
spontaneous  cure  take  place.  Rupture  of  a  large  aneurysm  into  a  cavity 
causes  intense  pallor,  advancing  weakness,  syncope,  and  death. 

Diagnosis. — A  cyst  or  abscess  over  a  vessel  may  show  transmitted  pulsa- 
tion which  is  not  expansile,  and  the  tumor  does  not  disappear  when  pressure 
is  made  upon  the  vessel  above  it.  The  pulsation, ceases  when  the  growth  is 
lifted  off  the  vessel,  or  when  the  position  is  changed  so  as  to  permit  it  to  fall 
away  from  the  vessel.  There  is  no  true  bruit,  and  the  history  is  widely 
different.  A  growth  under  a  vessel  may  lift  the  ves.sel  and  simulate  an 
aneurysm,  but  the  pulsation  is  not  noted  in  the  entire  growth,  the  growth 
does  not  disappear  on  proximal  pressure,  and  there  is  only  a  false,  and  never 
a  true,  bruit.  The  larger  the  growth  under  a  vessel,  the  less  is  the  pulsation, 
because  of  pressure  narrowing  the  caliber  of  the  vessel.  A  sarcoma,  especially 
a  soft  sarcoma  attached  to  the  bone,  and  also  a  nevoid  mass,  pulsate  and 
often  have  a  bruit;  the  tumor  never  disappears  from  proximal  pressure, 
though  it  may  slowly  diminish  in  size,  to  gradually  enlarge  again  when  pressure 
is  withdrawn.  These  growths  do  not  feel  fluid,  and  are  rarely  circumscribed. 
An  aneurysm  may  cease  to  pulsate  from  consolidation  leading  to  cure,  or 
from  rupture.  Rupture  of  a  large  aneurysm  into  a  cavity  induces  deadly 
pallor,  syncope,  and  rapid  death.  Rupture  of  an  aneurysm  of  an  extremity 
into  the  tissues  is  made  manifest  by  a  sensation  of  something  breaking,  by 
pain,  by  Sudden  increase  in  size,  by  diminution  or  absence  of  bruit  and  pulsa- 
tion, by  absence  of  pulse  below  the  aneurysm,  by  swelling  and  coldness  of 
the  limb,  and  by  shock. 

Treatment. — In  inoperable  aneurvsms  general,  medical,  and  dietetic 
treatment  must  be  tried.  A  chief  element  in  treatment  is  rest  in  bed  to 
diminish  the  rapidity  and  force  of  the  circulation  and  favor  fibrinous  deposit. 
Valsalva  long  ago  suggested  rest,  occasional  bleeding,  and  a  diet  just  above 


298  Diseases  and  Injuries  of  the  Heart  and  Vessels 

the  point  of  starvation.  Tuffnell's  plan  is  to  reduce  the  heart-beats  by  rest 
and  mental  quiet,  and  to  rigidly  restrict  the  diet  so  as  to  diminish  the  total 
amount  of  blood  and  render  it  more  fibrinous.  Liquids  are  restricted  in 
amount,  and  the  patient  lives  through  each  twenty-four  hours  upon  four  ounces 
of  bread,  a  very  httle  butter,  eight  ounces  of  milk,  and  three  ounces  of  meat. 
This  plan  is  pursued  for  several  months  if  possible,  or  it  is  employed  for 
several  weeks,  intermitted  for  a  short  period,  the  rigid  diet  again  returned  to, 
and  so  on,  over  and  over  again.  There  can  be  no  doubt  that  Tuffnell's 
treatment  sometimes  cures  aneurysm  by  decidedly  lowering  the  blood-pres- 
sure. Many  who  suffer  from  aneurysm  may  be  permitted  to  go  about, 
taking  their  time  about  everything  and  avoiding  work,  worry,  and  excite- 
ment. The  diet  should  be  low  and  non-stimulating,  and  the  bowels  must 
be  maintained  in  a  loose  condition. 

Even  in  an  operable  case  diet  and  rest  are  of  imi)ortance.  The  patient 
should  remain  in  bed  for  a  number  of  days  before  operation,  the  daily  diet 
consisting  of  ten  or  twelve  ounces  of  solid  food  with  a  pint  of  milk.  If  the 
circulation  is  very  active,  use  aconite  and  allay  pain  by  morphin. 

lodid  of  potassium  in  doses  of  20  grains  vmdoubtedly  does  good  in  aneurysm 
and  not  only  in  syphilitic  cases.  It  seems  to  lower  the  blood-pressure.  Bal- 
four taught  that  it  thickened  the  walls  of  the  sac.  Osier  says  it  relieves  the 
pain.  Iron,  acetate  of  lead,  and  ergotin  are  prescribed  by  some.  Digitalis 
is  contraindicated,  as  it  raises  the  blood-pressure.  S.  Solis  Cohen  has  used 
with  some  success  the  hydrated  chlorid  of  calcium.  Morphin  and  bromid  of 
potassium  are  occasionally  useful  to  tranquilize  the  circulation,  allay  pain,  or 
secure  sleep.     Aconite  and  veratrum  viride  ha\-e  long  been  employed. 

Lancereaux  and  others  claim  that  hypodermatic  injections  of  gelatin  at 
some  indifferent  point  may  cure  aortic  and  subclavian  aneurysm.  In  1896 
Dastres  and  Floresco  proved  that  gelatin  injected  in  the  blood  increases 
coagulability.  Later  Lancereaux  and  Paulesco  showed  that  injections  into 
the  subcutaneous  tissue  act  similarly.  Carnot  pointed  out  that  gelatin 
ai)plied  to  a  wound  may  arrest  bleeding.  How  gelatin  acts  is  uncertain,  but 
that  it  does  increase  blood-coagulability  seems  proved.  The  value  of  injec- 
tions of  gelatin  for  aneurysm  is  in  dispute.  Lancereaux  warmly  advocates  its 
use  for  sacculated  aneurysm  and  says  that  after  the  first  dose  the  aneurysm 
is  seen  to  shrink  and  the  pulsation  is  observed  to  lessen.  He  injects  it 
.slowly  and  with  aseptic  care  into  the  subcutaneous  tissue  of  the  thigh,  using 
normal  salt  solution  containing  from  5  to  to  per  cent,  gelatin.  He  never 
injects  less  than  5  gm.  He  gives  an  injection  every  tenth  to  fifteenth  day  and 
administers  from  ten  to  twenty  injections.  But  the  treatment  is  not  free  from 
danger;  several  deaths  have  taken  place,  and  several  persons  have  died  from 
tetanus.  Care  must  be  taken  not  to  inject  gelatin  into  a  vessel,  and  it  must 
never  be  thrown  about  the  aneurysmal  sac.  It  irritates  the  kidneys  and 
its  use  is  contraindicated  in  renal  disease.  The  injections  cause  much  pain, 
and  it  is  very  doubtful  if  they  do  any  real  good  in  aneurysm.  If  used,  it 
should  be  given  at  the  temperature  of  the  body,  and  not  over  3  gm.  should 
be  administered  at  one  dose.  A  10  percent,  solution  is  the  proper  strength 
and  from  10  to  20  c.c.  the  correct  dose.  Gelatin  can  be  given  by  the  mouth. 
When  thus  given  it  is  not  so  j)owerful,  but  its  coagulating  property  is  not 
destroyed    by  digestion.     Gelatin  in  normal  .salt   solution  is  known  as  Car- 


Treatment  of  Aneurysm  299 

not's  solution.  Carnot's  solution  is  best  prepared  b\-  Sailer's  formula,  as 
follows  (Joseph  Sailer,  in  "Therapeutic  Gazette,"  August,  1901):  Take  5 
gm.  of  common  salt,  i  liter  of  distilled  water,  and  100  gni.  of  gelatin.  Bring 
the  water  to  a  temperature  of  80°  C.  and  slowly  stir  in  the  gelatin  until  it 
is  all  in  solution.  Remove  the  solution  from  the  stove,  cool  it  to  40°  C,  add 
to  it  the  white  of  one  egg,  and  stir  for  several  minutes,  and  then  put  the  flask 
on  the  stove  and  boil  the  fluid.  The  white  of  egg  coagulates  and  clears  the 
solution.  Filter  through  gauze  and  then  through  paper.  Place  the  fluid  in 
test-tubes,  each  of  which  will  contain  10  c.c,  and  insert  a  cotton  plug  in  the 
mouth  of  each  tube.  Sterilize  by  putting  the  tubes  in  a  steam  sterilizer  for 
fifteen  minutes  on  three  successive  days.  When  we  wish  to  use  a  tube, 
place  it  in  a  cup  of  hot  water  until  the  gelatin  liquefies,  pour  the  gelatin 
into  a  sterile  glass,  and  draw  it  up  into  a  sterile  syringe.  When  kept  several 
weeks  the  tubes  dry  out. 

Other  expedients  sometimes  used  in  the  treatment  of  aneurysm  are:  the 
kneading  of  the  sac  to  release  a  clot,  in  the  hope  that  it  will  plug  the  mouth 
of  the  sac  or  the  artery  beyond  it — this  is  dangerous;  electricity;  electrolysis; 
the  injection  of  an  astringent  liquid;  the  insertion  of  a  fine  aspirating  needle 
and  the  pushing  through  it  into  the  sac  of  a  large  quantity  of  silver  wire,  in 
the  hope  that  it  will  aid  in  whipping  out  fibrin.  Some  physicians  have  in- 
serted needles  and  horsehair. 

Treatment  by  Pressure. — Instrunienta/  pressure  is  made  by  applying  two 
Signorini  tourniquets  or  some  specially  devised  apparatus  to  hmit  the  flow^ 
of  blood  through  an  aneurysm  without  entirel}'  stopping  it,  the  aneurysmal 
sac  being  felt  to  still  slightly  pulsate.  In  some  situations  Lister's  abdominal 
tourniquet  is  applied;  in  other  regions  we  may  use  Tuffnell's  compress,  which 
is  like  a  spring  truss  and  is  strapped  in  place.  A  heavy  body  suspended  over 
the  artery  and  resting  part  of  its  weight  upon  the  vessel  has  occasionally 
brought  about  cure.  Compressing  instruments  can  be  worn  for  from  twelve 
to  sixteen  hours  at  a  time;  usually  they  are  removed  to  permit  sleep  and  are 
reapplied  the  next  day,  and  so  on  for  several  days.  Before  applying  the 
compress  be  sure  the  sac  is  full  of  blood,  and  render  this  certain  by  apyilying 
for  a  few  minutes  distal  compression.  This  method  may  cure,  but  it  is  very 
painful.  It  cannot  be  used  successfully  in  treating  aneurysm  of  the  axillary, 
subclavian,  or  carotid  arter}'.     It  aids  in  the  formation  of  an  active  clot. 

Digital  pressure,  made  with  the  thumb  aided  by  a  weight,  and  maintained 
for  many  hours  by  a  relay  of  assistants,  has  cured  many  cases.  This  method 
may«be  used  alone  or  may  be  used  as  an  accessory  to  instrumental  pressure. 
Its  chief  field  is  in  the  treatment  of  aneurysm  for  which  other  methods  are 
inapplicable  (orbit  and  root  of  neck).  It  entirely  cuts  off  the  blood  and  pro- 
motes the  formation  of  a  passive  clot.  If  cure  does  not  take  place  in  three 
days,  abandon  pressure.  It  must  often  be  abandoned  far  earlier  because  of 
pain. 

Direct  pressure  upon  the  sac  has  been  used  in  aneurysm  of  the  popliteal 
artery,  the  pressure  being  obtained  by  flexing  the  leg;  and  in  aneurysm  of  the 
brachial  artery  pressure  has  been  applied  at  the  bend  of  the  elbow  by  flexing 
the  elbow.  The  pressure  of  a  hollow  rubber  ball  has  been  used  in  aneurysm 
of  the  subclavian. 

Rapid  pressure  completely  arrests  the  passage  of  blood  througli  the  sac 


300  Diseases  and  Injuries  of  the  Heart  and  Vessels 

for  a  limited  time,  and  is  applied  while  the  patient  is  under  the  influence  of 
an  anesthetic.  Take,  for  example,  a  case  of  popliteal  aneurysm:  the  patient 
is  placed  under  the  influence  of  ether ;  two  Esmarch  bandages  are  used, 
one  being  applied  to  the  hmb  from  the  toes  up  to  the  lower  limit  of  the 
aneurysm,  and  the  other  from  the  groin  down  to  the  upper  limit  of  the  sac, 
and  the  Esmarch  band  is  fastened  above  the  upper  bandage.  This  pro- 
cedure stagnates  the  blood  both  in  the  veins  and  in  the  arteries,  and  the 
sac  remains  full  of  blood.  Pressure  is  thus  maintained  for  three  or  four 
hours,  and  on  removing  the  Esmarch  apparatus  a  tourniquet  is  put  on  the 
artery  above  the  aneurysm  and  partly  tightened  in  order  to  limit  the  amount 
of  blood  passing  through  and  thus  prevent  the  washing  away  of  clot.  This 
method  of  rapid  pressure  sometimes  cures  by  forming  a  passive  clot,  but  it 
sometimes  results  in  gangrene.     It  was  devised  by  John  Reid. 

Operative  Treatment :  By  the  Ligature. — Ligation  of  the  main  artery  is,  as 
a  rule,  the  best  procedure.  The  methods  of  ligation  are — (i)  the  method 
of  x\ntyllus ;  (2)  extirpation  of  the  sac;  (3)  the  method  of  Anel;  (4)  the 
method  of  Hunter;  (5)  the  method  of  Wardrop;  and  (6)  the  method  of 
Brasdor. 

In  the  method  of  AntyUus  (Fig.  95),  as  usually  described,  the  sac  itself  is 
attacked.  The  artery  is  ligated  immediately  above  and  below  the  sac,  the 
sac  is  opened  and  its  contents  turned  out,  or  the  sac  is  extirpated.  As  a 
matter  of  fact,  Antyllus  advocated  applying  a  ligature  on  each  side  of  the  sac 
and  opening  the  tumor  in  order  to  evacuate  its  contents,  but  he  distinctly 
opposed  extirpation  because  of  its  danger.  All  we  know  of  Antyllus  is 
found  in  the  writings  of  Oribasius,  who  lived  in  the  fourth  century  (B.  G.  A. 
Moynihan,  in  "Annals  of  Surgery,"  July,  1898).  Syme  maintained  many 
years  ago  that  incision  of  the  sac  is  the  proper  operation  for  aneurysm 
of  the  gluteal,  iliac,  carotid,  and  axillary  arteries,  but  Syme's  method  is 
productive  of  fearful  hemorrhage  and  the  plan  of  Antyllus  is  vastly  better. 
Syme  opened  the  sac,  inserted  his  finger  and  plugged  the  artery  toward  the 
heart  until  a  ligature  was  applied  and  tied,  and  packed  the  sac  with  Hnt. 

Extirpation  of  the  sac,  if  practised,  should  be  carried  out  after  applying 
a  ligature  on  each  side  after  the  method  of  Antyllus.  It  was  originally 
practised  by  Philagrius  and  was  reintroduced  by  Purmann  in  1699 
(Moynihan). 

Extirpation  finds  warm  advocates  in  Delbet,  Littlewood,  and  Moynihan. 
Moynihan  claims  that,  as  compared  with  distal  ligature,  there  is  a  greater 
chance  of  recovery,  no  chance  of  recurrence,  less  risk  of  gangrene,  and  com- 
plete recovery  from  troubles  due  to  nerve  interference  ("Annals  of  Surgery," 
July,  1898).  Extirpation  is  the  best  operation  for  traumatic  aneurysm, 
but  if  the  vessel  is  seriously  diseased  near  the  sac  some  other  method  should 
be  employed.  The  operation  is  growing  in  favor  and  will  probably  in 
most  instances  become  the  operation  of  choice  ("Annals  of  Surgery," 
July,  1898). 

The  Method  of  Anel. — In  Anel's  method  the  artery  is  ligated  above  the 
sac,  and  so  close  to  it  that  there  are  no  anastomotic  branches  between  the 
sac  and  the  ligature  (Fig.  96).  It  is  used  only  for  traumatic  aneurysms,  and 
is  never  employed  when  the  vessel  is  diseased  beyond  the  aneurysm.  Ex- 
tirpation is  preferable  to  Anel's  operation. 


Treatment  of  Aneun^sm 


?oi 


The  Method  of  Hunter. — This  operation^  which  is  the  modern  method  of 
ligation,  was  devised  by  the  illustrious  John  Hunter.  He  is  said  bv  Sir 
Everard  Hume  to  have  recognized  the  fact  that  the  vessel  adjacent  to  an 
aneurysm  was  apt  to  be  diseased,  and  he  discovered  the  anastomotic  circula- 
tion. Putting  together  these  two  facts,  he  devised  the  operation  which  goes 
by  his  name.  It  consists  in  applying  a  ligature  between  the  heart  and  the 
aneurysm,  but  so  far  above  the  sac  that  collateral  branches  are  given  off 
between  it  and  the  point  of  ligation  (Fig.  97).  This  operation,  which  is  done 
upon  a  healthy  area,  does  not  permanently  cut  off  all  blood,  but  so  diminishes 
the  force  and  frequency  of  the  circulation  that  an  active  clot  forms  within 


Fig.   95. — Old  opuration  of  .Antyllus  for  an- 
eur\'sm  ("Am.  Text-Book  of  Surgery"  ). 


Fig.  96. — Anels  operation  for  aneurysm 
("Am.  Te.\t-Book  of  Surgery  "). 


the  sac.  Thus  is  lessened  the  danger  of  secondary  hemorrhage  and  of  gan- 
grene. According  to  Stimson  ("Xew  York  Med.  Jour.,"  July,  1884),  Hunter 
reall}'  builded  better  than  he  knew,  for  he  sought  only  to  tie  the  arterv  without 
opening  the  sac  and  at  a  healthy  point,  but  said  not  a  word  about  the  necessity 
of  having  branches  between  the  sac  and  the  ligature  or  about  the  desirability 
of  diminishing  the  flow  of  blood  instead  of  cutting  it  off  completely  (Movnihan, 
in  "Annals  of  Surgery,"  July,  1S9S).  Hunter  tied  the  artery  in  the  region 
now  known  as  Hunter's  canal.     Scarpa  introduced  the  custom,  which  we 


F'S-  97- — Hunter's  method  of  ligating  for  aneurysm:  a.  The  aneurysm  ;  b.  the  point  of  ligation  ;  c, 
the  branches  between  the  aneurysm  and  the  ligature.  The  arrow  shows  the  direction  of  the  blood- 
current. 


still  follow,  of  tying  it  in  Scarpa's  triangle.  The  Hunterian  method  is,  in 
the  majority  of  cases,  the  proper  operation  for  aneurysm.  In  some  cases, 
pulsation  does  not  return  after  tightening  the  ligature;  in  most  cases,  however, 
it  reappears  for  a  time  after  about  thirty-si.x  hours,  but  is  weak  from  the 
start,  constantly  diminishes,  and  finally  disappears  permanently.  Previous 
prolonged  compression  by  enlarging  the  collateral  branches  permits  strong 
pulsation  to  recur  soon  after  ligation,  and  thus  militates  against  cure;  hence 
it  is  a  bad  plan  to  use  pressure  in  cases  admitting  of  ligation,  and  in  which 
the  success  of  pressure  is  very  doubtful.  Occasionally  after  Hunter's  opera- 
tion the  sac  suppurates    producing  symptoms  like  those  of  abscess.     Sup- 


302  Diseases  and  Injuries  of  the  Heart  and  Vessels 

puration  may  occur  between  the  first  and  the  thirty-second  week  after  hgation.* 
When  pus  forms,  open  freely  as  we  would  open  an  abscess,  and,  if  no  blood 
flows,  treat  as  an  abscess,  but  have  a  tourniquet  loosely  applied  for  several 
days  ready  to  screw  up  at  the  first  sign  of  danger.  If  hemorrhage  occurs, 
tie  the  vessel  above  and  below  the  aneurysm,  open  the  sac,  and  pack  with 
iodoform  gauze.  If  bleeding  recurs,  there  is  no  use  reapplying  the  ligature 
and  there  is  httle  use  tying  higher  up.  If  dealing  with  an  arm,  try  the  appli- 
cation of  a  ligature  higher  up;  if  dealing  with  a  leg,  amputate  at  once. 

Distal  Ligation. — When  an  aneurysm  is  so  near  the  trunk  that  Hunter's 
operation  is  impracticable,  or  when  the  artery  on  the  cardiac  side  of  the 
tumor  is  greatly  diseased,  distal  ligation  may  be  employed.  Distal  ligation 
forms  a  barrier  to  the  onflow  of  blood,  collateral  branches  above  the  aneurysm 
enlarge,  the  blood-current  is  gradually  diverted,  and  a  clot  may  form  within 
the  aneurysm.  Distal  ligation  is  used  in  some  aneurysms  of  the  aorta,  iliacs, 
innominate  carotids,  and  subclavians.     It  occasionally  causes  rupture  of  the 


Fig.  gS. — Brasdor's  operation  (Holmes).  Fig.  qq. — VVardrop's  operalion  (Holnie.s). 

sac  of  the  aneurysm.  I  have  obtained  one  notably  successful  result  in  an 
aneurysm  of  the  innominate  artery  by  ligation  of  the  carotid  and  subclavian 
of  the  right  side. 

The  operation  oj  Brasdor  consists  in  t\ing  the  main  trunk  some  little 
distance  below  the  aneurysm  (Fig.  98).  It  completely  arrests  circulation 
in  the  sac. 

Tlie  operation  oj  Wardrop  consists  in  tying  one  of  the  branches  of  the 
artery  below  the  aneurysm.  Wardrop  originally  advocated  ligation  at  a 
point  where  there  is  no  intervening  branch  between  the  sac  and  the  ligature. 
Later  he  advocated  ligation  at  a  point  \\here  there  is  an  intervening  branch. 
Since  then  it  is  the  custom  to  consider  Wardrop's  operation  to  be  the  ligation 
of  one  branch  below  the  aneurysm,  as  shown  in  Fig.  qq.  The  circulation  is 
but  partially  arrested  by  Wardrop's  oyjeration.  An  .v-ray  yjicture  should 
be  taken  in  every  case  of  aortic  aneurysm.  Such  a  i)icture  may  aid  us  in 
coming  to  a  conclusion  as  to  which  vessel  or  vessels  to  tie. 

Matas's  Operation  (Arteriorrhaphy). — In  a  limb  the  blood  is  emptied  out 
by  elevation  and  is  kept  out  by  an  Rsmarch  band.  In  a  limb  near  the 
body  or  in  the  neck  the  main  artery  is  exposed,  a  traction  looj)  is  placed 
■■  See  the  ca^e  described  by  Sir  Astley  Cooper. 


Treatment  of  Aneurysm  303 

under  the  artery  between  the  aneurysm  and  the  heart,  and  the  vessel 
is  compressed  b}'  an  assistant.  The  sac  is  exposed,  opened,  and  emptied. 
The  type  of  sac  is  studied  and  the  number  of  openings  determined.  In  a 
fusiform  aneurysm  the  continuity  of  the  artery  cannot  be  restored  and 
sutures  are  aT)ph'ed  in  order  to  close  the  openings  and  obliterate  the  sac.  In 
a  sacciform  aneurysm  with  a  single  opening  it  is  often  possible  to  close  this 
o])ening  by  sutures  without  lessening  the  caliber  of  the  vessel  and  thus  cure 
the  aneurysm  without  destroying  arterial  continuity  (see  Rudolph  Matas  in 
"Annals  of  Surgery,"  Feb.,  1903).  If  a  branch  opens  from  the  sac,  the 
opening  must  be  sutured.  Matas  has  operated  upon  four  cases  by  this 
method. 

After  ligating  for  aneurysm  of  an  extremity  by  any  of  these  methods, 
elevate  the  limb,  keep  it  warm,  and  subdue  arterial  e.xcitement.  When 
gangrene  of  a  limb  follows  ligation,  await  a  hne  of  demarcation,  and  when 
it  forms,  amputate.  Rupture  of  the  sac  after  ligation  may  produce  gangrene 
or  be  associated  with  suppuration,  the  first  condition  demanding  amputation, 
and  the  second  incision  for  drainage. 

Injection  of  (-oagit/ati)ig  agents  into  the  sac  (ergot,  perchlorid  of  iron,  etc.) 
is  very  dangerous  and  is  to  be  utterly  condemned.  It  may  lead  to  suppura- 
tion, gangrene,  rupture,  or  embolism. 

Manipulation  to  break  up  the  clot  was  suggested  by  Sir  \Vm.  Fergusson, 
and  has  been  practised.  The  object  aimed  at  is  to  have  a  fragment  of  clot 
block  uj)  the  vessel  upon  the  peripheral  side  of  the  artery  and  act  like  a  distal 
ligature.  The  method  is  dangerous,  especially  in  carotid  aneurvsm,  and 
should  never  be  employed. 

Amputation,  instead  of  distal  ligation,  is  performed  in  some  i)erilous  cases 
of  subclavian  aneurysm. 

Electrolysis. — An  attemj)t  may  be  made  to  coagulate  the  blood  at  once, 
or  from  time  to  time  an  endeavor  may  be  m.ade  to  produce  fibrinous  deposits, 
but  the  first  method  is  the  better.  It  is,  however,  rarely  possible  to  at  once 
occlude  a  sac,  and  pulsation,  which  is  for  a  time  abolished,  recurs  as  the  gas 
present  is  absorbed.  Use  the  constant  current.  Take  from  three  to  six 
cells  which  stand  in  point  of  size  between  those  used  for  the  cautery  and  those 
used  for  ordinary  medical  purposes.  .\  |)latinum  needle  is  attached  to  the 
positive  pole  and  a  steel  needle  to  the  negative  pole,  each  needle  being  insulated 
by  vulcanite  at  the  spot  where  the  tissues  will  touch  it.  The  ase]:)ticized 
needles  are  plunged  into  the  sac  where  it  is  thick,  and  they  are  ke])t  near 
together.  The  current  is  passed  for  a  variable  period  (from  half  an  hour  to 
an  hour  and  a  half).  This  operation  is  not  dangerous.  Pressure  stops  the 
bleeding.  Electrolvsis  often  ameliorates,  and  sometimes,  though  xerv  rarelv, 
cures,  aortic  aneurysms.* 

Acupressure  consists  of  the  partial  introduction  of  a  number  of  ordinary 
sewing  needles  into  an  aneurysmal  sac  and  leaving  them  in  it  for  li\e  or  six 
(lays  or  more.  Prof.  Macewen  introduces  a  needle,  and  with  it  irritates  the 
interior  of  the  sac  of  an  aneurvsm,  hoping  thus  to  cause  deposition  of  leuko- 
cytes and  clot-formation. 

Introduction  oj  Wire. — Insert  into  the  sac  a  hypodermatic  or  small  aspirat- 
ing needle,  and  push  through  the  needle  or  cannula  a  considerable  quantity 
*  See  John  Duncan,  in  Heath's  Dictionary. 


304  Diseases  and  Injuries  of  the  Heart  and  Vessels 

of  aseptic  gold  wire,  which  is  allowed  to  remain  permanently.  Electrolysis 
should  be  combined  with  the  introduction  of  wire.  This  operation  was 
first  proposed  by  Corradi.  Loreta  and  Barwell  both  inserted  wire  into  an 
aneurysm  before  Corradi,  but  Corradi  inserted  wire  and  also  used  electricity. 
Corradi's  operation  can  be  used  when  distal  ligation  cannot  be  carried  out, 
and  can  be  used  even  when  the  vessel  is  extremely  atheromatous.  It  finds 
its  chief  use  in  aneurysms  of  the  thoracic  aorta  and  innominate.  In  some 
cases  of  abdominal  aneurysm  the  belly  has  been  opened  and  the  operation 
carried  out.  Some  cases  have  been  notably  improved,  and  one  of  Stewart's 
cases  was  apparently  cured.*  The  operation  is  performed  with  aseptic  care. 
If  the  thoracic  aorta  is  to  be  operated  upon,  an  anesthetic  is  not  required. 
If  the  abdominal  aorta  is  to  be  wired,  the  patient  must  be  anesthetized.  The 
wire  used  must  have  been  previously  drawn,  so  that  it  will  easily  pass  through 
a  hypodermatic  needle  and  will  coil  up  spirally  within  the  sac  (Stewart). 
The  best  wire  is  of  silver  or  gold.  It  is  a  great  mistake,  Stewart  says,  to 
introduce  a  large  quantity.  He  considers  that  a  globular  sac  three  inches 
in  diameter  requires  from  three  to  five  feet,  and  a  sac  five  inches  in  diameter 
requires  from  eight  to  ten  feet.  A  hypodermatic  needle,  insulated  up  to 
one-quarter  inch  of  the  point,  is  carried  into  the  interior  of  the  aneurysm 
through  a  fairly  thick  portion  of  the  sac.  The  required  amount  of  wire  is 
introduced.  The  wire  is  attached  to  the  positive  pole  of  the  battery.  The 
negative  pole  is  fastened  to  a  large  flat  piece  of  clay  or  a  pad  of  moistened 
absorbent  cotton,  and  the  negative  electrode  is  placed  upon  the  back  or 
abdomen.  The  current  is  turned  on  gradually  until  the  necessary  strength 
is  obtained  (40  to  80  ma.).  When  ready  to  terminate  the  operation  the 
current  is  lowered  gradually  to  zero,  the  needle  is  withdrawn,  the  wire  is  cut 
off  close  to  the  skin,  the  end  is  pushed  under  the  skin  and  the  puncture  is 
covered  with  iodoform  collodion.  The  entire  operation  requires  from  three- 
quarters  of  an  hour  to  one  and  a  half  hours. f  A  clot  forms  with  considerable 
rapidity  and  expansile  pulsation  may  lessen  or  cease.  The  operation  can 
be  repeated  if  necessary. 

Treatment  of  Aneurysm  following  Wound  of  a  Healthy  Artery. — 
The  prognosis  in  such  a  case  is  usually  extremely  good.  The  treatment  is 
as  for  the  other  forms.  Extirpation  is  particularly  adapted  to  such  direct 
traumatic  aneurysms. 

Diffuse  Traumatic  Aneurysm. — When  an  artery  ruptures  or  an  aneu- 
rysm ruptures  and  a  large  mass  of  blood  is  extravasated  into  the  tissues,  no 
sac  exists,  and  the  condition  is  usually  called  diffuse  traumatic  aneurysm. 
In  diffuse  traumatic  aneurysm,  a  large,  oblong,  fluctuating  swelling  is  found. 
If  the  rent  is  large,  there  are  bruit  and  pulsation.  There  is  no  pulsation  in 
the  artery  below  the  aneurysm,  and  the  limb  is  cold  and  swollen.  The  skin 
is  at  first  of  a  natural  color,  but  becomes  thin  and  purple. 

Treatment. — Cut  down  upon  the  seat  of  rupture  and  tie  on  each  side 
of  the  tear.  For  a  ruptured  aneurysm  perform  the  operation  of  Antyllus. 
If  the  main  vein  is  also  ruptured,  amputate. 

■•■  IJ.  D.  Stewart,  in    Phila.  Med    Jour.,  Oi  t.   12,  i^gS. 

t  The  above  description  is  condensed  from  tiiat  of  D.  D.  Stewart,  in  Phila.  Med. 
Jour.,  Nov.   12,     898 


Arteriovenous  Aneurysm  305 

Arteriovenous  aneurysm  was  first  described  by  Wm.  Hunter  in  1757. 
By  the  term  we  mean  an  unnatural  passageway  between  a  vein  and  an  artery, 
through  which  passage  blood  circulates.  There  are  two  forms:  (a)  aneurysmal 
varix,  or  Pott's  aneurysm,  a  vein  and  an  artery  directly  communicating;  and 
(b)  varicose  anetirysm,  a  vein  and  an  artery  communicating  through  an  in- 
tervening sac.  These  conditions  arise  usually  from  punctured  wounds,  the 
instrument  passing  through  one  vessel  and  into  the  other,  blood  flowing  into 
the  vein,  the  subsequent  inflammation  gluing  the  two  vessels  together,  and 
the  aperture  failing  to  close  (aneurysmal  varix.  Fig.  100).  After  the  infliction 
of  the  wound  the  two  vessels  may  separate;  the  blood  continuing  to  flow 
from  artery  into  vein,  and  the  blood-pressure,  by  consolidating  tissue,  forming 
a  sac  of  junction  (varicose  aneurysm.  Fig.  loi).  Wounds  produced  by  small 
bullets  ma\-  result  in  arteriovenous  aneurysm.  Aneurysmal  varix  is  a  less 
grave  disorder  than  varicose  aneurysm.  Arteriovenous  aneurysm  used  to 
be  most  frequent  at  the  bend  of  the  elbow,  the  vessels  being  injured  during 
venesection.  The  condition  may  occur  in  the  neck,  the  axilla,  the  extremities, 
or  the  groin.  I  assisted  Prof.  Keen  in  an  operation  upon  an  aneurysmal 
varix  of  the  common  carotid  and  internal  jugular  vein,  and  assisted  Dr. 
Hearn  in  operating  on  a  varicose  aneurysm  involving  the  external  iliac  vessels. 
Treves  operated  on  a    case  involving   the  internal  maxillary  vessels.     Very 


Fig.  100. — Plan  of  aneurysmal  varix.  Fig.  loi. — Varicose  aneurysm  (Spence 


rarely  an  arteriovenous  aneurysm  forms  spontaneously.  Spontaneous  arterio- 
venous aneurysm  is  most  frequent  between  the  aorta  and  vena  cava.  There 
is  no  tendency  to  spontaneous  cure  in  arteriovenous  aneurysm.  Edema  is  the 
rule,  muscular  atrophy  is  common,  and  ulceration  or  even  gangrene  may  occur. 
Symptoms  of  Aneurysmal  Varix. — The  arterial  blood  is  cast  forcibly 
into  the  vein  and  as  a  consequence  the  vein  becomes  enlarged,  tortuous,  and 
thickened.  The  scar  of  a  wound  is  almost  invariably  apparent.  At  the  point 
of  trouble  the  most  marked  dilatation  exists  and  it  is  of  bluish  color.  The 
tumor  pulsates  markedly,  imparts  a  sensation  to  the  finger  like  that  felt  when 
the  hand  is  laid  upon  the  back  of  a  purring  cat.  This  thrill  or  vibration  is 
very  characteristic.  A  sound  of  a  hissing  or  buzzing  nature  can  be  easily 
heard.  The  tumor  at  once  disappears  on  pressure  being  made  upon  it  or  on 
the  artery  between  it  and  the  heart.  It  is  diminished  in  size  by  raising  the 
limb,  is  increased  in  size  by  a  dependent  position  of  the  limb  and  by  com- 
pressing the  vein  between  the  heart  and  the  tumor.  The  adjacent  veins  are 
dilated  and  often  the  dilatation  is  manifested  over  a  wide  area  above  and 
below,  and  the  thrill  and  bruit  are  transmitted  a  considerable  distance.  If 
an  extremity  is  involved  it  is  usually  edematous.  The  parts  as  a  rule  are 
painful.  The  condition  progresses,  but  very  slowly,  and  sometimes  years  may 
elapse  without  any  notable  aggravation. 


3o6  Diseases  and  Injuries  of  the  Heart  and  Vessels 

Symptoms  of  Varicose  Aneurysm. — In  this  condition  we  find  many  of 
the  symptoms  of  aneurysmal  varix,  but  in  varicose  aneurysm  pressure  over 
the  artery  of  supply  between  the  heart  and  the  lesion  does  not  cause  the  entire 
disappearance  of  the  tumor;  the  veins  collapse,  it  is  true,  but  a  distinct  tumor 
remains  which  may  be  emptied  by  direct  pressure. 

Treatment. — The  prognosis  after  operation  is  better  than  in  ordinary 
aneurysm  (Treves),  but  nevertheless  it  is  wisest  to  refrain  from  operating 
on  aneurysmal  varix  so  long  as  the  condition  is  not  progressing  obviously,  is 
borne  without  inconvenience,  and  is  not  leading  to  complications.  Varicose 
aneurysm  should  be  operated  upon.  If  we  refrain  from  operating  upon 
aneurysmal  varix  the  patient  should  wear  a  support ;  but  if  the  part  becomes 
painful  or  if  there  seems  to  be  danger  of  rupture  of  the  vein,  each  vessel 
should  be  tied  above  and  below  the  opening  and  a  portion  of  each  vessel 
should  be  excised,  the  excised  area  including  the  opening.  In  varicose 
aneurysm  each  vessel  above  and  below  the  sac  must  be  ligated,  and  the 
sac  and  a  portion  of  each  vessel  should  be  excised. 

Cirsoid  aneurysm,  or  aneurysm  by  anastomosis,  consists  in  great 
dilatation  with  pouching  and  lengthening  of  one  or  several  arteries.  The 
disease  progresses  and  after  a  time  involves  the  veins  and  capillaries.  The 
walls  of  the  arteries  become  thin  and  the  vessels  tend  to  rupture.  Cirsoid 
aneurysm  is  most  commonly  met  with  upon  the  forehead  and  scalp  of  young 
people,  where  it  sometimes  takes  origin  from  a  nevus.  It  is  sometimes  seen 
upon  the  back  or  upper  extremity.  The  cause  is  unknown.  Usually  there 
is  no  assignable  cause,  but  occasionally  the  condition  follows  an  injury. 
Pregnancy  causes  a  cirsoid  aneurysm  to  grow  rapidly,  and  so  usually  does 
the  onset  of  puberty.  Occasionally  some  of  the  enlarged  vessels  fuse  and 
form  a  great  cavity.  If  rupture  occurs,  desperate  hemorrhage  inevitably 
ensues. 

Symptoms. — There  is  a  pulsating  mass,  irregular  in  outline,  composed 
of  dilated,  elongated,  and  tortuous  vessels  that  empty  into  one  another.  The 
mass  is  soft,  can  be  much  reduced  by  direct  pressure,  and  is  diminished  by 
compression  of  the  main  artery  of  supply.     A  thrill  and  a  bruit  exist. 

Treatment. — In  treating  a  cirsoid  aneurysm  the  ligation  of  the  larger 
arteries  of  supply  is  a  wretched  failure.  Subcutaneous  ligation  at  many 
points  of  the  diseased  area  has  effected  cure  in  some  cases,  but  it  has  failed 
in  more.  Direct  pressure  is  also  entirely  useless.  Ligation  in  mass  has  been 
successful.  Destruction  by  caustic  has  its  advocates.  Electropuncture  with 
circular  compression  of  the  arteries  of  supply  has  once  or  twice  effected  a 
cure.  Injection  of  astringents  has  been  recommended.  Verneuil  ligated 
the  afferent  arteries,  incised  the  tissues  around  the  tumor,  and  sank  a  con- 
stricting ligature  into  the  cut.  The  proper  method  of  treatment  is  excision 
after  exposure  and  ligation  of  every  accessible  tributary  of  sui)ply.  In  a  very 
extensive  mass  extirpation  is  impossible;  hence  one  of  the  other  methods 
suggested  must  be  employed.  A  very  considerable  mass  can  be  excised,  and 
the  resulting  wound  should  be  covered  with  Thiersch  skin-grafts. 

Wounds  of  arteries  are  divided  into  contused,  incised,  lacerated, 
puncturcrl,  and  gunshot-wounds,  and  vascular  ruptures. 

Contused  and  Incised  Wounds. — A  contusion  may  destroy  vitality  and 
be   followed   by   sloughing  and   hemorrhage.     A   contusion   may  rupture  a 


Wounds  of  Arteries  307 

blood-vessel,  and  is  especially  apt  to  do  so  if  the  vessel  is  diseased.  Blood 
is  at  once  effused  at  the  seat  of  rupture.  If  an  artery  is  ruptured,  there  may 
or  mav  not  be  a  bruit  and  pulsation  over  the  seat  of  rupture,  pulse  is  absent 
below,  and  the  leg  below  the  injury  swells  and  becomes  cold.  If  a  large 
vein  ruptures,  a  blood  tumor  forms,  which  does  not  pulsate  and  has  no  bruit, 
and  the  limb  below  becomes  intensely  edematous.  Gangrene  is  apt  to  follow 
the  rupture  of  a  main  blood-vessel  of  an  extremity.  A  contusion  may  rupture 
the  internal  and  middle  coats  of  an  artery,  the  external  coat  remaining  intact. 
When  this  happens  the  internal  coat  curls  up  and  the  middle  coat  contracts 
and  retracts,  the  blood-stream  is  arrested,  and  a  large  clot  forms  within  the 
arterv.  If  the  clot  blocks  up  many  collaterals,  gangrene  will  follow,  and, 
as  has  been  pointed  out,  the  gangrene  will  not  be  preceded  by  swelling  at  the 
seat  of  injurv,  which  always  occurs  if  a  vessel  is  ruptured.  A  contused 
wound  may  do  httle  damage,  or  it  may  produce  gangrene  from  thrombosis, 
or  it  mav  cause  secondary  hemorrhage.  In  an  incised  wound  of  an  artery 
there  is  profuse  hemorrhage.  The  artery  after  a  time  is  apt  to  contract  and 
retract,  bleeding  being  thus  arrested.  A  transverse  wound  causes  profuse 
bleeding,  but  there  is  a  better  chance  for  natural  arrest  than  in  an  oblique 


Hig.  102.— Clots    formed  after  division  of  an  artery:    i,  2,    3,  Outer,  middle,  and  inner  coats; 
branches  ;  d,  d,  internal  clot ;  <»,  e,  external  clot. 


or  in  a  longitudinal  wound.  The  clot  which  forms  within  a  cut  artery  is 
known  as  the  "internal  clot."  It  used  to  be  taught  that  the  internal  clot 
always  reaches  as  high  as  the  first  collateral  branch,  and  subsequently  is 
replaced  by  fibrous  tissue,  which  permanently  obhterates  the  vessel,  and  con- 
verts it  into  a  shrunken  fibrous  cord.  As  a  matter  of  fact,  when  the  parts  are 
aseptic  after  a  ligation  the  clot  is  rarely  bulky  and  is  often  very  scant}-,  repair 
being  quickly  effected  by  proliferation  of  endothelial  cells.  Between  the 
vessel  and  its  sheath,  over  the  end  of  the  vessel,  and  in  the  surrounding  peri- 
vascular tissues  is  the  ''external  clot"  (Fig.  102). 

A  lacerated  wound  of  an  artery  causes  little  primary  hemorrhage.  The 
internal  coat  curls  up,  the  circular  muscular  fibers  of  the  media  contract 
upon  it,  the  longitudinal  fibers  retract  and  draw  the  vessel  within  the  sheath, 
and  the  external  coat  becomes  a  cap  over  the  orifice  of  the  vessel.  All  of 
these  conditions  favor  clotting.  The  vessel-wall  is  so  damaged  that  secondary 
hemorrhage  is  usual. 

Punctured  Wounds. — In  punctured  wounds  primary  hemorrhage  is 
slight   unless   a   large   vessel   is   punctured.     Secondary   hemorrhage   is    not 


3o8  Diseases  and  Injuries  of  the  Heart  and  Vessels 

common.  Traumatic  aneurysm  and  arteriovenous  aneurysm  are  not  unusual 
results. 

Gunshot-wounds  of  arteries  by  pistol  balls  and  the  balls  of  large-caliber 
rifles  are  apt  to  be  contusions  which  may  eventuate  in  sloughing  and 
secondary  hemorrhage  or  thrombosis  and  gangrene.  A  shell-fragment  makes 
a  lacerated  wound.  A  modern  rifle-bullet  makes  a  clean-cut  division  of  an 
artery.  Secondary  hemorrhage  after  gunshot-wounds  is  most  hkely  to  occur 
during  the  third  week  after  the  injury.  Partial  rupture  of  an  artery  may 
cause  sloughing  and  secondary  hemorrhage,  thrombosis  and  gangrene,  or 
aneurysm.  A  complete  rupture  constitutes  a  lacerated  wound,  and  is  a  con- 
dition accompanied  by  diffuse  hemorrhage  into  the  tissues. 

Wounds  of  veins  are  classified  as  are  wounds  of  arteries.  The  symptom 
of  any  vascular  wound  is  hemorrhage. 

I.   Hemorrhage,  or  Loss  of    Blood. 

Hemorrhage  may  arise  from  wounds  of  arteries,  veins,  or  capillaries,  or 
from  wounds  of  the  three  combined.  In  arterial  hemorrhage  the  blood  is 
scarlet  and  appears  in  jets  from  the  proximal  end  of  the  vessel,  which  jets 
are  synchronous  with  the  pulse-beats;  the  stream,  however,  never  intermits. 
The  stream  from  the  distal  end  is  darker  and  is  not  pulsatile.  Venous  hemor- 
rhage is  denoted  by  the  dark  hue  of  the  blood  and  by  the  continuous  stream. 
In  capillary  hemorrhage  red  blood  wells  up  like  water  from  a  squeezed  sponge, 
and  the  color  is  between  the  bright  red  of  arterial  blood  and  the  dark  color  of 
venous  blood. 

In  subcutaneous  hemorrhage  from  rupture  of  a  large  blood-vessel  there 
are  great  swelling,  cutaneous  discoloration,  and  systemic  signs  of  hemorrhage. 
If  a  main  artery  ruptures  in  an  extremity,  there  is  no  pulse  below  the  rupture, 
and  the  limb  becomes  cold  and  swollen.  At  the  seat  of  rupture  a  large 
fluctuating  swelling  forms,  and  sometimes  there  are  bruit  and  pulsation. 
If  a  vein  ruptures  in  an  extremity,  a  large,  soft,  non-pulsatile  swelling  arises, 
there  is  no  bruit,  and  intense  edema  occurs  below  the  seat  of  ruptui"e.  Profuse 
hemorrhage  induces  constitutional  symptoms,  and  death  may  occur  in  a  few 
seconds.  Loss  of  half  of  the  blood  will  usually  cause  death  (from  four  to  six 
pounds),  though  women  can  stand  the  loss  of  a  greater  relative  proportion 
of  blood  than  men.  Young  children,  old  people,  individuals  exhausted  by 
disease,  drunkards,  sufferers  from  Bright's  disease,  diabetes,  and  sepsis 
stand  loss  of  blood  very  badly.  An  individual  with  ohstructive  jaundice  is 
apt  to  suffer  from  persistent  oozing  of  blood  after  operation,  an  oozing  which 
is  particularly  persistent  and  dangerous  in  obstruction  of  the  bile-ducts  due 
to  malignant  disease.  It  not  unusually  causes  death.  Generally,  after  bleed- 
ing has  gone  on  for  a  time,  syncope  occurs.  Syncope  is  Nature's  eflort  to 
arrest  hemorrhage,  for  during  this  state  the  feeble  circulation  and  the  increased 
coagulability  of  blood  give  time  for  the  formation  of  an  external  clot.  When 
reaction  occurs,  the  clot  may  hold  and  be  reinforced  by  an  internal  clot,  or  it 
may  be  washed  away  with  a  renewal  of  bleeding  and  syncope.  These  episodes 
may  be  repeated  until  death  supervenes.  Nausea  exists  and  there  may  be 
regurgitation  from  the  stomach.  Vertigo  is  present.  There  is  dimness  of 
vision  or  everything  looks  black;  black  specks  float  before  the  eyes  (muscae 
volitantes),  or  the  patient  sees  flashes  of  light  or  colors.     There  is  a  roaring 


Treatment  of  Hemorrhage  309 

sound  in  the  ears  (tinnitus  aurium).  The  patient  yawns,  is  restless,  tosses 
to  and  fro,  and  great  thirst  is  complained  of.  The  mind  may  be  clear,  but 
dehrium  is  not  unusual,  and  convulsions  often  occur.  After  a  profuse  hemor- 
rhage an  individual  is  intensely  pale  and  his  skin  has  a  greenish  tinge;  the 
eyes  are  fixed  in  a  glassy  stare  and  the  pupils  are  widely  dilated,  and  react 
slowlv  to  light;  the  respirations  are  shallow  and  sighing;  the  skin  is  covered 
with  a  cold  sweat;  the  legs  and  arms  are  extremely  cold,  and  the  body-tempera- 
ture is  below  normal.  The  pulse  is  soft,  small,  compressible,  fluttering,  or 
often  cannot  be  detected ;  the  heart  is  very  weak  and  fluttering,  and  the  arterial 
tension  is  almost  abolished.  There  is  muscular  tremor;  the  patient  tosses 
about,  and  asks  often  and  in  a  feeble  voice  for  water.  The  suffering  from 
thirst  is  terrible  and  no  amount  of  water  gives  relief.  There  is  often  dreadful 
dyspnea,  and  a  man  who  is  bleeding  to  death  grasps  at  his  chest,  rises  up 
upon  his  elbow,  and  then  falls  back  in  a  dead  faint.  Usually  reaction  occurs, 
though  the  patient  is  obviously  weaker  than  before;  again  a  faint  may  happen, 
and  so  there  is  fainting  spell  after  fainting  spell  until  death  ensues.  Con- 
vulsions frequently  precede  death.  In  hemorrhage  the  hemoglobin  is  greatly 
diminished  in  amount.  In  an  intra-abdominal  hemorrhage  the  above  symp- 
toms are  noted,  and,  except  in  splenic  hemorrhage,  blood  gathers  in  both 
loins,  and  dulness  on  percussion  exists  which  gradually  rises  and  shifts  as  the 
patient's  position  is  shifted.  The  blood  also  gathers  in  the  rectovesical 
pouch  in  the  male,  and  in  the  recto-uterine  pouch  in  the  female,  and  may  be 
detected  by  digital  examination.  If  the  spleen  is  wounded,  the  blood  clots 
quickly,  and  an  area  of  dulness,  which  does  not  shift  and  which  progressively 
increases,  is  noted  in  the  splenic  region. 

Treatment. — When  such  a  dangerous  condition  is  due  to  an  intra- 
abdominal hemorrhage,  the  surgeon  at  once  opens  the  abdomen  and  arrests 
bleeding  while  the  assistants  apply  the  treatment  advised  in  the  following 
remarks.  If  a  large  vessel  in  an  extremity  has  been  divided,  temporarily 
arrest  bleeding  by  digital  pressure  in  the  wound,  or  the  application  of  an 
Esmarch  band  above  the  wound  (if  the  bleeding  is  arterial).  In  some  cases 
forced  flexion  is  used.  In  any  case  lower  the  head,  and  have  compression 
made  upon  the  femorals  and  subclavians,  so  as  to  divert  more  blood  to  the 
brain,  or  bandage  the  extremities  (autotransfusion).  Apply  artificial  heat. 
The  value  of  adrenalin  in  restoring  or  maintaining  arterial  tension  has  been 
,  demonstrated  by  Crile.  We  should  give  the  patient  by  hypodermoclysis  one 
j)int  of  hot  normal  salt  solution  containing  one  dram  of  the  i  :  1000  solution 
of  adrenalin  chlorid.  The  fluid  is  allowed  to  run  in  the  subcutaneous  tissue 
beneath  the  breast.  The  infusion  of  one  pint  or  more  of  hot  salt  solution 
into  a  vein  is  a  very  valuable  remedy;  it  gives  the  heart  something  to  contract 
upon  and  thus  maintains  cardiac  action.  If  the  depression  is  very  severe, 
inject  ether  hypodermatically,  then  brandy,  and  then  atropin.  Strychnin 
may  be  given  hypodermatically  in  doses  of  gr.  2^^,  but  atropin  is  of  more 
service.  Digitalin  is  advised  by  some,  but  it  is  not  sufficiently  rapid  in 
action.  Give  enemata  of  hot  coft'ee  and  brandy.  Apply  mustard  over  the 
heart  and  spine.     Lay  a  hot-water  bag  over  the  heart. 

In  hemorrhage  from  a  vessel  of  an  extremity,  we  temporarily  arrest  bleeding 
while  bringing  about  reaction.  As  soon  as  reaction  is  established  permanently 
arrest  bleeding  by  the  ligature.     In  intra-abdominal  or  concealed  hemorrhage 


10 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


it  is  not  possible  to  temporarily  arrest  it  and  wait  for  reaction,  but  the  abdomen 
must  be  opened  and  the  work  proceeded  with  in  spite  of  the  patient's  condi- 
tion.    Every  moment  we  wait  he  is  growing  worse. 

A  severe  hemorrhage  is  apt  to  be  followed  by  fever,  due  to  the  absorption 
of  fibrin  ferment  from  extravasated  blood  and  its  action  upon  a  profoundlv 
debihtated  system.  After  a  severe  hemorrhage  leukocytes  are  increased,  not 
only  relati\"ely,  but  absolutely.  Red  corpuscles  are  diminished  both  relatively 
and  absolutely.  Hemoglobin  diminishes;  many  of  the  corpuscles  become 
irregular  and  microcvtes  are  noticed. 


Fig.  103. — Halsted's  straight  artery  forceps. 


In  treating  a  patient  who  has  thoroughly  reacted  after  a  severe  hemor- 
rhage, apply  cold  to  the  head.  Fluids  and  ice  are  grateful.  Frequentlv 
sponge  the  skin  with  alcohol  and  water.  Milk  punch,  koumiss,  and  beef- 
peptonoids  are  given  at  frequent  intervals. 


Fig.  [04. — Curved  hemostatic  forceps. 

Hemostatic  agents  comjjrise  (i)  the  ligature  and  suture;  (2)  torsion; 
(3)  acupre.ssure ;  (4)  elevation;  (5)  compression;  (6)  styptics;  (7)  the  actual 
cautery;  and  (8)  forced  flexion  of  limbs. 

The  ligature  was  known  to  the  ancients,  hut  was  rediscovered  b}-  Ambroise 
Pare.  The  Hgature  may  be  made  of  .silk,  floss-silk,  or  catgut.  Whatever 
material  is  u.sed  must,  of  course,  be  rendered  aseptic.  A  ligature  should 
be  about  ten  inches  long.  The  vessel  to  be  tied  must  be  drawn  out  with 
forceps  and  separated  for  a  short  distance  from  its  sheath,  but  must  not  be 
separated  to  any  considerable  extent;  to  do  so  may  lead  to  necrosis  of  the 


Hemostatic  Acrents 


3" 


vessel  and  secondary  hemorrhage.  The  hemostatic  forceps  (Figs.  103,  104, 
105)  is  in  most  cases  a  better  instrument  than  the  tenaculum  (Fig.  106).  The 
tenacuhim  makes  a  hole  in  the  vessel,  and  sometimes  a  slit-like  tear.  A 
portion  of  this  opening  may  remain  back  of  the  tied  ligature,  the  vessel  may 


Fig.  105. — Straight  hemostatic  forceps. 

retract  a  little,  or  the  ligature  may  slip  slightly,  and  bleeding  may  occur. 
When  the  artery  lies  in  dense  tissues  or  is  retracted  deeply  in  muscle  or  fascia, 
the  tenaculum,  when  carefully  used,  is  the  better  instrument.  The  ligature 
is  tied  in  a  reef-knot  (Fig.  107),  not  in  a  granny-knot  (Fig.  ro8),  and  not  in  a 


surgeon's  knot  (Fig.  log).  It  is  often  the  purpose  of  the  surgeon  to  divide  the 
internal  and  middle  coats  of  the  vessel,  and  if  such  is  his  desire  the  first  knot 
is  firmly  tied.  The  second  knot  must  not  be  tied  too  tightly,  or  it  will  cut  the 
ligature.     The  ligature   must   not  be  jerked  as  it  is  being  tied.     If  a  third 


Fig.  107. — Method  of  tying  square 
or  reef-knot. 


Fig.  108. — Method  of  tying  grann\- 
knot. 


knot  overlies  the  first  two,  the  ligature  can  be  cut  off  close  to  the  knot; 
otherwise  it  is  cut  off  so  that  short  ends  are  left.  Both  ends  of  a  divided 
vessel  should  be  ligated.  If  a  vessel  is  atheromatous,  it  is  not  desirable 
to  divide  the  internal  and  middle  coats.     In  this  case  a  ligature  should  be 


312 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


applied  lirmly  rather  than  tightly,  and  another  ligature  should  be  put  on 
above  it,  or  hgation  can  be  effected  by  the  stay  knot.  If  an  artery  is  incom- 
pletely divided,  a  ligature  should  be  applied  on  each  side  of  the  wound,  and 
the  vessel  divided  between  the  ligatures.  If  a  large  vein  is  slightly  torn,  try 
to  pinch  up  the  vein-walls  around  the  rent  and  apply  a  hgature  (lateral 
ligature.  Figs,   iii,  123).     If  a  vein  is  longhudinally  torn,  close  the  wound 


Fig.  109. — Method  of  tying  surgeon's  knot. 

with  a  Lembert  suture  of  silk  (Ricard,  Niebergall,  the  author  and  others 
have  done  this  successfully).  Murphy,  of  Chicago,  has  recently  shown 
that  longitudinal  wounds  or  small  lateral  wounds  of  either  veins  or  arte- 
ries can  be  closed  successfully  with  silk  sutures,  and  if  a  transverse  wound 
includes  more  than  one-half  of  the  circumference  of  the  vessel,  after  the 
vessel  is  completely  divided,  the  ends  can  be  successfully  united  by  end- 
to-end  anastomosis.*      After  such  an  operation  the  vessel  is  probably  ulti- 


Fig.  110. — Hagedorn's  needles. 


Fig.  III. — Method  of  controlling  hemorrhage  by 
ligature  (after  Esmarch):  a,  Artery  ligated ;  d, 
lateral  ligature  of  vein. 


mately  obliterated  by  endothelial  proliferation.  It  carries  blood  for  a  time 
only,  but  carries  it  long  enough  to  lessen  the  danger  of  gangrene.  While  the 
vessel  is  closing,  the  collaterals  are  dilating.  Depage  .successfully  sutured  the 
common  carotid  artery  ("Journal  de  Chir.  et  Ann.  de  la  Soc.  Beige  de 
Chir.,"  Jan.  and  Feb.,  1902).  Pringle  successfully  sutured  an  oblique  wound 
of  the  external  iliac  artery.  The  wound  was  one-quarter  of  an  inch  in  length. 
During  the  operation  pressure  was  made  on  the  aorta  ("Scottish  Med.  and 
*See  Medica!  Record,  Jan.  16,  1897. 


Hemostatic  Ag-ents 


313 


Surg.  Jour.,"  Oct.,  1901).  Manteuffel,  Marchant,  and  others  have  per- 
formed like  operations.  Matas  ("  Annals  of  Surgery,"  Feb.,  1903)  has 
collected  30  cases  of  suture  of  arteries  by  lateral  or  circular  arteriorrhaphy. 
Some  surgeons  use  catgut  for  sutures;  others  use  silk.  There  is  some 
danger  that  aneurysm  may  form  at  the  region  sutured.  The  rule  not  to 
suture  but  rather  do  end-to-end  anastomosis  if  more  than  one-half  of  the 
circumference  of  the  vessel  is  divided  is  contradicted  by  A.  E.  Halstead's 
case  ("Med.  Record,"  July  20,  1901).  This  surgeon  cut  two-thirds  through 
the  circumference  of  the  axillary  artery.  He 
sutured  the  wound  with  catgut,  passing 
each  stitch  through  the  two  outer  coats  of 
the  vessel.  Two  months  later  the  radial 
pulse  returned.  In  longitudinal  wounds 
Halstead  recommends  the  use  of  a  continu- 
ous suture.  Personally,  in  suturing  vessels 
I  would  use  fine  silk.  I  have  sutured  suc- 
cessfully in  one  case  a  longitudinal  tear  in 
the  internal  jugular  vein  and  in  another 
case  a  small  transverse  cut  in  the  axillary 
vein.  In  extensive  tears  of  a  vein  ligate  the  vessel  in  two  places  and 
cut  between  the  ligatures.  When  the  parts  about  an  artery  are  so 
thickened  that  the  vessel  cannot  be  drawn  out,  arm  a  Hagedorn  needle 
(Fig.  no)  with  catgut  and  pass  the  latter  around  the  vessel  in  such  a 
manner  that  the  catgut  will  include  the  vessel  with  some  of  the  surrounding 
tissue.     Then  tie  the  ligature  (Fig.  112).     This  method  is  known  as  the  ap- 


Fig.  112. — Arrest  of  hemorrhage  by  pass- 
ing a  suture-ligature. 


Fig.  113. — Vasotribe  of  Doyen. 


plication  of  a  suture-ligature,  and  is  pursued  in  necrosis,  atheroma,  scar- 
tissue,  sloughing,  etc.  Never  include  a  nerve  of  any  size  in  the  ligature. 
If  this  mode  of  ligation  fails,  try  acupressure. 

Doyen,  when  about  to  tie  a  thick  pedicle,  crushes  it  by  means  of  a  very 
powerful  instrument  and  then  ties  a  hgature  about  the  crushed  and  attenuated 
area.  The  vessels  are  closed  by  laceration  wide  of  the  ligature  and  the 
ligature  does  not  tend  to  slip.  Some  trust  such  a  stump  without  a  ligature, 
but  most  surgeons  prefer  to  ligate.  This  instrument  is  known  as  the  vaso- 
tribe or  angiotribe  and  is  used  particularly  in  hysterectomy.  Fig.  113  shows 
a  vasotribe. 


314  Diseases  and  Injuries  of  the  Heart  and  Vessels 

Torsion. — Torsion  was  practised  by  the  ancients,  but  was  reintroduced 
in  modern  times,  particularly  by  Amussat,  Velpeau,  Syme,  and  Bryant  of 
London.  By  means  of  torsion  the  internal  and  middle  coats  are  ruptured, 
and  the  external  coat  is  twisted.  The  middle  coat  retracts  and  contracts,  and 
the  inner  coat  inverts  into  the  lumen  of  the  artery.  It  is  a  safe  procedure,  and 
is  practised  upon  vessels  as  large  as  the  femoral  by  many  surgeons  of  high 
standing.  Before  the  days  of  asepsis  torsion  possessed  the  signal  merit  of 
not  introducing  possible  infection  in  ligatures.  At  the  present  time  it  offers 
no  particular  advantage.  It  is  no  quicker  than  the  ligature,  and  damages 
the  vessel  so  much  that  necrosis  may  occur.  It  cannot  be  used  if  the  vessels 
are  diseased.     In  what  is  known  as  free  torsion  the  vessel  is  grasped,  drawn 

out  and  twisted  until  the  free  end  of 
the  vessel  is  twisted  off.  Limited  tor- 
sion is  more  often  used.  The  vessel 
is  drawn  out  of  its  sheath  by  a  pair 
of  forceps  held  horizontally,  and  is 
grasped  a  little  distance  above  its  e.x- 
tremity  by  another  pair  of  forceps  held 
vertically  (Fig.  114).  The  first  instru- 
ment is  used  to  twist  the  artery  six  to 

Fig.    114.— Method    of   controlling    hemorrhage       ^Ight  times. 

by  torsion.  Acupressure  is  pressure  applied  by 

means  of  a  long  pin.  The  method 
of  hemostasis  by  acupressure  was  devised  by  Sir  James  Y.  Simpson.  A  pin 
is  simply  passed  under  a  vessel  (transfixion),  leaving  a  little  tissue  on  each 
side  between  the  pin  and  vessel.  A  pin  can  be  passed  under  a  vessel,  and 
a  wire  be  thrown  over  the  needle  and  twisted  (circumclusion).  The  pin  can 
be  inserted  upon  one  side,  passed  through  half  an  inch  of  tissues  up  to  the 
vessel,  be  given  a  quarter-twist,  and  be  driven  into  the  tissues  across  the 
artery  (torsoclusion).  Some  tissue  may  be  picked  up  on  the  pin,  folded  over 
the  vessel,  and  pinned  to  the  other  side  (retroclusion).  Acupressure  is  occa- 
sionally used  to  arrest  hemorrhage  in  inflamed  or  atheromatous  vessels,  in 
sloughing  wounds,  in  scar-tissue,  and  when  a  hgature  will  not  hold  firmly. 

Elevation  is  used  as  a  temporary  expedient  or  in  association  with  some 
other  method.  It  is  of  use  in  a  wound  of  a  bursa,  in  bleeding  from  a  ruptured 
varicose  vein,  and  is  frequently  used  with  compression. 

Compression  is  either  direct  or  indirect — that  is,  in  the  wound  or  upon 
its  artery  of  supply.  In  the  removal  of  the  upper  jaw  arrest  bleeding  by 
plugging.  In  injur}-  of  a  cerebral  sinus,  plug  with  gauze.  Compression 
and  hot  water  (115°-!  20°  F.)  will  stop  capillary  bleeding.  A  graduated 
compress  was  formerly  recommended  in  hemorrhage  from  the  palmar  arch. 
A  compress  will  arrest  bleeding  from  superficial  veins.  The  knotted  bandage 
of  the  scalp  will  arrest  bleeding  from  the  temporal  artery.  Long-continued 
pressure  causes  pain  and  inllammation. 

Indirect  cf)mpre.ssion  is  used  to  prevent  hemorrhage  or  to  temporarily 
arrest  it.  It  may  be  effected  by  encircling  a  limb  above  a  bleeding  point 
with  an  Esmarch  band  or  by  applying  a  tourniquet  or  an  improvised  tourniquet 
(Fig.  117).  It  may  also  be  effected  by  a  clamp.  Crile  has  devised  a  clamp  to 
effect  temporary  closure  of  the  carotid  artery.     In  o|jerations  about  the  head 


Hemostatic  Accents 


315 


one  or  both  carotids  may  be  closed  for  a  considerable  time  and  bleeding  ma\' 
thus  be  largely  prevented.  In  10  cases  Crile  temporarily  closed  both  carotids. 
A  hypodermatic  injection  of  atropin  is  given  to  prevent  inhibition,  the  vessels 
are  exposed,  and  the  clamps  are  applied  with  just  sufficient  firmness  to  ap- 
proximate the  vessel-walls.     Xo  clot  will  form  if  the  walls  are  not  compressed. 

The    patient   is   in    the   Trendelenburg   position. 
,      .  If  it  is  found  that  respiratory  difficulty  occurs,  one 

"  '^^ '  clamp  must  be  loosened.     After  the  completion  of 

the  operation  the  patient  must  be  brought  to  the 
horizontal  before  the  clamps  are  removed  (Crile. 
in  "Annals  of  Surgery,"  April.   1902). 

Digital  compression  is  a  form  of  indirect  com- 
pression. It  can  be  maintained  for  only  a  few  min- 
utes by  one  person,  but  a  relay  of  assistants  can 


Fig.  115. — Tamponade  of  inter- 
costal artery  (alter  Von  Laugen- 
beck). 


Fig.  116. — Conical  aseptic  tampon  compressing  an  artery 
(Senn). 


carry  it  out  for  a  considerable  time.     In  compressing  the  subclavian  artery, 
wrap  a  key  as  shown  in  Fig.  118.  and  compress  the  artery  against  the  outer 
surface  of  the  first  rib.     The  shoulder  must  be  depressed  and  pressure  applied 
in  the  angle  between  the  posterior  border  of  the 
sternocleidomastoid  and  the  upper  border  of  the 
clavicle.  .  The  direction  of  the  pressure  should 
be  downward,  backward,  and  inward. 


Fig.  117. — Impromptu  tourniquet  for  compressing  an 
arterv  with  a  handkerchief  and  a  stick. 


-Handle  of  duor-key, 
padded. 


The  brachial  artery  can  be  compressed  against  the  humerus.  In  the  upper 
part  of  the  course  of  the  artery  the  pressure  should  be  from  within  outward 
(Fig.  iig),  in  the  lower  part  from  before  backward  (Fig.  120).  The  abdom- 
inal aorta  can  be  compressed  by  Macewen's  method  {q.  v.).  The  common 
iliac  can  be  compressed  through  the  rectum  by  means  of  a  round  piece  of 
wood  known  as  Davy's  lever.  The  femoral  artery  can  be  compressed  just 
below  Poupart's  ligament  against  the  psoas  muscle  and  head  of  the  femur 


3i6 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


(Fig.    i2i).      The    pressure  should  be  directly  backward.     In  the  middle 
third  of  the  thigh  digital  compression  is  unsatisfactory,  and  a  tourniquet 

should  always  be  used  or  an 
Esmarch  band  be  employed. 

Forced  flexion  is  a  variety 
of  indirect  compression  intro- 
duced by  Adelmann.  It  will 
arrest  bleeding  be'ow  the  point 
compressed,  but  soon  becomes 
intensely  painful.  Forced  flex- 
ion can  be  maintained  by  ban- 
dages. Brachial  hyperflexion 
is  maintained  by  ty'ng  the  fore- 
arm to  the  arm.  It  is  often 
associated  with  the  use  of  a 
pad  in  front  of  the  elbow. 
Genuflexion  is  maintained  by  tying  the  foot  to  the  thigh.  It  is  increased 
in  eflaciency  by  placing  a  pad  in  the  popliteal  space. 

Styptics. — Chemicals  are  now  rarely  used  to  arrest  hemorrhage.  In  epis- 
taxis  we  may  pack  with  plugs  of  gauze  saturated  with  a  lo  per  cent,  solution 
of  antipyrin.  In  bleeding  from  a  tooth-socket  freeze  with  chlorid  of  ethyl 
spray,  and  then  pack  with  gauze  soaked  with  lo  per  cent,  solution  of  antipyrin 
or  pack  with  dry  sponge  or  styptic  cotton  (absorbent  cotton  soaked  in  Monsel's 


Fig.  119. — Digital  compression  of  the  brachial  artery. 


Fig.  120.— Digital  compression  ol  the 
jbrachial  artery. 


Fig.  121. 


-Digital  compression  of  the 
femoral  arterv. 


solution  and  dried).  A  bit  of  cork  may  be  forced  into  the  .socket.  In  bleeding 
from  an  incised  urinary  meatus  pack  with  styptic  cotton  and  compress  the 
lips  of  the  meatus.  Cold  water,  chlorid  of  ethyl  spray,  and  ice  act  as  styptics 
by  producing  reflex  vascular  contraction.  Hot  water  produces  contraction 
and  coagulates  the  albumin.  The  temperature  should  be  from  115°  to 
120°  F.  A  mixture  of  equal  parts  of  alcohol  and  water  stops  capillary 
oozing. 


Hemostatic  Agents  317 

The  Use  of  Gelatin  in  Controlling  Hemorrhage. — It  seems  very  positively 
proved  that  gelatin  increases  the  coagulability  of  the  blood,  if  given  hypo- 
dermatically.  It  has  been  shown  by  Horatio  C.  Wood,  Jr.  ("American 
Medicine,"  May  3,  1902),  that,  even  when  administered  by  the  stomach, 
digestion  does  not  destroy  its  coagulating  effect  upon  the  blood.  Carnot,  of 
Paris,  used  it  locally  and  with  success  to  control  epistaxis  in  a  sufferer  from 
hemophilia.  He  then  employed  it  to  arrest  bleeding  from  hemorrhoids, 
tumors,  and  incised  wounds;  and  demonstrated  in  animals  that  it  will  arrest 
oozing  from  the  cut  surface  of  the  liver.  Carnot  used  a  5  or  10  per  cent, 
solution.  It  has  been  employed  with  success  to  control  hemorrhage  in 
many  situations,  is  of  value  when  applied  locally,  and  possibly  of  use  when 
injected  subcutaneously. 

Intravenous  injections  are  extremely  dangerous,  and  are  apt  to  be  fol- 
lowed by  embolism.  Subcutaneous  injections  are  decidedly  painful,  and 
are  not  altogether  safe,  producing  albuminuria  and  occasional  embolism. 
Another  danger  that  may  follow  the  subcutaneous  administration  of  gelatin 
is  the  development  of  tetanus,  and  several  cases  have  been  reported.  The 
existence  of  disease  of  the  kidneys  contraindicates  the  hypodermatic  use  of 
gelatin. 

It  has  been  successfully  used  as  an  enema  in  intestinal  hemorrhage,  and 
as  an  injection  in  hemorrhage  from  the  bladder.  I  have  used  it  with  success 
in  arresting  bleeding  from  the  cut  surface  of  the  human  liver;  to  check 
bleeding  from  an  incised  wound  in  a  victim  of  leukemia;  to  arrest  the  post- 
operative oozing  in  sufferers  from  cholemia;  and  in  several  cases  of  severe 
epistaxis. 

When  employed  locally  in  solution,  it  should  be  of  a  strength  of  from  2  to 
5  per  cent,  in  normal  salt  solution.  For  hypodermatic  use  some  employ  a 
5  per  cent.,  some  a  2  per  cent.,  and  some  a  i  per  cent,  solution.  In  using 
a  I  or  2  per  cent,  solution  a  very  large  amount  of  fluid  must  be  injected. 
This  causes  pain;  and  Sailer  maintains  that  the  pain  is  slight  or  absent,  if  the 
solution  is  not  turbid  and  if  but  10  c.c.  of  a  10  per  cent,  solution  are  injected. 
The  injection  may  be  repeated  until  from  i  to  3  gm.  of  gelatin  have  been 
administered.  It  should  be  injected  on  the  outer  side  of  the  thigh,  under 
the  breast,  or  between  the  shoulder-blades.  If  the  drug  is  given  by  mouth, 
TOO  c.c.  of  a  10  per  cent,  solution  is  the  dose;  and  this  may  be  repeated  every 
two  or  three  hours. 

On  account  of  the  possible  danger  of  the  development  of  lockjaw,  great  care 
in  sterilizing  must  always  be  exercised.  The  method  of  preparation  suggested 
by  Joseph  Sailer  will  be  found  of  the  greatest  value.  (For  the  formula  for  this 
see  page  299.) 

In  view  of  the  fact  that  gelatin  is  such  an  excellent  culture-material, 
whenever  it  is  used  in  the  rectum,  nose,  pharynx,  vagina,  or  bladder,  it  should 
be  mixed  with  some  antiseptic  agent. 

The  exact  mode  in  which  gelatin  acts  in  producing  coagulation  is  not 
certain.  Floresco  maintains  that  it  acts  hke  an  acid.  Laborde  states  that 
undissolved  particles  of  gelatin  serve  as  centers  for  coagulation.  Other 
e.xperimenters  insist  that  gelatin  tlestroys  the  leukocytes,  and  thus  hberates 
fibrin  ferment. 


311 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


Suprarenal  extract  is  a  valuable  agent  to  control  capillary  oozing.  It 
constricts  capillaries,  and  if  applied  to  a  mucous  membrane  will  rapidly  blanch 
it.  It  is  extensively  used  to  check  bleeding  during  operations  on  the  nose, 
throat,  larynx,  and  ear,  and  to  arrest  epistaxis  and  bleeding  from  the  uterus. 
The  solution  to  employ  is  adrenalin  chlorid  of  a  strength  of  from  i  :  10,000 
to  r  :  1000.  X  piece  of  cotton  soaked  in  this  solution  is  pressed  lightly 
upon  the  part  or  it  is  sprayed  upon  the  part  by  an  atomizer  ("Practical 
Therapeutics,"  by  H.  A.  Hare). 

Chlorid  oj  calcium,  given  internally,  favors  coagulation  of  the  blood  and 
is  used  to  check  oozing  or  to  prevent  hemorrhage.  It  is  used  particularly 
in  jaundice  cases  when  operation  must  be  performed.  If  given  several  times 
a  day  for  two  or  three  days  it  increases  the  coagulability  of  the  blood;  but 
if  given  for  more  than  four  days,  actually  diminishes  it.     The  initial  dose  is 


Fig.  122. — I'aqiielin  caulerv . 


from  15  to  30  grains,  then  gr.  v  every  hour  are  given  until  five  or  six  doses 
have  been  taken.  It  is  apt  to  provoke  gastric  irritability,  and  it  is  often 
advisable  to  give  it  by  the  rectum. 

The  actual  cautery  is  a  very  ancient  hemostatic.  It  is  still  used  occasion- 
ally after  excising  the  upper  jaw,  in  bleeding  after  the  removal  of  some 
mahgnant  growths,  in  continued  hemorrhage  from  the  prostatic  plexus  of  veins 
after  lateral  lithotomy,  and  to  stop  oozing  after  the  excision  of  venereal  warts. 
We  are  often  driven  to  its  use  in  "bleeders" — that  is,  those  persons  who  have 
a  hemorrhagic  diathesis,  and  who  may  die  from  having  a  tooth  pulled  or  from 
receiving  a  scratch.  It  will  arrest  hemorrhage,  but  the  necrosed  tissue  sepa- 
rates, and  when  it  separates  secondary  hemorrhage  is  apt  to  set  in.  The  iron 
for  hemostatic  [)urposes  must  be  at  a  cherry  heat.  The  old-fashioned  iron, 
which  was  heated  in  a  charcoal  furnace,  is  rarely  used.  It  is  large,  clumsy, 
and  cools  quickly  if  the  bleeding  is  profuse.  In  an  emergency  we  may  heat 
a  f)oker  or  a  coil  of  telegraph  wire.  The  best  instrument  is  the  Paquelin 
cautery.  The  Paquelin  cautery  consists  of  an  alcohol  lamp,  a  metal  chamber 
containing  benzene,  a  tube  of  entrance  for  air  containing  two  bulbs,  an  exit 


Hemostatic   Methods  319 

tube,  and  a  wooden-handled  cautery  instrument,  the  tip  of  which  is  hollow 
and  composed  of  platinum  (Fig.  122).  This  can  be  kept  hot  even  when 
bleeding  is  profuse.  If  the  iron  is  very  hot,  it  will  not  stop  bleeding  com- 
pletely. In  order  to  use  the  Paquelin  cautery,  light  the  lamp,  heat  the  cautery- 
tip  in  the  flame,  until  it  becomes  red,  remove  it  from  the  flame,  and  squeeze 
the  bulb  repeatedly  until  the  tip  becomes  bright  red.  Each  time  the  bulb 
not  covered  with  netting  is  squeezed  air  is  driven  through  the  metal  chamber 
into  the  tube  and  cautery,  and  this  air  carries  wath  it  the  vapor  of  benzene, 
which  passes  to  the  hot  tip  and  takes  fire.  The  degree  of  heat  maintained 
depends  upon  the  rapidity  with  which  the  bulb  is  squeezed. 

Skene  has  devised  a  method  known  as  electrohemostasis.  He  grasps  the 
vessel  or  tissue  with  specially  constructed  forceps,  an  electric  current  generates 
heat,  the  tissue  is  cooked,  and  the  walls  of  the  vessel  united.  A  heat  of  from 
i8o°-i90°  F.  is  required.  For  the  small  instrument  Skene  uses  a  current 
of  2  ma.  and  for  the  larger  instrument  a  current  of  8  ma.* 

Downes  has  devised  an  instrument  to  apply  electrothermic  hemostasis  in 
abdominal  and  pelvic  operations.  He  asserts  that  by  this  method  an  intra- 
abdominal operation  can  be  rendered  bloodless;  that  the  lymph-ducts  are 
sealed  and  the  stump  is  sterile;  that  adhesions  are  less  apt  to  form;  and  that 
there  is  less  post-operative  pain  than  if  the  ligature  were  used  ("  Boston  Med. 
and  Surg.  Jour.,"  July  10.  1902). 

Rules  jor  Arresting  Primary  Hemorrhage. — i.  In  arterial  hemorrhage 
tie  the  artery  in  the  wound,  enlarging  the  wound  if  necessary  (Guthrie's  rule). 
In  tying  the  main  artery  of  the  limb  in  continuity  for  bleeding  from  a  point 
below  we  fail  to  cut  off  the  bleeding  from  the  distal  extremity,  and  hemor- 
rhage is  bound  to  recur.  If  the  surgeon  does  not  look  into  the  wound, 
he  cannot  know  what  is  cut:  it  may  be  only  a  branch,  and  not  a  main 
trunk.     The  same  rule  obtains  in  secondary  hemorrhage. f 

2.  We  can  safely  ligate  veins  as  we  would  arteries. 

3.  In  a  wound  of  the  superficial  palmar  arch  tie  both  ends  of  the  divided 
vessel. 

4.  In  a  wound  of  the  deep  palmar  arch  enlarge  the  wound,  if  necessarv, 
in  the  direction  of  the  fle.xor  tendons,  at  the  same  time  maintaining  pressure 
upon  the  brachial  artery.  Catch  the  ends  of  the  arch  with  hemostatic  forceps 
and  tie  both  ends.  If  the  artery  can  be  caught  by,  but  cannot  be  tied  over 
the  point  of,  the  forceps,  leave  the  instrument  in  place  for  four  days.  If  the 
artery  cannot  be  caught  with  forceps,  use  a  tenaculum.  The  ends  of  the 
divided  vessel  can  be  caught  and  must  be  caught  even  if  large  incisions  are 
needed  to  effect  it.  An  incision  which  will  probably  always  expose  the  vessel 
is  as  follows:  Make  a  cut  on  a  line  with  the  injury  from  the  web  of  the  fingers 
to  above  the  carpus,  separating  the  metacarpal  and  carpal  bones,  until  the  arter}- 
is  reached.  (This  is  really  Mynter's  incision  for  excision  of  the  wrist.)  In 
former  days,  if  the  surgeon  found  trouble  in  grasping  the  ends  of  the  vessel, 
he  applied  a  graduated  compress  (Fig.  116).  This  is  applied  as  follows:  Insert 
a  small  piece  of  gauze  in  the  depths  of  the  wound,  put  over  this  a  larger  piete, 
and  keep  on  adding  bit  after  bit,  each  successive  piece  larger  than  its  prede- 
cessor, until  there  exists  a  conical  pad,  the  apex  of  which  is  at  the  point  of  heni- 

*Ne\v  York  Medical  Journal,  Feb.  i8,  1898. 

I  For  Murpliv's  observations  on  anastomosis  of  vessels,  see  page  312. 


320  Diseases  and  Injuries  of  the  Heart  and  Vessels 

orrhage  and  the  base  of  which  is  external  to  the  surface  of  the  palm.  Ban- 
dage each  finger  and  the  thumb,  put  a  piece  of  metal  over  the  pad,  wrap 
the  hand  in  gauze,  place  the  arm  upon  a  straight  splint,  apply  firmly 
an  ascending  spiral  reverse  bandage  of  the  arm,  starting  as  a  figure-of- 
eight  of  the  wrist,  and  hang  the  hand  in  a  sling.  Instead  of  applying 
a  splint,  we  may  place  a  pad  in  front  of  the  elbow  and  flex  the  forearm  on 
the  arm.  The  palmar  pad  is  left  in  place  for  six  or  seven  days  unless 
bleeding  continues  or  recurs.  The  graduated  compress  is  unreliable,  hence  it  is 
a  dangerous  methoc  of  treatment.  It  is  an  evasion.  It  should  be  employed 
at  the  present  time  only  as  a  temporary  expedient,  until  ligatures  can  be 
applied.  The  old  rule  of  surgery  was  as  follows:  If  bleeding  is  main- 
tained or  begins  again  after  application  of  a  graduated  compress,  ligate  the 
radial  and  ulnar  arteries.  If  this  maneuver  fails,  we  know  that  the  interos- 
seous artery  is  furnishing  the  blood  and  that  the  brachial  must  be  tied  at 
the  bend  of  the  elbow.  If  this  fails,  amputate  the  hand.  At  the  present 
dav  it  is  hard  to  conceive  of  such  radical  procedures  being  necessary  for 
hemorrhage. 

5.  In  primary  hemorrhage,    if  the  bleeding  ceases,  do  not  disturb  the 
parts  to  look  for  the  vessel.     If  the  vessel  is  clearly  seen  in  the  wound,  tie  it; 


Fig.  123. — Application  of  lateral  ligature  to  a  vein. 


Otherwise  do  not,  as  the  bleeding  may  not  recur.  This  rule  does  not  hold 
good  when  a  large  artery  is  probably  cut,  when  the  subject  will  require  trans- 
portation (as  on  the  battle-field),  when  a  man  has  delirium  tremens,  mania, 
or  delirium,  or  when  he  is  a  heavy  drinker.  In  these  cases  always  look  for 
an  artery  and  tie  it. 

6.  When  a  person  is  bleeding  to  death  from  a  wound  of  an  extremity, 
arrest  hemorrhage  temporarily  by  digital  pressure  in  the  wound  and  apply 
above  the  wound  a  tourniquet  or  Esmarch  bandage.  Bring  about  reaction 
and  then  ligate,  but  do  not  operate  during  collapse  if  the  bleeding  can  be 
controlled  by  pressure. 

7.  If  a  transverse  cut  incompletely  divides  an  artery,  it  may  be  found 
possible  and  may  be  considered  desirable  to  suture  the  cut.  Longitudinal 
cuts  can  certainly  be  sutured.  If  suturing  is  impossible,  or  if  the  surgeon 
prefers  not  to  attem[)t  it,  apply  a  ligature  on  each  side  of  the  vessel-wound 
and  then  sever  the  artery  so  as  to  permit  of  complete  retraction. 

8.  If  a  branch  comes  c)ff  just  below  the  ligature,  tie  the  branch  as  well  as 
the  main  trunk. 

9.  If  a  branch  of  an  artery  is  divided  very  close  to  a  main  trunk,  the  rule 
used  to  be,  tie  the  branch  and  also  the  main  trunk.     It  was  thought  that  if 


Hemostatic   Methods  321 

the  branch  alone  were  tied,  the  internal  clot,  being  very  short,  would  be 
washed  away  by  the  blood-current  of  the  larger  vessel.  We  now  know  that 
the  clot  is  not  required  in  repair,  and  under  aseptic  conditions  it  is  trivial  in 
size  and  rarely  reaches  the  first  collateral  branch.  Repair  is  effected  by 
endothelial  proliferation. 

10.  If  a  large  vein  is  shghtly  torn,  put  a  lateral  ligature  upon  its  wall 
(Fig.  123).  Gather  the  rent  and  the  tissue  around  it  in  a  forceps  and  tie  the 
pursed-up  mass  of  vein-wall.  It  is  a  wise  plan  to  pass  the  ligature  through  the 
two  outer  coats  by  means  of  a  needle  and  tie  the  knot  subsequently.  This 
expedient  prevents  slipping.  If  a  longitudinal  w^ound  exists  in  a  large  vein, 
take  an  intestinal  needle  and  fine  silk  and  sew  it  up  with  a  Lembert  suture. 
Transverse  wounds  can  also  be  sutured. 

11.  When  a  branch  of  a  large  vein  is  torn  close  to  the  main  trunk,  tie 
the  branch,  and  not  the  main  trunk.     Apply  practically  a  lateral  ligature. 

12.  If,  after  tying  the  cardial  extremity  of  a  cut  artery,  the  distal  ex- 
tremity cannot  be  found,  even  after  enlarging  the  wound  and  making  a  careful 
search,  firmly  pack  the  wound. 

13.  In  bleeding  from  diploe  or  cancellous  bone,  use  Horsley's  antiseptic 
wax,  or  break  in  bony  septa  with  a  chisel,  or  plug  with  threads  of  gauze  or 
scrapings  of  catgut. 

14.  In  bleeding  from  a  vessel  in  a  bony  canal,  plug  the  canal  with  an 
antiseptic  stick  and  break  the  wood,  or  fill  up  the  orifice  of  the  canal  w'ith 
antiseptic  wax;  or,  if  this  fails,  ligate  the  artery  of  supply. 

15.  In  bleeding  from  the  internal  mammary  artery  the  old  rule  was  to 
pass  a  large  curved  needle  holding  a  piece  of  silk  into  the  chest,  under  the 
vessel  and  out  again,  and  tie  the  thread  tightly;  but  it  is  better  to  make  an 
incision  and  ligate  the  artery. 

16.  In  bleeding  from  an  intercostal  artery  make  pressure  upward  and 
outward,  by  a  tampon  (Fig.  115),  or  throw  a  ligature  by  means  of  a  curved 
needle  entirely  over  a  rib,  tying  it  externally;  or,  what  is  better,  resect  a  rib 
and  tie  the  artery. 

17.  In  collapse  due  to  puncture  of  a  deep  vessel,  the  bleeding  having 
ceased,  do  not  hurry  reaction  by  stimulants.  Give  the  clot  a  chance  to  hold. 
Wrap  the  sufferer  in  hot  blankets.  If  the  condition  is  dangerous,  however, 
stimulate  to  save  life. 

18.  In  punctured  wounds,  as  a  rule,  try  pressure  before  using  ligation. 

19.  After  a  severe  hemorrhage  ahvays  put  the  patient  to  bed  and  elevate 
the  damaged  part  (if  it  be  an  extremity  or  the  head). 

20.  A  clot  which  holds  for  twelve  hours  after  a  primary  hemorrhage  will 
probably  hold  permanently;  but  even  after  twelve  hours  be  watchful  and 
insist  on  rest. 

21.  If  recurrence  of  a  hemorrhage  from  a  limb  is  feared,  mark  with  anilin 
or  iodin  the  spot  on  the  main  artery  where  compression  is  to  be  applied, 
apply  a  tourniquet  loosely,  and  order  the  nurse  to  screw  it  up  and  to  send  for 
the  physician  at  the  first  sign  of  renewed  bleeding.  This  must  often  be 
done  in  gunshot-wounds. 

22.  When  the  femoral  vein  is  divided  high  up,  the  advice  commonly 
given  is  to  ligate  the  vein  and  also  the  femoral  artery.  Braune  taught  that 
because  of  the  venous  vahes  there  is  no  collateral  circulation,  and  to  tic  the 

21 


322 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


vein  alone  renders  gangrene  inevitable.  Niebergall  shovi^s  that  the  valves 
may  be  overcome  by  moderate  arterial  pressure,  and  thus  collateral  circula- 
tion be  established.  Hence,  when  the  femoral  vein  is  divided  tie  the  vein, 
but  leave  the  artery  untied,  so  as  to  furnish  the  necessary  pressure.* 

23.  In  extradural  hemorrhage,  trephine.  The  side  to  be  trephined  is 
determined  by  the  symptoms,  and  not  by  the  situation  of  the  injury.  The 
opening  is  made  on  a  level  wath  the  upper  orbital  border  and  one  and  a  quarter 
inches  behind  the  external  angular  process.  This  opening  exposes  the 
middle  meningeal  and  its  anterior  branch.  If  this  does  not  expose  a  clot, 
trephine  over  the  posterior  branch,  on  the  same  level  and  just  below 
the  parietal  eminence.  When  the  clot  is  found,  enlarge  the  opening  with 
the  rongeur,  scoop  out  the  clot,  and  arrest  the  bleeding  by  passing  catgut 
Ht^atures  on  each  side  of  the  injury  in  the  vessel  through  the  dura,  under  the 
artery  and  out  again,  and  then  tying  them.  If  the  artery  hes  in  a  bony  canal, 
plug  the  canal  with  Horsley's  wax.  In  subdural  hemorrhage  open  the  dura 
and  endeavor  to  hgate.  If  this  procedure  is  impossible,  pack  with  one  piece 
of  iodoform  gauze. 

24.  In  hemorrhage  from  a  cerebral  sinus  catch  the  edges  of  the  opening 
with  forceps,  if  possible,  and  apply  a  lateral  ligature,  or  leave  the  forceps  in 
place  for  forty-eight  hours,  or  compress  firmly  with  one  large  piece  of  iodo- 
form gauze. 

25.  In  extramedullary  spinal  hemorrhage  rapidly  advancing  and  threaten- 
ing life  perform  a  laminectomy  and  arrest  the  hemorrhage. 

26.  In  bleeding  from  a  tooth-socket  use  chlorid  of  ethyl  spray  or  ice. 
If  this  treatment  fails,  plug  with  gauze  infiltrated  with  tannin  or  soaked  in 
antipyrin  solution  of  a  strength  of  10  per  cent.,  or  in  Carnot's  solution  of 
gelatin,  close  the  jaws  upon  the  plug,  and  hold  them  with  Barton's  bandage. 
If  this  expedient  fails,  soak  the  plug  in  Monsel's  solution,  or  plug  with  a  bit 
of  cork  or  dry  sponge,  and  if  this  is  futile,  use  the  cautery.  Pressure  on  the 
carotid  and  ice  over  the  jaw  and  neck  are  indicated.  It  may  be  necessary  to 
tie  the  external  carotid  artery. 

27.  In  intra-abdominal  hemorrhage  open  the  belly.  In  intra-abdominal 
hemorrhage  it  is  necessary  to  operate  during  shock.  If  the  blood  accumulates 
so  rapidly  as  to  jKevent  the  location  of  the  bleeding  point,  compress  the 
aorta  or  pack  the  abdominal  cavity  with  large  sponges.  In  seeking  for  the 
bleeding-point  remove  the  sponges  one  by  one,  or  have  the  pressure  momen- 
tarily relaxed  from  time  to  time.  In  parenchymatous  hemorrhage  from  the 
liver  try  packing  with  iodoform  gauze.  If  this  fails,  suture  the  torn  edge  or 
u.se  the  cautery.  .Severe  wounds  of  the  spleen  demand  splenectomy.  Wounds 
of  the  kidney  may  be  sutured,  but  may  require  partial  or  complete  nephrec- 
tomy. Mesenteric  vessels  are  ligated  en  masse  with  silk  (Senn).  Wounds 
of  the  stomach  and  intestines  causing  hemorrhage  require  stitching  of  their 
edges.  When  there  are  a  great  many  points  of  bleeding,  take  a  number 
of  sponges,  tie  a  piece  of  tape  firmly  to  each  one,  pack  many  places  in  the 
belly  with  the  sponges,  bring  the  tapes  out  of  the  wound,  and  remove  the 
sponges  from  below  u|nvar(l  one  at  a  time,  securing  the  bleeding  points  as 
they  come  into  view. 

28.  In  abdominal  section  for  disease  of  the  female  pehic  organs  bleeding 
*  Niebergall,  Deut.  Zeit.  f.  (^hir,,  vf)l.  xxxvii,  Nos.  3  and  4. 


Hemostatic   Methods  323 

is  limited  by  the  clamp  or  by  pressure-forceps.  Ligation  en  masse  is  often 
practised.  Use  silk.  A  large  mass  can  be  transfixed  and  tied  in  sections. 
Bleeding  edges  are  stitched.  Areas  of  oozing  are  treated  with  temporary 
pressure  and  hot  water,  or,  if  this  fails,  by  the  cautery.  Packing  can  be 
used  as  a  tamponade,  which  is  a  gauze  pouch,  pieces  of  gauze  being  packed 
into  this  pouch  after  its  insertion  into  the  belly  (Fig.  23). 

29.  A  ruptured  varicose  vein  requires  a  compress,  a  bandage  from  the 
periphery  up,  and  elevation. 

30.  Most  cases  of  capillary  bleeding  can  be  controlled  by  compression 
with  gauze  pads  soaked  in  water  at  a  temperature  of  115°  to  120°  F.  This 
contracts  the  vessels  and  seals  them  with  coagulated  albumin.  Keetly  in 
1878  impressed  the  profession  with  the  value  of  hot  water  as  a  styptic.  Cen- 
turies ago  surgeons  used  hot  oil  for  the  same  purpose.  Capillary  bleeding 
can  often  be  controlled  by  the  application  of  gauze  soaked  in  Carnot's  solution 


Fig.  124. —  Pluggiiie:  the  nares  for  epistaxis  (Guerin). 


of  gelatin.  A  solution  of  suprarenal  extract  may  control  capillary  oozing.  If 
other  means  fail  to  control  capillary  hemorrhage,  the  cautery  must  be  used. 
Understand  that  the  term  capillary  bleeding  does  not  so  much  mean  bleed- 
ing from  genuine  capillaries  as  it  does  bleeding  from  arterioles  and  venules. 

31.  Pressure  above  a  wound  arrests  arterial  hemorrhage,  but  aggravates 
venous  bleeding.  Pressure  below  a  wound  arrests  venous  hemorrhage,  but 
increases  arterial  bleeding.     Remember  these  facts  when  ap])lving  pressure. 

32.  A  moderate  epistaxis  may  be  arrested  by  an  injection  of  peroxid  of 
hydrogen,  an  injection  of  a  solution  of  antip}Tin,  or  an  injection  of  Carnot's 
.solution  of  .salt  and  gelatin.  Favorite  domestic  expedients  are  keeping  the 
arms  raised  above  the  head  and  applying  ice  to  the  l)a(k  of  the  neck.  In 
severe  epistaxis,  or  bleeding  from  the  nose,  examine  the  nose  by  means  of 
a  head-mirror  and  a  speculum.  If  a  h'ttle  point  of  ulceration  i^  found,  touch 
it  with  a  hot  iron.  If  the  bleeding  is  a  general  ooze,  if  it  is  high  up,  or  if  the 
cautery  does  not  arrest  it,  pack  the  nares.     It  may  be  necessan-  to  pack  one 


324  Diseases  and  Injuries  of  the  Heart  and  Vessels 

nostril  or  both.  Pass  a  Bellocq  cannula  (Fig.  124)  along  the  floor  of  one 
nostril  into  the  pharynx,  project  the  stem  into  the  mouth,  tie  a  plug  of  lint 
or  gauze  wet  with  Carnot's  solution  of  salt  and  gelatin  to  the  stem,  and  with- 
draw it.  Hold  the  double  string  which  emerges  from  the  nostril  in  the  hand 
and  pack  gauze  wet  with  gelatin  solution  from  before  backward.  Tie  the 
strings  together  over  the  plug;  if  both  nostrils  are  plugged,  the  strings  from 
one  nostril  are  fastened  to  the  strings  from  the  other.  Do  not  use  subsulphate 
of  iron,  as  it  forms  a  disgusting,  clotty,  adherent  mass.  If  a  Bellocq  cannula 
is  not  obtainable,  push  a  soft  catheter  into  the  pharynx,  catch  it  with  a  finger, 
pull  it  forward,  and  tie  the  plug  to  it.  Remove  the  plug  in  two  or  three  days. 
Do  not  leave  it  longer.  It  blocks  up  decomposing  fluids  and  may  lead  to 
blood-poisoning.  Pick  out  the  front  plug  first,  hold  the  string  of  the  second 
plug  in  the  hand,  push  the  plug  back  into  the  pharynx,  catch  it  with  forceps, 
and  withdraw  plug  and  string  through  the  mouth. 

^2.  In  gunshot- wounds  the  primary  hemorrhage  is  slight  unless  a  large 
vessel  is  cut.  The  bleeding  may  be  visible  or  may  be  internal  (concealed), 
the  blood  running  into  a  natural  cavity  or  among  the  muscles.  Capillary  ooz- 
ing is  arrested  by  very  hot  water  and  compression.  Venous  bleeding  is  usually 
arrested  by  compression.  If  a  large  vessel  is  the  source  of  bleeding,  enlarge 
the  wound  and  tie  the  vessel.  If  the  artery  cannot  be  found  in  the  wound, 
tie  the  main  trunk. 

34.  In  prolonged  bleeding  from  a  leech-bite  try  compression  over  a  plug 
saturated  with  alum  or  with  tannin.  If  this  fails,  pass  under  the  wound  a 
harelip  pin  and  encircle  it  with  a  piece  of  silk.  If  this  fails,  use  the  actual 
cautery  or  excise  the  bite  and  suture  the  incision. 

35.  In  severe  bleeding  from  the  ear  elevate  the  head,  put  an  ice-bag  over 
the  mastoid,  give  opium  and  acetate  of  lead,  and,  if  blood  runs  into  the  mouth, 
plug  the  Eustachian  tube  with  a  piece  of  catheter. 

36.  Umbilical  hemorrhage  in  infants  requires  pressure  over  a  plug  con- 
taining tannin,  alum,  or  gelatin  solution.  If  compression  fails,  pass  harelip 
pins  under  the  navel  and  apply  a  twisted  suture.  If  this  fails,  use  the  actual 
cautery. 

37.  Rectal  bleeding  requires  elevation  of  the  buttocks,  insertion  of  plugs 
of  ice,  ice  to  the  anus  and  perineum,  astringent  injections  (alum),  and  the 
internal  use  of  opium  and  acetate  of  lead.  If  these  means  fail,  plug  the 
bowel  over  a  catheter,  or  insert  and  inflate  a  Peterson  bag  or  a  colpeurynter, 
or  tampon  and  use  a  T-bandage.  If  the  bleeding  persists  or  if  a  considerable 
vessel  is  bleeding,  stretch  the  sphincter,  catch  the  bowel  and  draw  it  down, 
seize  the  vessel,  and  tie  it  if  possible;  if  not,  leave  the  forceps  in  place.  Failing 
in  this,  the  actual  cautery  must  be  used. 

38.  Subcutaneous  hemorrhage,  if  severe  and  persistent,  demands  that 
an  incision  be  made  and  ligatures  be  applied. 

39.  Bleeding  from  a  cut  urethral  meatus  requires  the  insertion  of  styptic 
cotton  and  the  application  of  pressure.  Moderate  bleeding  from  the  deeper 
urethra  can  usually  be  arrested  by  a  very  warm  bougie,  by  very  warm  in- 
jections, or  by  tying  a  condom  over  a  catheter,  and,  after  inserting  it,  inflat- 
ing the  condom  by  blowing  through  the  catheter  and  plugging  the  orifice  of 
the  instrument,  thus  using  pressure.  Sitting  with  the  perineum  on  a  thickly 
folded  towel  is  useful.     Ice  to  the  perineum  does  good.     The  patient  can 


Hemostatic   Methods 


325 


lie  down,  have  a  folded  towel  applied  to  the  perineum,  and  a  crutch-handle 
pushed  upon  the  towel,  the  lower  end  of  the  crutch  being  jammed  against 
the  foot  of  the  bed.  If  a  sohd  bougie  has  been  first  introduced,  firm  pressure 
can  be  made  by  this  method.  If  these  means  are  futile,  perform  an  external 
urethrotomy  and  reach  the  bleeding  point. 

40.  Hemorrhage  from  the  prostate  requires  hot  injections,  the  introduction 
of  a  large  bougie  first  dipped  in  very  warm  water,  and  the  retention  of  a 
catheter  for  two  days.  Perineal  section  may  be  required,  or  suprapubic 
cystotomy  with  packing  which  does  not  occlude  the  ureteral  orifices. 

41.  Vesical  hemorrhage  usually  ceases  spontaneously,  in  which  case  the 
urine  must  be  drawn  off  and  the  viscus  be  washed  out  frequently  with  a 
solution  of  boric  acid,  to  prevent  septic  cystitis.  If  blood-clots  prevent  the 
flow  of  urine,  break  them  up  with  a  catheter  or  a  lithotrite  and  inject  vinegar 
and  water,  a  2  per  cent,  solution  of  carbolic  acid,  or  a  solution  of  bicarbonate 
of  sodium.  Perfect  quiet  is  to  be  maintained,  cold  acid  drinks  given, 
ice-bags  put  to  the  perineum  and  hypogastric  region,  and  opium  with 
acetate  of  lead,  or  gaUic  acid  to  be  given  by  the  mouth.  If  the  hemorrhage 
is  severe  or  persistent,  perform  a  suprapubic  cystotomy,  wash  out  the  bladder, 
and,  if  necessary,  plug  the  bladder  with  gauze,  leaving  the  ureters  uncovered. 

42.  In  hemorrhage  after  lateral  lithotomy,  ligate  if  possible.  If  the 
vessel  can  be  caught  but  cannot  be  ligated,  leave  the  forceps  in  place.  If 
it  is  not  possible  to  catch  the  vessel  with  forceps,  use  a  tenaculum.  If 
the  tenaculum  fails,  pass  a  threaded  curved  needle 

through  the  tissues  around  the  vessel  and  tie  the 
ligature  (suture  ligature).  Plugs  of  ice  and  injec- 
tions of  hot  water  may  be  tried.  These  means 
failing,  pressure  is  indicated.  Take  a  cannula, 
fasten  to  it  a  chemise  (Fig.  125),  empty  clots  from 
the  bladder,  insert  the  instrument  into  the  viscus, 
and  pack  gauze  between  the  sides  of  the  cannula 
and  the  chemise.  The  chemise  is  bulged  out  and 
pressure  is  made.  Tie  the  cannula  by  means  of 
tapes  to  a  T-bandage.  Pressure  is  thus  combined 
with  vesical  drainage.  Buckstone  Brown  makes 
pressure  by  inflating  a  rubber  bag  with  air.  The 
hot  iron  may  occasionally  be  demanded. 

43.  Renal  bleeding  requires  ice  to  the  loin,  tan- 
nic acid  and  opium,  gallic  acid  or  sulphuric  acid 
internally,  and  perfect  quiet.  The  use  of  a  cysto- 
scope  will  show  from  which  ureter  blood  is  emerg- 
ing. If  the  bleeding  threatens  life  and  the  diseased 
organ   is   identified,  make   a   lumbar  incision,  and 

suture   or  perform  nephrectomy;  if  not  sure  which  organ  is  diseased, 
form  an  e.xploratory  laparotomy. 

44.  Vaginal  hemorrhage  requires  the  ligature  or  the  tampon. 

45.  Severe  uterine  hemorrhage  (unconnected  with  pregnancy)  requires 
the  tampon.  Persistent  hemorrhage  due  to  morbid  growths  may  require 
removal  of  the  tubes  and  appendages,  ligation  of  the  uterine  and  ovarian 
arteries,  or  hysterectomy. 


Fig.  i; 


-Cannula 


per- 


326  Diseases  and  Injuries  of  the  Heart  and  Vessels 

46.  Hematemesis,  or  bleeding  from  the  stomach,  is  treated  by  the  swallow- 
ing of  ice,  giving  tannic  acid  (dose,  20  or  30  grains)  or  Monsel's  solution  (3 
drops).  Gelatin  by  the  mouth  is  recommended.  Never  give  tannic  acid 
and  Monsel's  solution  at  the  same  time,  as  they  mix  and  form  ink.  Opium 
is  usually  ordered.  Acetate  of  lead  and  opium  and  gallic  acid  are  favorite 
remedies,  and  ergot  is  used  b}-  many.  Give  no  food  by  the  stomach.  If  life 
is  threatened  by  bleeding  from  an  ulcer,  open  the  belly  and  excise  the  ulcer 
and  suture  the  wound.  If  severe  hemorrhage  follows  injury,  perform  an  ex- 
ploratory laparotomy.  Always  remember  that  furious  and  even  fatal  gastro- 
intestinal hemorrhage  may  be  due  to  cirrhosis  of  the  liver,  and  a  shght  injury 
may  be  the  exciting  cause  of  such  a  hemorrhage.  In  this  condition,  of 
course,  operation  is  useless. 

47.  In  bleeding  from  the  small  bowel  give  acetate  of  lead  and  opium, 
sulphuric  acid,  or  Monsel's  salt  in  pill  form  (3  grains),  allow  no  food  for  a 
time,  and  insist  on  liquid  diet  for  a  considerable  period.  If  hemorrhage 
threatens  life,  do  a  celiotomy  and  find  the  cause.  If  ulcer  exists,  excise  it 
and  suture,  or  suture  a  perforation  without  previously  excising.  If  violent 
hemorrhage  follows  injury,  explore  to  discover  the  cause. 

48.  In  bleeding  from  the  large  bowel,  use  styptic  injections  (10  grains 
of  alum  or  5  grains  of  bluestone  to  5j  of  water).  If  bleeding  is  low  down, 
use  small  amounts  of  the  solution;  if  high  up,  large  amounts.  Do  not  use 
absorbable  poisons.  In  dangerous  cases  perform  an  exploratory  operation 
to  find  the  cause.     (For  rectal  bleeding  see  37,  p.  324). 

49.  Hemoptysis  or  bleeding  from  the  lung,  is  treated  by  morphin  hypo- 
dermatically,  by  perfect  rest,  by  dry  cups  or  ice  over  the  affected  spot  if  it 
can  be  located,  and  by  the  administration  of  gaUic  acid,  which  drug  aids 
coagulation.*     Of  late,  nitrite  of  amyl  by  inhalation  has  given  good  results. 

50.  In  hemorrhage  from  wound  of  the  lung  do  not  open  the  chest  unless 
hfe  is  threatened.  If  life  is  endangered,  resect  a  rib,  allow  the  lung  to  col- 
lapse, and  see  if  this  arrests  bleeding.  If  bleeding  still  continues,  remove 
several  ribs,  find  the  bleeding  point,  ligate  or  employ  forcipressure.  A  small 
cavity  may  be  packed  with  gauze.  If  a  large  surface  is  bleeding,  fill  the 
pleural  sac  with  gauze  and  pack  more  gauze  against  the  oozing  surface. f 

Reactionary  or  Recurrent  Hemorrhage  (called  also  Consecutive, 

Intermediate,  or  Intercurrent). — This  form  of  hemorrhage  comes  on  during 
reaction  from  an  accident  or  an  operation — that  is,  during  the  first  forty- 
eight  hours,  but  usually  within  twelve  hours.  It  is  bleeding  from  a  vessel  or 
vessels  which  did  not  fjleed  during  the  shock  which  accompanied  operation, 
and  which  vessels  were  overlooked  and  not  tied.  It  may  be  due  to  faultily 
applied  ligatures.  It  is  favored  by  vascular  excitement  or  hypertrophied 
heart.  The  bleeding  is  rarely  sudden  and  severe,  but  is  usually  a  gradual 
drop  or  trickle.  The  Esmarch  apparatus  is  not  unusually  the  cause.  The 
constricting  band  paralyzes  the  smaller  arteries,  which  do  not  bleed  during 
shock  and  do  not  contract  as  shock  departs;  hence  bleeding  comes  on  with 
reaction.     Tcj  lessen  the  danger  of  the  Esmarch  apparatus  use  a  broad  con- 

*The  use  of  ergot  i.s  a  general  but  questionable  practice.  Bartholow  and  others  hold 
that  this  drug  does  harm  ;  it  contracts  all  the  arterioles,  and  hence  more  blood  flows  from  an 
area  where  there  is  damage.  Purgatives  do  good  in  l)leeding  from  the  lung  by  taking  blood 
to  the  abdomen  and  lowering  blood-pressure. 

f  See  author's  case,  Annals  of  Surgery,  Jan.,  1898. 


Secondarv   Hemorrhage 


327 


stricting  band  rather  than  a  rubber  tube.  After  an  amputation,  when  the 
larger  vessels  have  been  tied,  gauze  pads  wet  with  hot  water  (115°  to  120°  F.) 
should  be  placed  between  the  flaps.  This  not  only  arrests  capillary  oozing, 
but  stimulates  vessels  and  shows  points  of  bleeding  which  were  not  previously 
visible,  and  these  points  are  ligated.  During  reaction  after  an  amputation, 
if  slight  hemorrhage  occurs,  elevate  the  stump  and  compress  the  flaps.  If 
the  hemorrhage  persists  or  at  any  time  becomes  severe,  make  pressure  on 
the  main  artery  of  the  limb,  open  the  flaps,  turn  out  the  clots,  fmd  the  bleeding 
point,  ligate,  asepticize,  close,  drain^  and  dress.  In  any  severe  reactionary 
hemorrhage  open  the  wound  at  once  and  ligate. 

Secondary  hemorrhage  may  occur  at  any  time  in  the  period  between 
forty-eight  hours  after  the  accident  or  operation  and  the  complete  cicatriza- 
tion of  the  wound.  Secondary  hemorrhage  may  be  due  to  atheroma,  to 
slipping  of  a  ligature,  to  inclusion  of  nerve,  fascia,  or  muscle  in  the  ligature, 
to  sloughing,  to  erysipelas,  to  septicemia,  to  pyemia,  to  gangrene,  and  to 
overaction  of  the  heart.  The  great  majority  of  cases  of  secondary  hemor- 
rhage are  due  to  infection,  and  the  application  of  modern  surgical  principles 
has  rendered  secondary  bleeding  a  rare  calamity.  If  during  an  operation 
the  vessels  are  found  atheromatous,  a  thread  should  be  passed,  by  means  of 
a  Hagedorn  needle,  around  the  vessel,  including  a  cushion  of  tissue  in  the 
loop  of  the  ligature  (this  prevents  cutting  through,  Fig.  112).  Acupressure 
may  be  used  in  such  a  case.  If  the  surgeon  decides  to  employ  the  hgature, 
he  must  not  tie  tightly,  but  must  endeavor  to  approximate  the  coats  rather 
than  to  cut  them.  Two  ligatures  can  be  applied  or  the  stay-knot  may  be 
used.  One  great  trouble  with  atheromatous  arteries  is  that  their  coats 
cannot  contract;  another  trouble  is  that  the  ligature  cuts  entirely  through 
them.  If  after  an  operation  the  pulse  is  found  to  be  forcible,  rapid,  and 
jerking,  give  aconite,  opium,  and  low  diet.  The  bleeding  may  come  on 
suddenly  and  furiously,  but  is  usually  preceded  by  a  bloody  stain  in  wound- 
fluids  which  had  become  free  from  blood. 

Treatment  of  Secondary  Hemorrhage. — Suppose  a  case  of  leg- 
amputation  in  w^hich,  several  days  after  the  operation,  a  httle  oozing  is  detecteck 
the  treatment  is  to  elevate  the  stump,  apply  two  compresses  over  the  flaps, 
and  carry  a  firm  bandage  up  the  leg.  If  the  bleeding  is  profuse  or  becomes 
so,  make  pressure  on  the  main  artery,  open  and  tear  the  flaps  apart  with  the 
fingers,  find  the  bleeding  vessel  and  tie  it,  turn  out  the  clots,  asepticize,  close, 
drain,  and  dress.  If  the  bleeding  begins  at  a  period  when  the  stump  is  nearly 
healed,  cut  down  on  the  main  artery  just  above  the  stump  and  ligate.  In 
secondary  hemorrhage  from  a  blood-vessel  in  nodular  tissue,  apply  a  suture- 
ligature  or  tie  higher  up,  or,  if  this  fails,  amputate.  When  secondary  hemor- 
rhage arises  in  a  sloughing  wound  apply  a  tourniquet  or  an  Esmarch  bandage, 
tear  the  wound  open  to  the  bottom  with  a  grooved  director,  look  for  the 
orifice  of  the  vessel,  dissect  the  artery  up  until  a  healthy  point  is  reached, 
cut  it  across,  and  tie  both  ends.  If  this  fails,  apply  a  suture-hgature  or 
use  acupressure.  In  secondary  hemorrhage  from  atheromatous  vessels,  use 
the  suture-ligature,  double  ligature  with  a  stay-knot,  or  employ  acupressure. 

Secondary  hemorrhage  may  occur  after  ligation  in  continuity,  the  blood 
usually  coming  from  the  distal  side.  If  the  dressings  are  slightly  stained 
with  blood,  put  on  a  graduated  compress.     If  the  bleeding  continues  or  is 


328  Diseases  and  Injuries  of  the  Heart  and  Vessels 

severe,  make  pressure  on  the  main  artery  of  the  hmb,  open  the  wound  and 
ligate,  wrap  the  part  in  cotton,  elevate,  and  surround  with  hot  bottles.  If 
this  religation  is  done  on  the  femoral  and  fails,  do  not  ligate  higher  up,  as 
gangrene  will  certainly  occur,  but  amputate  at  once,  above  the  point  of  hemor- 
rhage. If  dealing  with  the  brachial  artery,  do  not  amputate,  but  ligate 
higher  up  and  make  compression  in  the  wound.  In  a  secondary  hemorrhage 
from  the  innominate,  tie  the  innominate  again  and  also  tie  the  vertebral. 

2.    Operations  on  the  Vascular  System. 

Paracentesis  auriculi,  or  tapping  the  heart-cavity,  has  been  suggested 
for  the  relief  of  an  overdistended  heart  from  pulmonary  congestion.  The 
right  auricle  can  be  tapped.  Push  the  aspirator  needle  directly  backward 
at  the  right  edge  of  the  sternum,  in  the  third  interspace.  This  operation  is 
not  recommended,  as  it  is  highly  dangerous  and  is  of  questionable  value. 

Paracentesis  pericardii,  or  tapping  the  pericardial  sac,  is  done  only 
when  life  is  endangered  by  effusion.  Introduce  the  needle  two  inches  to 
the  left  of  the  left  edge  of  the  sternum,  in  the  iifth  interspace,  and  push  it 
directly  backward  (thus  avoiding  the  internal  mammary  artery).  The 
operation  of  tapping  is  extremely  dangerous.  The  heart  is  lifted  up  and 
pushed  forward  by  an  effusion  and  the  needle  is  apt  to  enter  it.  The  puncture 
of  a  ventricle  may  do  no  harm,  although  it  is  apt  to,  but  the  puncture  of  an 
auricle  is  liable  to  be  followed  by  fatal  hemorrhage.  It  is  wiser  and  safer 
to  expose  the  pericardium  and  incise  it,  as  is  done  for  pericardial  suppuration. 

Operation  for  Pericardial  Effusion  or  Suppuration. — The  oper- 
ation of  tapping  should  be  abandoned  in  favor  of  a  safer  but  more  radical 
procedure.  There  is  no  spot  where  we  can  introduce  the  needle  with  perfect 
safety,  and  the  heart  or  pleura  may  be  wounded;  further,  as  Brentano  shows,* 
tapping  will  not  completely  empty  the  sac.  In  a  purulent  case  tapping  gives 
practically  no  chance  of  cure.  No  general  anesthetic  should  be  used.  A 
portion  of  the  fifth  rib  or  the  cartilage  on  the  fifth  rib  should  be  excised,  the 
pericardium  exposed  and  punctured  in  order  to  determine  the  nature  of  the 
fluid  present.  If  the  fluid  is  serous,  it  can  be  drained  away  through  a  small 
incision,  and  the  pericardium  may  either  be  sutured  or  drained  with  gauze. 
If  the  fluid  be  purulent,  the  pericardium  should  be  stitched  to  the  chest-wall 
and  opened.  Clots  should  be  removed  by  irrigation  with  hot  salt  solution 
and  a  drainage-tube  should  be  introduced. 

Operation  for  Wound  of  the  Heart. — In  many  cases  it  is  obviously 
impossible  to  administer  an  anesthetic,  but  when  possible  it  should  be  given 
because  the  movements  of  the  patient  while  under  the  knife  make  operation 
difficult  and  increase  bleeding.  Ether  may  be  used  or  we  may  take  Hill's 
advice  and  give  chloroform.  Hill  would  give  an  anesthetic  unless  the  patient 
is  unconscious  and  the  corneal  reflex  is  abohshed.  Personally,  I  would  be 
dispo.sed  to  use  local  anesthesia  unless  the  patient's  general  condition  were 
good  or  at  least  fair.  The  pericardium  is  exposed  freely  and  Rotter's  incision 
gives  excellent  access.  This  exposure  is  described  by  Hill  in  the  "  Medical 
Record,"  November  29,  1902,  and  was  employed  in  his  successful  case. 
Begin  an  incision  over  the  third  rib  five-eighths  of  an  inch  from  the  left  edge 
of  the  sternum  and  carry  it  outward  along  the  rib  for  four  inches.  Begin  an 
*Deut.  med.  Woch.,  Feb.  11,  1890. 


Operation  for  Varix  of  Leg  329 

incision  over  a  corresponding  point  of  the  sixth  rib  and  carry  it  out  for  a  like 
distance.  Join  the  outer  extremities  of  these  cuts.  Cut  through  the  ribs 
and  pleura  with  bone  forceps  and  scissors.  Raise  the  flap  upon  its  hinges 
of  cartilages,  and  have  an  assistant  grasp  the  lung  to  prevent  collapse. 
The  pericardium  thus  exposed  is  opened  more  widely  if  necessary.  Hill 
advises  us  to  steady  the  heart  by  passing  the  hand  under  it  and  lifting  it. 
Parrozzani  did  this  by  passing  a  finger  through  the  wound.  Other  sur- 
geons have  used  traction  sutures  of  silk.  Interrupted  sutures  are  preferred 
to  the  continuous  suture.  Either  silk  or  catgut  can  be  used.  They  should 
be  inserted  with  a  round-edged  needle,  and  should,  if  possible,  be  passed 
and  tied  during  diastole.  "As  few  as  possible  should  be  passed  commen- 
surate with  safety  against  leakage,  as  they  cause  a  degeneration  of  the 
muscular  fiber"  (L.  L.  Hill,  in  "Medical  Record,"  November  29,  1902). 
The  pericardial  and  pleural  sacs  are  cleansed  with  salt  solution.  The 
question  of  drainage  is  still  sub  judice.  I  would  be  inclined  to  drain  the 
pericardium  with  gauze.  The  pleural  sac  is  treated  according  to  indications 
in  each  case. 

Operation  for  Varix  of  Leg. — Many  cases  do  not  require  operation. 
In  some,  operation  is  positively  harmful.  In  some  selected  cases  it  is  very 
useful  to  remove  certain  complications  (ulcer,  eczema,  etc.),  and  to  relieve 
the  patient  from  annoyance,  but  the  operation  rarely  absolutely  cures  the 
condition.  The  indications  and  contraindications  are  discussed  on  page  290. 
Never  operate  if  phlebitis  exists,  except  to  treat  thrombosis. 

Trendelenburg's  Operation. — I  have  employed  this  with  much  satis- 
faction in  cases  of  varix  of  the  leg  following  involvement  of  the  saphenous 
in  the  thigh.  Trendelenburg  believes  that  in  varix  the  valves  in  the  saphenous 
become  incompetent  because  of  high  central  pressure.  The  veins  of  the  leg 
distend,  as  they  are  unable  to  support  such  a  long  column  of  blood,  and 
finally  the  blood  begins  to  flow  in  the  wrong  direction  in  the  saphenous,  a 
"  vicious  circle"  being  established.  We  determine  whether  a  case  is  a  suitable 
one  for  Trendelenburg's  operation  as  follows:  While  the  patient  is  lying  down, 
raise  the  extremity  as  though  we  intended  to  empty  it  of  blood  previous  to 
amputation.  After  three  minutes  compress  the  saphenous  vein  about  the 
lower  third  of  the  thigh  by  means  of  a  moist  gauze  bandage,  which  must  not 
be  so  tight  as  to  shut  off  the  deeper  vessels.  Lower  the  leg  and  have  the 
patient  stand  up.  If  blood  flows  into  the  saphenous  from  above  and  distends 
the  portion  of  the  vein  above  the  compress,  the  valves  are  incompetent  and 
Trendelenburg's  operation  may  be  performed.  The  operation  is  performed  as 
follows:  Make  an  incision  about  four  inches  long  over  the  internal  saphenous 
vein  at  the  junction  of  the  lower  and  middle  thirds  of  the  thigh.  Expose  the 
vein,  ligate  each  visible  branch,  ligate  the  saphenous  at  the  lower  end  of  the 
wound  and  also  at  the  upper  end,  and  remove  the  portion  of  vein  included 
between  the  ligatures.  By  this  operation  the  central  pressure  is  intercepted 
and  the  dilated  veins  in  consequence  shrink.  Some  surgeons  have  advised 
the  removal  of  the  entire  length  of  the  long  saphenous  vein.  If  Trendelen- 
burg's operation  fails  and  a  relapse  occurs,  extirpate  the  varicose  veins  of 
the  leg,  first  making  them  prominent  by  applying  an  Esmarch  band  lightl}- 
about  the  thigh  while  the  patient  is  standing.  After  the  application  of  the 
band  he  lies  down  and  is  given  ether. 


330  Diseases  and  Injuries  of  the  Heart  and  Vessels 

Madelung  cuts  down  over  the  varices  and  hgates  at  various  points.  Scheie 
makes  a  circular  cut  (a  circumcision)  completely  around  the  leg  at  the  junc- 
tion of  the  upper  and  middle  thirds,  the  incision  reaching  to  the  deep  fascia. 
All  bleeding  points  are  ligated  and  the  edges  of  the  incision  are  stitched 
together.  Fergusson  ties  the  saphenous  vein  near  the  femoral  and  removes 
a  section  from  it.  This  makes  the  varices  clearly  evident.  A  semilunar 
incision  is  made  to  surround  the  varices,  which  incision  reaches  to  the  deep 
fascia.  The  flap  is  raised  and  dissected  up,  the  vessels  are  tied,  and  the  flap 
is  sutured  in  place.  The  author  of  this  operation  claims  that  it  is  most 
satisfactory  and  certain.  Phelps  advises  multiple  ligation,  which  may  be 
described  as  follows:  At  several  points  over  the  long  saphenous  vein  he 
makes  skin  incisions  in  the  long  axis  of  the  vessel.  Each  incision  is  two 
inches  long.  At  each  point  two  ligatures  are  placed  one  inch  apart  and  the 
portion  of  vein  between  them  is  removed. 

Open  Operation  for  Varicocele. — The  open  operation  is  by  far  the 
best  procedure  for  varicocele.  The  instruments  used  are  a  scalpel,  an  aneurysm 
needle,  curved  needles,  a  grooved  director,  a  dissecting  forceps,  Allis's  dry 
dissector,  hemostatic  forceps,  and  scissors. 

Operation. — The  patient  is  placed  in  a  recumbent  position.  He  may 
be  given  a  general  anesthetic  or  Schleich's  fluid  may  be  injected.  The 
operator  stands  on  the  diseased  side.  The  assistant  stands  on  the  sound 
side  and  makes  pres.sure  over  the  inguinal  ring  of  the  affected  side.  A  fold 
of  skin  is  pinched  up  on  the  scrotum,  and  the  surgeon  transfixes  it  in  the 
line  of  the  cord,  so  that  he  will  have  an  incision  about  one  and  a  half  inches 
long  running  downward  from  below  the  external  ring.  The  skin  and  fascia 
are  cut  with  a  scalpel,  the  veins  are  well  exposed  by  means  of  an  Allis  dis- 
sector, and  the  cord  is  located  and  held  aside.  A  double  ligature  of  strong 
catgut  or  chromicised  gut  is  passed  under  the  veins  by  an  aneurysm  needle. 
The  threads  are  separated  one  inch,  tied  tightly,  and  the  ends  are  left  long. 
The  veins  between  the  hgatures  are  excised.  The  two  gut  ligatures  are  tied 
together  and  cut.  This  shortens  the  cord.  The  scrotum  is  sewed  up  with 
silkworm-gut,  a  small  drainage-tube  being  used  for  twenty-four  hours.  Heal- 
ing is  complete  in  one  week. 

Bloodgood,  of  Johns  Hopkins  Hospital,  points  out  that  it  is  well  to  avoid 
dividing  the  genital  branch  of  the  genitocrural  nerve  which  supplies  the 
cremaster  muscle.  If  this  nerve  should  be  divided,  the  cremaster  will  become 
lax  and  return  of  the  varicocele  will  be  favored.  Bloodgood  makes  the 
incision  over  the  external  ring,  draws  the  veins  up  and  resects  them.  A 
wound  so  placed  heals  more  certainly  and  promptly  than  does  a  wound  of 
the  scrotum. 

Subcutaneous  Ligature  for  VaricoceIe.~In  this  operation  employ 

every  antiseptic  precaution.  The  patient  stands,  and  the  operator,  sitting 
in  front  of  him,  holds  the  veins  in  a  fold  of  skin  away  from  the  vas  deferens 
by  means  of  the  thumb  and  index-finger  of  the  left  hand.  A  large  straight 
needle  carrying  a  double  piece  of  strong  silk  is  pas.sed  entirely  through  the 
scrotum,  between  the  veins  and  the  vas.  The  needle  is  again  inserted  at 
the  [juncture  from  which  it  emerged,  is  carried  around  under  the  skin  and 
in  front  of  the  veins,  and  emerges  at  its  original  point  of  entry.  The  veins 
are  thus  surrounded  by  the  silk.     The  patient,  who  now  lies  down,  is  placed 


Transfusion   of  Blood  331 

under  the  first  stage  of  ether,  and  the  double  ligatures  are  separated  as  far 
as  possible  from  each  other,  tied,  and  cut  off,  the  knots  slipping  in  through 
the  puncture.  This  operation  presents  certain  dangers.  The  veins  may  be 
wounded  and  the  vas  or  other  structures  may  be  included.  In  an  operation 
it  is  always  best  to  be  able  to  see  what  we  are  doing;  and  the  open  operation, 
being  safe,  is  preferred  to  the  subcutaneous. 

Phlebotomy,  or  Venesection. — The  instrument  used  in  venesection 
is  a  lancet  or  bistoury.  A  fillet  or  tape,  an  antiseptic  pad,  and  a  bandage  are 
required.     A  stick  should  be  at  hand  for  the  patient  to  grasp. 

Operation. — The  patient  sits  on  a  chair  "  with  the  arm  abducted,  ex- 
tended, and  incHned  outward"  (Barker).  The  parts  are  asepticized  and  a 
tape  is  tied  around  the  arm  just  above  the  elbow.  The  surgeon  stands  to 
the  right  of  the  arm,  holds  the  elbow  with  his  left  hand,  and  puts  his  thumb 
upon  the  vein  below  the  intended  point  of  puncture.  The  patient  grasps  a 
stick  firmly  and  works  his 
fingers  in  order  to  cause  the 
veins  to  distend.  Either  the 
median  cephalic  or  the  me- 
dian basilic  may  be  opened 
(Figs.  126,  127).  The  median 
basilic  is  the  more  distinct, 
and  is  the  vein  usually  se- 
lected. In  opening  it  do  not 
cut  too  deep,  as  nothing  but 
the  bicipital  fascia  separates 
it    from     the    brachial     arterv.  _.  ,        .  .  , 

'  Fig.    126.— Incisions    for  Fig.     127.  —  buiici  hoial 

The  median  cephalic  may  be  Se-  venesection  (Bernard  and  veins  in  front  of  elbow 
lected   (we  thus  avoid  endanger-       Huette).  (Bernard  and  Huette). 

ing  the  brachial  artery) ;    under 

this  vein  lies  the  external  cutaneous  nerve  (Fig.  127).  Steady  the  vein  with  the 
thumb  and  open  it  by  transfixion,  making  an  oblique  cut  which  divides  two- 
thirds  of  it.  Remove  the  thumb  and  allow  bleeding  to  go  on,  instructing  the 
patient  to  work  his  fingers.  When  faintness  begins,  remove  the  fillet,  put  an 
antiseptic  pad  over  the  puncture,  ajjply  a  spiral  reversed  bandage  of  the 
hand  and  arm  and  a  figure-of-eight  bandage  of  the  elbow,  and  place  the  arm 
in  a  sling  for  several  days. 

Transfusion  of  Blood. — This  operation  has  been  a  recognized  pro- 
cedure since  1824,  though  it  has  been  known  since  1492,  when  transfusion 
was  employed  in  the  case  of  Pope  Innocent  VIII.  Its  chief  use  was  in  se\-ere 
hemorrhage,  especially  post-partum,  in  which  it  served  to  replace  the  blood 
lost  and  supplied  something  for  the  heart  to  contract  upon  until  new  blood 
formed.  Senn  insists  that  the  operation  has  proved  an  absolute  failure. 
It  does  not  prevent  death  from  hemorrhage,  and  the  transferred  blood- 
elements  do  not  retain  vitality.  Von  Bergmann  showed  that  after  severe 
hemorrhage  we  do  not  need  to  inject  nutritive  elements,  but  do  need  to  restore 
the  greatly  diminished  intracardiac  and  intravascular  pressure.  At  the 
present  day  a  saline  fluid  is  infused  in  preference  to  transfusing  blood.  In 
fact,  the  operation  of  transfusion  has  become  all  but  extinct.  It  exposes 
the  patient  to  the  danger  of  embolism  and  infection,  its  employment  requires 


332 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


material  and  instruments  often  difficult  to  obtain  in  an  emergency,  and  it 
has  no  single  element  of  value  beyond  that  secured  by  the  use  of  salt  solution, 
except  in  cases  overcome  by  illuminating  gas,  in  which  a  more  prolonged 
good  effect  is  produced  than  by  salt  solution. 

Intravenous  infusion  of  saline  fluid  is  used  after  severe  hemorrhage, 
in  shock,  in  diabetic  coma,  in  post-operative  suppression  of  urine,  and  occa- 
sionally in  sepsis.  After  a  hemorrhage  its  beneficial  effects  are  often  prompt 
and  obvious.  This  saline  fluid  increases  the  arterial  tension,  gives  the 
heart  enough  matter  to  contract  upon,  and  so  restores  the  activity  of  the 
circulation,  and  does  not  destroy  the  red  corpuscles  as  plain  water  would  do. 
We  may  use  a  simple  apparatus  consisting  of  a  rubber  tube,  a  funnel,  and 
an  aspirating  needle.  Some  employ  an  Aveling  syringe,  and  others  Collin's 
apparatus  (Fig.  128).  The  last-named  instrument  can  be  used  without  any 
danger  of  air  entering  with  the  fluids.  Spencer's  instrument  (Fig.  129)  is 
convenient  and  useful.     Normal  salt  solution  is  the  fluid  usually  employed, 

of  a  strength  of  0.6  per  cent,  (a  heap- 
ing teaspoonful  of  common  salt  to  a 
quart  of  warm  boiled  water).  Some 
surgeons  employ  an  artificial  serum 
which  contains  50  grains  of  chlorid  of 

1,^  „,  ,     .  sodium,  3  grains  of  chlorid  of  potas- 

^^^S_^\  h  I   I  slum,  25  grains  of  sulphate  of  sodium, 

W  I.       i  25  grains  of  carbonate  of  sodium,  and 

2  grains  of  phosphate  of  sodium  in  a 
quart  of  boiled  water.  Szumann's  so- 
lution consists  of  6  parts  of  common 
salt,  I  part  of  sodium  carbonate,  and 
1000  parts  of  water.  The  following  so- 
lution is  used  by  Locke  and  Hare :  cal- 
cium chlorid,  25  gm. ;  potassium  chlo- 
rid, I  gm.;  sodium  chlorid,  9  gm.;  ster- 
ile water  sufficient  to  make  i  liter.  One 
bottle  of  the  commercial  fluid  when 
diluted  to  i  liter  gives  a  solution  of  the  above  composition.  The  results 
from  artificial  serum  containing  many  elements  are  no  better  than  from 
normal  salt  solution.  Whatever  fluid  is  used,  it  should  be  at  a  temperature 
of  105°  F.  or  over  as  it  enters  the  vein.  The  stimulant  effect  of  the  heat 
is  of  great  value.  The  fluid  must  not  be  allowed  to  cool;  and  a  nurse  gives 
constant  attention  to  the  temperature  of  the  fluid  in  the  reservoir.  This  de- 
gree of  heat  will  not  damage  the  corfjuscles;  in  fact,  Dawbarn  has  used 
saline  fluid  at  a  temperature  of  118°  F.  without  doing  damage  to  cor- 
puscles and  with  great  benefit  to  the  patient.  From  \  pint  to  2  pints  or 
even  more  are  slowly  injected,  the  condition  of  the  patient  determining  the 
amount  given.  In  one  case  of  violent  hemorrhage  the  author  used  over  2 
quarts.  In  order  to  infuse  this  fluid,  tie  a  fillet  well  above  the  elbow,  and 
exjjose  by  dissection  the  median  basilic  vein,  or  the  basilic  vein  in  the  por- 
tion of  its  course  where  it  is  superficial  to  the  deep  fascia.  Tie  the  vein. 
Incise  it  above  the  ligature,  insert  a  fine  cannula,  and  hold  the  cannula 
firmly  in  lumen  by  tightening  a  second  Hgature  (Figs.  63,  128).     Remove 


Fig.  128. — Intravenous  injection  of  saline  fluid. 


Hemophilia,   or    Hemorrhagic    Diathesis 


333 


Fig  129. — Spencer's  apparatus  for  the  infusion  of 
saline  fluid  into  a  vein.  The  cannula  can  be  plunged 
directly  into  the  vessel  without* preliminary  incision. 


the  fillet.  Slowly  and  gradually  introduce  the  fluid,  carefully  watching  the 
pulse.  Occupy  at  least  ten  minutes  in  introducing  a  pint,  e.xcept  in  a  very 
desperate  case  of  hemorrhage,  when  the  rapidity  of  the  flow  may  be  accele- 
rated. When  the  tension  of  the  pulse  returns,  withdraw  the  cannula,  tie  the 
second  ligature  tightly,  sew  up 
the  wound,  and  dress  it  asepti- 
cally.  In  very  severe  operations 
an  assistant  should  conduct  the 
infusion  while  the  surgeon  is 
operating.  It  may  be  necessary 
to  repeat  the  operation  if  the 
circulation  fails  again.  The  in- 
fusion of  a  very  large  amount 
of  saline  fluid  may  do  harm.  It 
may  embarrass  the  heart  and 
may  lead  to  edema  of  the  lungs  ^^ 
or  brain. 

Arterial  Transfusion  and 
Infusion  of  Saline  Fluid  in 
Arteries. — Hueter  preferred  the 
arterial  method  of  transfusion, 
in  order  to  send  the  blood 
more  gradually  to  the  heart,  and  thus  prevent  sudden  disturbance  of 
the  circulation.  A  little  air  in  an  artery  will  do  no  harm,  and  the  danger  of 
venous  embolism  is  avoided.  Saline  fluid  can  be  infused  into  an  artery. 
The  radial  artery  is  exposed  and  surrounded  by  three  ligatures,  and  the  thread 
toward  the  heart  is  at  once  tied.  The  distal  ligature  is  shghtly  tightened  to 
cut  ofT  anastomotic  blood-supply.  The  artery  is  cut  transversely  half  through ; 
the  syringe  is  inserted,  pointed  toward  the  periphery,  and  fastened  by  the 
third  ligature;  the  second  ligature  is  loosened  and  the  blood  is  injected.  On 
finishing,  the  peripheral  thread  is  tied  tightly  and  that  portion  of  the  artery 
which  held  the  cannula  is  excised.  Dawbarn  puts  a  hypodermatic  needle 
into  the  radial  artery  and  injects  saline  fluid. 

Hemophilia,  or   Hemorrhagic    Diathesis.— The  term  hemophilia 

expresses  the  existence  in  an  individual  of  a  tendency  to  profuse  or  even 
uncontrollable  hemorrhage  spontaneously  or  as  a  result  of  some  very  trivial 
injury. 

Hemorrhage  may  take  place  from  mucous  or  serous  membranes  or  from 
wounds  of  the  cutaneous  surface,  into  tissue,  into  organs,  under  the  scalp,  or 
into  the  external  genitals.  In  a  hemophiliac,  if  a  cut  is  made,  the  hemorrhage 
from  the  larger  vessels  is  easily  arrested,  but  capillary  oozing  continues. 

The  condition  is  far  more  common  in  males  than  in  females,  and  if  it 
exists  in  a  female,  which  it  rarely  does,  it  is  not  usually  provocative  of  danger- 
ous hemorrhage.  The  disease  is  transmitted  by  heredity.  It  is  transmitted 
to  a  son  by  a  mother,  who  is  usually  free  from  the  disease,  but  whose  father 
had  it,  and  the  son  bleeds  dangerously  from  slight  causes.  The  existence 
of  the  tendency  is  rarely  suspected  until  the  first  dentition,  and  possibly  not 
till  puberty;  "70  per  cent,  of  cases  appear  before  the  fifth  year."*     The 

*R.  C.  Cabot,  in  •■International  Text-book  of  Surgery." 


334  Diseases  and  Injuries  of  the  Heart  and  Vessels 

discovery  of  the  existence  of  such  a  condition  may  not  be  made  until  a  tooth 
is  pulled,  and  extraction  is  followed  by  persistent  bleeding.  It  is  alleged 
that  the  tendency  may  disappear  in  middle  Hfe. 

The  cause  of  the  condition  is  unknown.  It  has  been  assumed  that  there 
is  a  condition  of  the  blood  which  prevents  coagulation,  but  the  blood  of  a 
hemophiliac  coagulates  outside  of  the  body  as  well  as  any  other  blood.  Fur- 
thermore, Agnew  had  a  case  in  which  hemophilia  was  limited  to  the  head 
and  neck,  and  there  have  been  cases  in  which  the  bleeding  occurred  from  one 
kidney.  Some  maintain  that  there  is  structural  defect  in  the  capillaries.  In 
a  case  of  hemophilia  in  the  Jefferson  Medical  College  Hospital  in  which  it 
was  absolutely  necessary  to  amputate  a  finger  because  of  a  crush,  a  careful 
study  of  the  vessels  of  the  finger  by  Dr.  Coplin  failed  to  show  any  disease 
of  the  blood-vessels.  A  surgeon  must  be  on  the  lookout  for  this  condition, 
and  should  inquire  for  it  before  deciding  to  do  an  operation.  If  it  exists,  only 
an  operation  of  imperative  necessity  should  be  undertaken. 

A  child  who  is  a  ''bleeder"  must  be  unceasingly  watched  and  guarded. 
A  tendency  to  profuse  oozing  exists  in  leukemia  because  of  the  condition  of 
the  blood,  but  this  is  not  hemophilia.  A  tendency  to  oozing  also  exists  during 
jaundice. 

Treatment. — The  oozing  is  difficult  and  often  impossible  to  control. 
The  internal  administration  of  such  drugs  as  ergot,  gallic  acid,  and  acetate 


Fig.  130. — Aneurysm  needle  of  Saviard. 

of  lead  is  useless.  It  is  claimed  that  chlorid  of  calcium  internally  is  of  service. 
The  local  use  of  a.stringents  is  of  no  avail.  Prolonged  elevation  may  in  rare 
cases  succeed.  In  the  case  in  the  Jefferson  Medical  College  Hospital  the 
bleeding  was  arrested,  after  numerous  expedients  failed,  by  compression 
and  hot  water.  Nurses  sat  by  the  bed  for  several  days,  constantly  com- 
pressed the  wound  with  gauze  pads  soaked  in  hot  water,  and  changed  the 
pads  as  soon  as  they  cooled.  The  local  use  of  Carnot's  solution  of  gelatin 
has  saved  several  cases  from  death.  It  has  been  advised  to  take  some  blood 
from  a  healthy  man  and  put  it  in  the  cut,  in  the  hojje  that  a  firm  clot  will 
form. 

3.   Ligation  of'   Aktkries  in  Continuity. 

The  instruments  used  in  this  ()i)eration  are  two  scalpels  (one  small, 
one  medium),  two  dis.secting  forceps,  .several  hemostatic  forceps,  blunt  hooks 
or  broad  metal  retractors,  an  Allis  dissector,  an  aneurysm  needle,  for  superfi- 
cial arteries  the  instrument  of  Saviard  (Fig.  130),  for  deep  vessels  the  needle 
ot  Dupuytren  (Fig.  131),  ligatures  of  catgut,  of  chromicized  gut,  or  of  silk, 
curved  needles  and  a  necflle  holder,  sutures  of  silkworm-gut,  and  the  re- 
flector or  electric  forehead-lamp  for  deep  vessels. 

The  position  in  which  the  patient  is  placed  varies  according  to  the  vessel 
to  be  ligated,  though  the  body  is  supine  except  when  ligation  is  to  be  performed 


Ligation   of  Arteries 


335 


Fig.  131. — Dupuytren's   aneurysm 
needles. 


on  the  gluteal,  sciatic,  or  popliteal  artery.  The  operator,  as  a  rule,  stands 
upon  the  affected  side,  cutting  from  above  downward  on  the  right  side,  and 
from  below  upward  on  the  left  side. 

Operation. — Accurately  determine  the  line  of  the  artery,  and  make  an 
incision  at  a  slight  angle  to  this  line,  avoiding  subcutaneous  veins,  and  holding 
the  scalpel  like  a  fiddle-bow  or  a  dinner-knife 
while  cutting  the  superficial  parts,  and  hke 
a  pen  while  incising  the  deeper  parts.  On 
reaching  the  deep  fascia  make  out  the  re- 
quired muscular  gap  by  the  eye  and  finger,  so 
moving  the  extremity  as  to  bring  individual 
muscles  into  action.  Treves  cautions  us  not 
to  depend  upon  the  yellow  line  of  fat,  which 
often  cannot  be  seen  in  emaciated  people  or 
when  an  Esmarch  bandage  is  employed;  nor 
upon  the  white  line  due  to  attachment  to  the 
fascia  of  an  intermuscular  septum.  In  open- 
ing the  deep  portion  of  the  wound  relax  the 
bounding  muscles  by  altering  the  posture. 
Open  a  muscular  interspace  with  a  sharp 
knife,  not  with  a  dissector.  Make  the  depths 
of  the  wound  as  long  as  the  superficial  incision. 

Do  not  tear  structures  apart  with  a  grooved  director;  cut  them.  Arrest 
hemorrhage  as  it  occurs.  Try  to  find  the  situation  of  the  artery  with  the 
finger.  Pulsation  is  present,  but  it  may  be  very  feeble  and  hard  to  detect. 
The  artery  feels  like  a  very  thin  rubber  tube;  it  is  compressible,  though  not 
so  easily  as  a  vein,  and  when  compressed  feels  like  a  flat  band  which  is  thinner 
in  the  center  than  at  the  edges  (Treves).  A  nerve  feels  like  a  hard,  round 
cord.  The  veins  are  soft,  larger  than  their  related  arteries,  and  so  very  com- 
pressible that  they  can  scarcely  be  felt  when  pressed  upon,  and  compression 
causes  distal  distention.  If  the  wound  can  be  seen  into  clearly,  it  will  be 
noted,  as  Treves  asserts,  that  "the  nerves  stand  out  as  clear,  rounded,  white 
cords;  that  the  veins  are  of  a  purple  color  and  of  somewhat  uneven  and  wavy 
contour;  that  the  artery  is  regular  in  outline  and  of  a  pale-pink  or  pinkish- 
yellow  tint,  the  large  vessels  being  of  lighter  color  than  the  small."  Each 
artery  of  the  upper  extremity  and  each  artery  below  the  knee  is  accom- 
panied by  two  veins,  known  as  "vencC  comites."  The  arteries  of  the  head 
and  neck,  except  the  lingual,  have  each  a  single  attending  vein;  the  lingual 
has  vena;  comites.  Most  of  the  smaller  arteries  of  the  trunk  (pudic,  internal 
mammary,  etc.)  have  vena?  comites.  These  companion  veins  may  lie  on 
each  side  of  the  artery  or  in  front  and  back  of  it,  and  they  communicate  with 
one  another  by  transverse  branches  crossing  the  artery.  On  reaching  the 
sheath  pick  up  this  structure  with  toothed  forceps  so  as  to  make  a  transverse 
fold,  and  thus  avoid  catching  the  artery  or  vein;  lift  the  fold  to  see  that  it  is 
free,  and  o])en  the  sheath  by  cutting  toward  the  edge  of  the  forceps  with  a 
scalpel  held  obliquely  with  its  back  toward  the  vessel,  thus  making  a  small 
longitudinal  incision  (PI.  2,  Figs.  1,2).  Hold  the  edge  of  the  incised  sheath 
with  the  forceps;  pass  a  metal  dissector  under  the  vessel  and  from  the  forceps; 
this  clears  one-half  of  the  vessel.     Grasp  the  other  edge  of  the  sheath  and  pass 


336  Diseases  and  Injuries  of  the  Heart  and  Vessels 

the  blunt  dissector  all  the  way  around  the  vessel.  Pass  an  aneurysm  needle 
under  the  cleared  vessel,  away  from  the  forceps  holding  the  sheath  and  away 
from  the  vessel's  most  dangerous  neighbor.  Thread  the  needle  and  withdraw 
it.  If  venae  comites  are  in  the  way,  try  to  separate  them;  but  if  this  proves 
diiiicult,  include  them  in  the  ligature.  In  small  vessels  always  include  them 
if  they  are  in  the  way,  as  this  saves  trouble.  If,  in  passing  the  needle,  a  large 
vein  is  severely  wounded  (such  as  the  femoral),  Jacobson  advises  the  em- 
ployment of  digital  pressure  in  the  lower  portion  of  the  wound  while  the 
artery  is  being  tied  on  a  level  above  or  below  that  of  the  vein-injury,  and 
after  ligation  the  maintenance  of  pressure  on  the  wound  for  a  couple  of  days. 
A  slight  puncture  in  a  vein  merely  requires  a  lateral  ligature.  A  small 
wound  can  be  closed  with  Lembert  sutures  of  fine  silk.  After  getting  a 
ligature  under  an  artery  press  for  a  moment  upon  the  artery  over  the  ligature, 
which  is  held  taut;  this  pressure  wih  arrest  pulsation  below  if  the  ligature 
is  around  the  main  artery  and  there  is  not  a  double  vessel.  Tie  the  thread 
at  right  angles  to  the  vessel  with  a  reef-knot  (Fig.  132),  rupturing  the  internal 
and  middle  coats.  As  the  ligature  is  tightened  place  the  extended  index- 
fingers  along  the  ligature  up  to  the  artery  (PI.  2,  Fig.  3),  using  the  middle 
joints  as  the  fulcrum  of  a  lever  by  placing  them  against  each  other. 

Ballance  and  Edmunds  have  recently  claimed,  as  Scarpa  and  Sir  Philip 

Crampton  did  long  since,  that  it  is  not  neces- 
sary to  divide  the  internal  and  middle  coats 
to  insure  obliteration.  If  this  claim  be  true, 
the  danger  of  secondary  hemorrhage  can  be 
greatly  lessened.  Holmes,  however,  thinks  the 
older  method  the  more  certain  of  the  two. 
Fig.  132.— Reef-knot.  Ballancc  and    Edmunds   use   floss   silk    as    a 

ligature  material,  because  it  is  soft,  broad, 
and  flat,  and  they  surround  the  artery  with  a  double  hgature.  Ballance 
and  Edmunds  thus  describe  the  application  of  the  stay-knot:  "The  best 
way  of  tying  two  ligatures  is  to  make  on  each  separately,  and  in  the  same 
way,  the  first  hitch  of  a  reef-knot,  and  to  tighten  each  separately  so  that  the 
loop  lies  in  contact  with  the  vessel  without  constricting  it.  Then  taking  the 
ends  on  one  side  together  in  one  hand  and  the  two  ends  on  the  other  side 
in  the  other  hand,  constrict  the  vessel  sufficiently  to  occlude  it,  and  finally 
complete  the  reef-knot.  The  simplest  way  of  completing  the  knot  is  to 
treat  the  two  ends  in  each  hand  as  a  single  thread  and  to  tie  as  if  completing 
a  single  reef-knot."  This  knot  is  shown  in  PI.  2,  Figs.  5,  6.  The  stay-knot 
applied  by  this  method  is  of  great  value  if  a  vessel  be  atheromatous.  Fig. 
133  shows  an  arterial  scar  after  ligation.  Fig.  134  shows  an  intravenous 
scar. 

The  chief  dangers  after  ligation  are  .secondary  hemorrhage  and  gangrene. 
Rigid  asepsis  usually  prevents  the  first;  rest,  elevation,  and  heat  antagonize 
the  second. 

Radial  Artery. — The  line  of  the  radial  artery  is  from  the  middle  of 
the  front  of  elbow-joint  to  the  ulnar  side  of  the  styloid  process  of  the  radius. 
The  line  in  the  tabatiere  is  from  the  apex  of  the  styloid  process  to  the  posterior 
angle  of  the  first  interosseous  space  (Fig.  135). 

Anatomy  (PI.  3,  Fig.  5). — The  radial  artery,  though  smaller  than  the 


LIGATIONS. 


Plate  2. 


I.  Opening  the  Sheath  for  Ligation  of  an  Artery  (Guerin).  2.  Sheath  of  Arter)'  Open  (Guerin). 
3.  Tightening  the  Knot  in  Ligation  (Guerin).  4.  Anatomy  of  the  Iliac  Arteries,  and  showing  the 
lines  of  incision  for  their  ligation  :  i,  Abernethy's  incision  (Guerin).  5,  6.  Ballance  and  E<^ 
mund's  Stay-knots. 


Intravascular  and  Intravenous   Scar 


2,17 


Vas  vasorum. 


Partly  lonneil  coiiiiecti\e 
tissue  trom  endothelia. 


^ 


Endothelial  C' 
prolifera 
tioii. 


— •" l-'-l .C_'_'_r5^  I'lolifeiated 

coniiectixe 
tissue  ill 
Itimeu. 


F'S-  I33- — Cross-section  of  obliterated  artery,  exhibitiiiij  the   histologic   appearances   ot   the    intra- 
vascular scar  (X  240)  (Senn). 


P'.?-    '34 —Histologic  structure  of  intravenous  scar,  right  internal  jugular  vein,  forty-nine  days  alter 
ligation.    Transverse  section  between  ligatures  (X  240)  (Senn). 


338  Diseases  and   Injuries  of  the   Heart  and  Vessels 

ulnar,  is  the  direct  continuation  of  the  brachial.  It  arises  from  the  bifurcation 
of  the  brachial  half  an  inch  below  the  bend  of  the  elbow,  runs  down  the  radial 
side  of  the  forearm  to  the  front  of  the  styloid  process  of  the  radius,  passes 
beneath  the  extensor  muscles  of  the  first  metacarpal  bone  and  of  the  first 
phalanx  of  the  thumb,  and  over  the  carpus  to  the  first  interosseous  space. 
Tt  is  crossed  by  the  tendon  of  the  extensor  secundi  internodii  pollicis,  enters 
into  the  palm  between  the  heads  of  the  first  dorsal  interosseous  muscle,  and 
forms  the  deep  palmar  arch.  The  artery  in  the  upper  two-thirds  of  its  course 
is  somewhat  overlaid  by  the  supinator  longus  muscle;  in  the  lower  one-third 
of  the  forearm  it  is  superficial.  In  the  upper  third  of  the  forearm  it  lies 
between  the  supinator  longus  on  the  outside  and  the  pronator  radii  teres  on 
the  inside;  in  the  lower  two-thirds  of  the  forearm  it  lies  between  the  supinator 
longus  on  the  outside  and  the  flexor  carpi  radiahs  on  the  inside.  Two  venae 
comites  attend  the  vessel.  The  radial  nerve  is  to  the  outer,  or  radial,  side 
of  the  artery,  well  removed  from  the  artery  in  the  upper  third,  nearer  to  the 
artery  in  the  middle  third,  far  external  to  the  artery  in  the  lower  third,  the 
nerve  at  this  point  passing  beneath  the  supinator  longus  muscle.  The  radial 
artery,  from  above  downward  rests  upon  the  biceps  tendon,  the  supinator 
brevis,  the  flexor  sublimis,  the  pronator  radii  teres,  the  flexor  longus  pollicis, 
the  pronator  quadratus  muscles,  and  the  radius.  The  best  guide  to  the 
radial  artery  in  the  forearm  is  the  outer  edge  of  the  flexor  carpi  radialis  muscle 
or  the  inner  edge  of  the  supinator  longus  muscle. 

The  tabatiere  anatomique  of  Cloquet,  or  the  anatomical  snuff-box,  is  a 
triangle  whose  base  is  the  lower  edge  of  the  posterior  annular  ligament,  the 
ulnar  side  being  formed  by  the  extensor  secundi  internodii  pollicis  tendon, 
the  radial  side  by  the  extensor  ossis  metacarpi  and  the  extensor  primi  internodii 
pollicis  tendons;  the  floor  consists  of  the  trapezium,  scaphoid,  their  dorsal 
ligaments,  and  the  base  of  the  first  metacarpal  bone. 

Operations. — Ligation  in  the  tabatiere  is  a  dissecting-room  operation  of 
but  little  practical  use.  The  patient  is  placed  in  a  recumbent  position,  the 
arm  is  abducted,  and  the  forearm  is  placed  midway  between  pronation  and 
supination  (Barker).  The  surgeon  stands  upon  the  side  operated  upon. 
An  incision  two  inches  in  length  is  made  along  the  radial  border  of  the  ex- 
tensor secundi  internodii  pollicis  muscle.  The  skin  and  superficial  fascia 
are  cut  and  some  venous  branches  are  divided.  The  deep  fascia  is  incised 
and  the  vessel  is  easily  found  and  tied  before  it  passes  between  the  heads  of 
the  first  dorsal  interosseous  muscle  (Barker). 

Ligation  oj  the  Lower  Third. — In  this  operation  (PI.  3,  Fig.  6,  and  Fig.  135) 
the  patient  is  placed  supine,  the  arm  is  abducted,  the  forearm  is  supinated,  is 
rested  upon  a  table,  and  is  held  by  an  assistant.  The  surgeon  stands  on  the 
side  operated  upon,  and  cuts  from  above  downward  on  the  right  forearm  and 
from  below  upward  on  the  left  forearm.  The  line  of  the  vessel  should  be 
determined,  and  may  be  indicated  with  iodin  or  anilin.  An  incision  one  and 
a  half  inches  long  is  made  at  a  slight  angle  to  this  line  and  midway  between 
the  supinator  longus  and  the  flexor  carpi  radialis  muscles,  which  incision 
must  not  extend  below  the  level  of  the  tuberosity  of  the  scaphoid  bone.  In 
the  superficial  fascia  watch  for  the  su])erficial  radial  vein,  and  if  it  comes  into 
view  push  it  aside.  Incise  the  superficial  fascia  and  lr)cate  each  guide-tendon. 
Open  the  deep  fascia  in  the  length  of  the  first  cut;  try  to  separate  the  veins, 


LIGATIONS. 


Plate  -z. 


Ulnar  Artery  339 

but  if  they  strongly  adhere  include  them  in  the  ligature.  There  is  no  special 
fascial  sheath.  The  radial  nerve  will  not  be  seen,  but  a  division  of  the  anterior 
cutaneous  nerve  is  frequently  found  in  relation  with  the  vessel.  The  needle 
can  be  passed  in  either  direction.  A  high  origin  of  the  superficialis  volae 
artery  is  confusing. 

Ligation  of  the  Middle  Third. — In  this  operation  the  position  of  the  patient 
should  be  the  same  as  in  the  preceding.  A  two-inch  incision  is  made.  \'eins 
of  the  subcutaneous  tissues  are  avoided.  Lying  upon  the  deep  fascia  is  the 
anterior  division  of  the  musculocutaneous  nerve.  Open  the  fascia;  find  the 
inner  edge  of  the  supinator  longus  muscle  and  draw  it  outward,  flexing  the 
elbow  partly  if  necessary.  Be  sure  not  to  cut  external  to  this  muscle.  Find 
the  vessel  where  it  is  bound  down  by  connective  tissue  to  the  pronator  radii 
teres  muscle,  separate  the  veins,  and  pass  the  ligature  from  without  inward. 
The  nerve  is  external. 

Ligation  oj  the  Upper  Third  (PI.  3,  Fig.  6,  and  Fig.  135).— In  this  oper- 
ation the  incision  is  as  described  above,  only  higher  up.  The  artery  is  be- 
tween the  supinator  longus  and  the  pronator  radii  teres,  which  muscles  are 
at  once  differentiated  by  the  different  direction  of  their  fibers.  The  artery 
is  usually  covered  by  the  supinator  longus  muscle,  which  must  be  retracted 
externally.  The  nerve  is  not  seen.  The  ligature  may  be  passed  in  either 
direction. 

Ulnar  Artery. — No  one  line  will  overlie  the  entire  ulnar  artery.  The 
line  of  the  upper  third  runs  from  the  middle  of  the  front  of  the  elbow-joint 
to  the  point  of  junction  of  the  upper  and  middle  thirds  of  the  ulna.  The 
line  of  the  lower  two-thirds  runs  from  the  tip  of  the  internal  condyle  of  the 
humerus  to  the  radial  side  of  the  pisiform  bone  (PI.  3,  Figs.  5,  6;   Fig.  135). 

Anatomy  (PI.  3,  Fig.  5). — The  ulnar  artery  arises  from  the  brachial 
bifurcation  and  runs  obliquely  inward  under  the  median  nerve  and  a  group 
of  muscles  from  the  internal  condyle;  it  turns  down  the  arm,  being  covered 
in  the  middle  third  of  its  course  by  the  flexor  carpi  ulnaris  muscle.  In  the 
lower  third  it  is  superficial,  between  the  tendons  of  the  flexor  carpi  ulnaris 
on  the  inside  and  the  flexor  sublimis  digitorum  on  the  outside,  the  vessel 
being  a  little  overlapped  by  the  flexor  carpi  ulnaris.  This  vessel  rests  first 
upon  the  brachialis  anticus  muscle,  next  upon  the  flexor  profundus,  to  which 
it  is  bound  by  a  distinct  process  of  fascia,  and  next  upon  the  annular  ligament, 
which  structure  it  crosses  to  become  the  superficial  palmar  arch.  Two  vena? 
comites  attend  the  vessel.  In  the  upper  third  the  nerve  is  well  internal,  but 
in  the  lower  two-thirds  the  nerve  lies  near  the  artery  and  to  its  ulnar  side. 
The  guide  is  the  outer  edge  of  the  flexor  carpi  ulnaris. 

Operations  (PI.  3,  Fig.  6,  and  Fig.  135). — Ligation  oj  the  Lower  Third. — 
The  position  in  this  operation  is  the  same  as  for  ligation  of  the  radial  artery. 
Make  a  two-inch  incision  to  the  radial  side  of  the  tendon  of  the  flexor  carpi 
ulnaris,  which  incision  should  not  be  taken  lower  than  a  point  one  inch  above  , 
the  pisiform  bone.  Avoid  the  superficial  ulnar  vein  in  the  subcutaneous  tissue. 
Open  the  deep  fascia,  find  the  tendon  of  the  flexor  carpi  ulnaris,  flex  the  wri.'^t 
and  draw  the  tendon  inward,  open  a  second  layer  of  fascia,  clear  the  vessel, 
separate  the  veins,  and  pass  the  ligature  from  within  outward  to  a\'oid  the 
nerve.  On  the  artery  is  the  palmar  cutaneous  branch  of  the  ulnar  nerve,  and 
this  branch  must  not  be  included  in  the  ligature. 


340  Diseases  and   Injuries  of  the  Heart  and  Vessels 

Ligation  of  the  Middle  Third  (PI.  3,  Fig.  6). — In  this  operation  the  posi- 
tion is  the  same  as  in  the  preceding  one,  the  incision  being  three  inches  long. 
Avoid  the  anterior  ulnar  vein  and  the  branches  of  the  internal  cutaneous 
nerve  in  the  superficial  fascia.  Open  the  deep  fascia  a  little  external  to  the 
superficial  cut  (Treves).  Find  the  space  betv^^een  the  flexor  carpi  ulnaris 
and  the  superficial  flexor,  feeling  with  the  index-finger,  and  when  the  space 
is  discovered  flex  the  wrist,  retract  the  flexor  carpi  ulnaris  inward  and  the 
flexor  sublimis  digitorum  outward,  open  the  fascia,  find  the  ulnar  nerve,  look 
external  to  it  for  the  artery,  clear  the  vessel,  separate  the  venae  comites,  and 
pass  the  needle  from  within  outward.  The  ulnar  artery  should  not  be  ligated 
in  continuity  in  the  upper  third  of  its  course. 

Brachial  Artery. — The  line  of  the  brachial  artery  is  from  the  junc- 
tion of  the  anterior  and  middle  thirds  of  the  outlet  of  the  axilla,  the  arm  being 
abducted  and  the  forearm  supinated,  to  the  middle  of  the  front  of  the  elbow- 
joint  (Fig.  135). 

Anatomy  (PL  3,  Fig.  i). — The  brachial  artery  is  the  prolongation  of  the 
axillary,  and  extends  from  the  lower  edge  of  the  teres  major  muscle  to  half 
an  inch  below  the  bend  of  the  elbow,  where  it  divides  into  the  radial  and 
ulnar  arteries.  It  lies  first  to  the  inner  side  of  the  arm,  but  passes  to  the 
front  of  the  elbow.  It  is  crossed  by  no  muscle,  and  is,  in  fact,  superficial, 
barring  its  being  somewhat  overlaid  in  part  of  its  course  by  the  edge  of  the 
biceps  muscle.  The  median  nerve  is  external  above,  crosses  over  the  vessel 
about  the  middle  of  the  arm,  and  reaches  the  inner  side  of  the  artery.  The 
coracobrachialis  and  biceps  muscles  are  external,  and  both  often  overlap 
the  vessel.  The  ulnar  nerve  is  internal  above,  and  the  median  nerve  is 
internal  below  the  middle.  The  basilic  vein  is  to  the  inner  side  of  the  artery, 
being  outside  the  deep  fascia  to  near  the  middle  of  the  arm,  at  which  point 
it  pierces  it.  The  artery  above  is  separated  from  the  long  head  of  the  triceps 
bv  the  musculospiral  nerve  and  superior  profunda  artery  and  vein;  it  rests 
from  above  down  on  the  inner  head  of  the  triceps,  the  coracobrachialis,  and 
the  brachialis  anticus  muscles.  The  artery  is  covered  by  skin,  by  superficial 
fascia,  and  by  deep  fascia.  The  internal  cutaneous  nerve  hes  in  front  of 
the  artery,  upon  the  deep  fascia,  until  it  pierces  the  fascia  along  with  the 
basilic  vein.  The  artery  has  vena;  comites,  and  in  its  upper  half  has  also 
the  basilic  vein  to  its  inner  side.  The  guide  to  the  brachial  is  the  inner  edge 
of  the  biceps  muscle.  Just  in  front  of  the  elbow-joint  the  artery  lies  in  a 
triangle,  the  base  of  which  is  formed  by  an  imaginary  transverse  line  above 
the  condyles,  and  the  apex  by  the  junction  of  the  pronator  radii  teres  and 
the  supinator  longus  muscles.  The  outer  line  is  the  supinator  longus,  the 
inner  line  is  the  jjronator  radii  teres,  and  the  floor  is  formed  by  the  brachialis 
anticus  and  the  su[)inator  brevis  muscles.  From  within  outward  the  triangle 
contains  the  median  nerve,  brachial  artery,  tendon  of  the  biceps,  anastomosis 
of  the  su[)erior  profunda  and  radial  recurrent  arteries,  and  the  musculospiral 
nerve. 

Operations. — Ligation  at  the  Bend  oj  the  Elbow. — In  this  operation  (PI.  3, 
Fig.  2,  anrl  Fig.  135)  the  patient  is  placed  supine,  the  arm  is  moderately 
abducted  and  extended,  and  is  allowed  to  lie  upon  its  posterior  a.spect.  The 
forearm  is  supinated.  The  surgeon  stands  upon  the  side  operated  upon,  and 
cuts  from  above  downward  on  the  right  side  and  from  below  upward  on  the  left 


Axillary   Artery  34 1 

side.  The  tendon  of  the  biceps  and  the  median  basilic  vein  must  be  accu- 
rately located.  An  incision  is  made  parallel  with  the  inner  edge  of  the  biceps 
tendon  and  two  inches  in  length,  the  center  of  this  cut  being  in  the  crease 
of  the  elbow.  On  exposing  the  median  basilic  vein,  retract  it  downward 
and  inward,  open  the  bicipital  fascia,  clear  the  artery  of  fat,  separate  the 
venae  comites,  and  pass  the  ligature  from  within  outward  to  avoid  the  median 
nerve.     The  above  operation  is  not  frequently  performed. 

Ligation  in  the  Middle  of  the  Arm  (Fig.  135). — In  this  operation  the  patient 
is  placed  supine,  the  arm  is  abducted,  and  the  forearm  is  supinated.  An 
assistant  holds  the  forearm,  but  the  arm  should  not  rest  upon  the  table,  because, 
if  it  be  allowed  to  do  so,  the  inner  head  of  the  triceps  will  be  forced  forward 
and  may  overlie  the  artery,  and  thus  complicate  the  operation.  Locate  the 
inner  edge  of  the  biceps,  which  is  the  guide.  Make  an  incision  three  inches 
long  in  the  line  of  the  arter\-.  Incise  the  skin  and  fascia,  flex  the  elbow  slightly, 
retract  the  biceps  outward,  feel  for  the  artery,  open  the  sheath,  separate  its 
vena?  comites,  and,  having  located  the  median  nerve,  pass  the  ligature  from 
it.  In  the  middle  of  the  arm  the  nerve  is  in  front  of  the  vessel,  abo\e  the 
middle  it  is  external  to  it,  and  below  the  middle  it  is  internal  to  it.  High  up 
the  arm  the  inner  edge  of  the  coracobrachialis  is  the  guide,  rather  than  the 
biceps.  Above  the  middle  of  the  arm  the  basilic  vein  is  beneath  the  deep 
fascia  and  passes  along  by  the  inner  side  of  the  artery;  hence,  high  up,  the 
artery  has  three  companion  veins,  the  vena^  comites  and  the  basilic  vein, 
and  there  is  seen  the  ulnar  nerve  to  the  inside  of  the  artery. 

Axillary  Artery. — To  determine  the  line  of  the  axillary  artery  place  the 
arm  at  a  right  angle  to  the  body,  with  the  patient  supine,  and  lay  down  a 
line  from  the  middle  of  the  clavicle  to  the  humerus  near  the  inner  border 
of  the  coracobrachialis.  The  line  of  the  third  portion  can  be  approximated 
by  projecting  the  line  of  the  brachial  upward  (Fig.  135). 

Anatomy  (PI.  3,  Fig.  3;  PI.  4,  Fig.  i).— The  axillary  artery  is  the  con- 
tinuation of  the  subclavian,  and  runs  from  the  lower  margin  of  the  first  rib 
to  the  inferior  border  of  the  teres  major  muscle.  It  is  divided  into  three 
portions  by  the  pectoralis  minor  muscle.  The  first  jjortion  is  above,  the 
second  portion  is  behind,  and  the  third  portion  is  below,  the  pectoralis  minor. 
The  position  of  the  artery  varies  with  the  position  of  the  limb.  When  the 
arm  is  parallel  with  the  body  the  artery  is  far  from  the  surface  and  forms 
a  curve  whose  convexity  is  upward  and  outward.  When  the  arm  is  at  a 
right  angle  to  the  body  the  vessel  is  nearer  the  surface  and  straight,  \^'hen 
the  arm  is  raised  above  a  right  angle  the  artery  comes  near  the  surface  and 
forms  a  curve  with  the  convexity  downward. 

The  first  ])ortion  of  the  axillary  artery  is  occasionally  ligaled.  It  lies  upon 
the  first  intercostal  muscle  and  the  first  serration  of  the  great  serratus  muscle, 
and  has  behind  it  the  posterior  thoracic  ner\e;  the  brachial  [plexus  is  external 
and  posterior  to  the  vessel;  on  its  inner  side  is  the  axillarv  veiii;  in  front  of 
it  are  the  clavicle,  the  great  pectoral  muscle,  the  subclavius  muscle,  the  costo- 
coracoid  membrane,  the  cephalic  and  acromiothoracic  veins,  and  the  external 
anterior  thoracic  nerxe.  The  branches  of  the  first  part  of  the  axillar\-  arterv 
are  the  superior  thoracic  and  the  acromiothoracic.  The  second  part  of  the 
artery  is  not  ligated.  The  brachial  ])lexus  surrounds  the  second  portion. 
The  third  part  is  covered  in  front,  above,  by  the  great  pectoral,  but  is  covered 


342 


Diseases  and   Injuries   of  the   Heart  and  Vessels 


below  by  skin  and  fascia;  behind,  it  has  the  tendon  of  the  subscapularis, 
the  latissimus  dorsi,  and  the  teres  major  muscles;  the  coracobrachialis  is  on 
the  outer  side;  the  axillary  vein  is  on  the  inner  side.  It  is  important  to  re- 
member that  there  may  be  three  veins,  one  external  and  two  internal.  The 
axillary  vein  is  formed  by  the  venae  comites  of  the  brachial  artery  joining, 
and  this  new  vein  effecting  a  junction  with  the  basilic  vein.  The  median 
nerve  lies  upon  the  axillary  artery  in  the  upper  part  of  the  third  portion  of 
the  vessel's  course,  and  passes  to  the  outer  side.  The  musculocutaneous 
nerve  is  external,  but  it  is  only  seen  high  up;  the  ulnar  nerve  is  internal; 
the  lesser  internal  and  the  internal  cutaneous  nerves  are  internal;  the  muscu- 
lospiral  and  the  circumflex  nerves  are  behind.  The  branches  of  the  third 
portion  of  the  axillary  artery  are  the  subscapular  and  the  anterior  and  pos- 
terior circumflex. 

Operations. — Ligation  of  the  Third  Portion  (PI.  3,  Fig.  4,  and  Fig.  135). — 
The  position  of  the  patient  should  be  supine,  with  the  shoulders  raised  and  the 
arm  abducted  to  a  right  angle.  The  surgeon  stands  between  the  patient's  arm 
and  side,  with  his  back  toward  the  subject's  feet.  An  incision  is  made  three 
inches  in  length.     It  begins  half-way  up  the  axilla  opposite  to  the  head  of  the 


Fig.  135. — Lines  of  incision   for  ligation  of   tlie  axillary  (third   portion),  brachial,  radial,  and  ulnar 

arteries  (MacCorniac). 


humerus,  and  is  taken  downward  parallel  to  the  lower  edge  of  the  great  pectoral 
muscle  and  crosses  the  junction  of  the  anterior  and  middle  thirds  of  the  outlet 
of  the  axilla.  The  integuments  and  fascia  are  incised.  The  vein  or  veins  will 
be  prominent  to  the  inner  side  and  may  overlie  the  vessel.  To  the  inner  side 
with  the  veins  are.  the  ulnar  and  internal  cutaneous  nerves.  The  median 
nerve  is  upon,  and  the  external  cutaneous  is  to  the  outer  side  of,  the  artery. 
Feel  for  the  pulsations  of  the  artery,  find  the  median  nerve,  and  draw  it  out- 
ward, draw  the  nerves  and  veins  which  lie  to  the  inner  side  inward,  clear  the 
artery  from  the  vena;  comites,  and  pass  the  ligature  from  within  outward. 
Apply  the  ligature  well  below  the  circumflex  branches. 

Ligation  oj  the  First  Part. — This  operation  (PI.  4,  Fig.  2,  and  Fig. 
137)  was  first  performed  in  1815  by  Chamberlaine,  of  Jamaica.  The 
patient  is  placed  supine,  the  upper  part  of  the  body  being  raised,  a  sand- 
pillow  being  placed  between  the  scapulae  to  insure  carrying  back  of  the 
point  of  the  shoulder,  and  the  arm  being  brought  down  along  the  side, 
In  operating  on  the  left  side  the  surgeon  stands  on  the  outer  side  of 
the  left  arm;  in  operating  on  the  right  side  he  stands  to  the  right  of 
the   subject's  head  and   leans   over   his   shoulder.     The   incision,   which   is 


Subclavian  Artery  343 

slightly  curved  downward,  begins  external  to  the  sternoclavicular  joint 
and  ends  internal  to  the  margin  of  the  deltoid,  thus  avoiding  the  cephalic 
vein.  The  incision  is  half  an  inch  below  the  clavicle  (Fig.  137).  Incise  the 
skin,  platsyma  myoides  muscle,  and  deep  fascia.  In  the  outer  angle  of  the 
wound  watch  for  the  acromiothoracic  artery  and  the  cephalic  vein.  Incise 
the  pectoralis  major;  draw  the  pectoralis  minor  downward;  retract  the  lower 
margin  of  the  wound,  cut  through  the  costocoracoid  membrane  close  to  the 
coracoid  process  and  the  upper  border  of  the  lesser  pectoral  muscle.  Bring 
the  arm  to  the  side  so  as  to  relax  the  structures.  Find  the  brachial  plexus, 
feel  for  the  artery  internal  to  it,  clear  the  vessel,  draw  the  vein  internally,  and 
pass  the  needle  from  within  outward.  This  avoids  the  dangerous  neighbor, 
which  is  the  axillary  vein.  This  operation  is  difficult,  dangerous,  and  unusual, 
and  in  its  performance  the  axillary  vein,  which  has  a  close  attachment  to  the 
costocoracoid  membrane,  is  apt  to  be  torn. 

Subclavian  Artery. — The  subclavian  artery  was  first  successfully  tied 
by  Post,  of  New  York,  who  applied  a  ligature  about  the  third  portion  of 
the  vessel  in  181 7.  The  first  part  of  the  subclavian  was  first  tied  by  Colles 
in  1818  (Treves's  "Manual  of  Surgery").  At  the  present  day  the  first  and 
second  portions  are  rarely  ligated.  Professor  Halsted  successfully  tied  the 
first  portion  of  the  left  side  for  aneurysm.  Schumpert  tied  it  successfully  for 
aneurysm.  I  assisted  Dr.  Nassau,  of  St.  Joseph's  Hospital,  Philadelphia,  in  a 
ligation  of  first  part  of  the  right  subclavian.  The  man  sufi'ered  from  a  rup- 
tured traumatic  aneurysm  of  the  third  portion  of  the  vessel.  The  operation 
was  followed  by  recovery.  Chilton  produced  a  cure  of  an  aneurysm  of  the 
third  portion  of  the  subclavian  of  the  right  side  by  tying  the  first  portion  and 
twenty-four  hours  later  tying  the  first  portion  of  the  axillary.  There  is  no  line 
for  this  vessel. 

Anatomy  (PI.  4,  Fig.  i). — The  subclavian  artery  of  the  right  side  arises 
from  the  innominate;  that  of  the  left  side,  from  the  arch  of  the  aorta.  The 
subclavian  is  divided  into  three  parts.  The  first  part  runs  from  the  origin 
of  the  vessel  to  the  inner  border  of  the  scalenus  anticus  muscle;  the  second 
part  lies  behind  the  scalenus  anticus  muscle;  and  the  third  part  runs  from  the 
outer  edge  of  the  muscle  to  the  lower  border  of  the  first  rib.  The  third  portion 
is  contained  in  the  subclavian  triangle  (Fig.  136),  and  is  superficial.  It  rises, 
as  a  rule,  to  half  an  inch  above  the  clavicle.  The  subclavian  vein  is  below 
the  artery,  being  separated  from  it  by  the  scalenus  anticus  muscle.  The 
brachial  ple.xus  is  above  and  external  to  the  artery.  The  vessel  rests  upon 
the  first  rib,  and  behind  it  is  the  scalenus  medius  muscle.  The  suprascapular 
and  transversalis  colli  arteries  and  veins  and  branches  of  the  cervical  plexus 
of  nerves  lie  in  front  of  the  artery,  and  the  external  jugular  vein  crosses  it  at 
its  inner  side.     The  third  portion  gives  off  no  branches. 

Ligation  of  the  Third  Part. — (See  PI.  4,  Fig.  2,  and  Fig.  137).  The  patient 
is  placed  upon  his  back,  the  shoulders  are  raised,  the  head  is  extended  and 
turned  toward  the  opposite  side,  the  arm  is  pulled  down  and  held  by  pushing  the 
forearm  under  the  patient's  back  (Treves).  This  pulls  down  the  clavicle,  thus 
increasing  the  size  of  the  subclavian  triangle.  The  operator  stands  facing 
the  shoulder,  with  his  back  toward  the  patient's  feet.  The  skin  over  the  sub- 
clavian triangle,  at  a  point  half  an  inch  above  the  clavicle,  is  drawn  down 
until  it  overlies  the  bone  and  is  incised.     This  maneuver  enables  the  surgeon 


344  Diseases  and   Injuries  of  the   Heart  and   Vessels 

to  avoid  the  external  jugular  vein  and  to  make  an  incision  in  the  skin  half  an 
inch  above  the  collar-bone.  The  incision  reaches  from  the  anterior  edge  of 
the  trapezius  to  the  posterior  border  of  the  sternocleidomastoid  (PI.  4,  Fig.  2, 
and  Fig.  137),  and  is  about  three  inches  long.  This  incision  di\ides  the  skin, 
superficial  fascia,  the  platysma  m\'oides,  the  vein  running  from  the  cephalic  to 
the  external  jugular,  and  some  superficial  nerves.  The  deep  fascia  is  o])ened. 
The  external  jugular  vein  is  drawn  into  the  inner  angle  of  the  wound,  and  is 
not  divided  unnecessarily;  if  forced  to  divide  the  vein,  tie  with  two  ligatures 
and  cut  between  them.  The  surgeon  seeks  to  find  the  outer  edge  of  the  an- 
terior scalene  muscle,  and  runs  the  finger  down  along  it  to  the  tubercle  on 
the  first  rib.  The  posterior  belly  of  the  t)mohyoid  muscle  is  drawn  upward 
by  an  assistant.  The  surgeon,  with  a  finger  on  the  tubercle,  recalls  the  facts 
that  the  vein  is  in  front  of  the  finger  and  the  artery  is  behind  it,  and  that  the 
subclavian  vein  is  on  a  lower  plane  than  the  artery.  The  artery  is  felt  beating 
as  it  lies  upon  the  rib.  The  artery  is  cleared  and  the  lower  cord  of  the  brachial 
plexus  is  expo.sed.  The  vein  must  be  guarded  with  the  finger  and  the  needle 
is  passed  from  above  downward,  as  the  plexus,  which  is  in  more  danger  than 
the  vein,  is  to  be  avoided.  In  this  operation  the  trans\ersalis  colli  and  supra- 
scapular arteries  must  not  be  cut,  as  they  are  necessary  to  the  future  anasto- 
motic circulation.  If  the  field  of  operation  is  too  small,  the  trapezius  or 
sternocleidomastoid,  or  both,  should  be  incised  transversely. 

Results. — According  to  Joseph  D.  Bryant,  there  have  been  134  deaths 
in  250  ligations  ("Operative  Surgery").  I  have  twice  tied  this  vessel  with 
.success. 

The  vertebral  artery  was  first  successfully  ligated  by  Smythe,  of 
New  Orleans,  in  1864.  He  had  ligated  the  innominate  for  aneurysm  of  the 
subclavian  and  at  the  same  time  tied  the  common  carotid.  Secondary  hemor- 
rhage occurred,  the  blood  coming  from  the  brain.  He  arrested  it  by  tying 
the  vertebral. 

Anatomy. — This  vessel  is  the  largest  branch  of  the  subclavian,  and  is 
the  first  branch  coming  from  the  first  portion  of  the  subclavian.  The  verte- 
bral artery  ascends  and  enters  the  foramen  in  the  transverse  process  of  the 
sixth  cervical  vertebra  (in  rare  cases  the  fifth  or  the  seventh),  and  ascends 
through  foramina  in  the  cervical  vertebra^,  passes  behind  the  articular  process 
of  the  atlas  and  over  the  po.sterior  arch  of  this  first  vertebra,  pierces  the  ])os- 
terior  occipito-atloid  ligament,  and  enters  the  skull  by  way  of  the  foramen 
magnum  (see  Gray).  It  joins  its  fellow  of  the  opposite  side  to  form  the 
basilar  artery.  .\t  its  point  of  origin  the  vertebral  artery  has  in  front  of  it  the 
internal  jugular  \ein  and  infericjr  thyroid  artery.  Gray  says  that  near  the 
spine  it  h'es  between  the  longus  colli  and  scalenus  anticus  muscles,  with  the 
thoracic  duct  to  the  left  and  in  front. 

Ligation. — The  position  of  the  paliciil  is  the  same  as  for  ligation  of  the 
carotid  artery.  Alexander  thus  describes  the  operation:  "  ;\n  incision  3  or  4 
inches  long  is  made  in  an  upward  and  outwarrl  direction  along  the  hollow 
which  exists  between  the  scalenus  anticus  and  the  sternomastoid  muscles. 
The  incision  should  begin  just  outside  and  on  a  level  with  the  ])oint  where  the 
external  jugular  vein  dips  over  the  edge  of  the  sternomastoid  muscle,  or,  if 
the  vein  is  invisible,  about  half  an  inch  above  the  clavicle.  The  external 
jugular  vein  is  drawn  inward  with  the  sternomastoid  muscle.     The  connective 


LIGATIONS. 


Plate  4. 


^(iiii 


'i|p^^%^^^ 


iii  I  I  I 


me  ■^;. 


^  % 


0 

Tl 

>. 

H 

C 

rt 

oa 

<: 

g 

•5  f^ 
b  .2 

T3      i) 


"  -5 


O     C 


6  t: 
2  < 


Innominate   Artery  345 

tissue  now  appearing,  the  wound  is  opened  by  a  blunt  dissector,  until  the 
scalenus  anticus  muscle,  the  phrenic  nerve,  and  the  transverse  cervical  artery 
are  seen.  It  cannot  be  too  well  remembered  that  the  pleura  is  at  the  inner 
side  of  the  wound,  while  below  lies  the  subclavian  artery.  It  is  now  only 
necessary  to  separate  the  edges  of  the  scalenus  anticus  and  the  longus  colli 
muscles  to  see  the  vertebral  artery  lying  in  the  space  between  them.  The 
artery  is  generally  completely  covered  by  the  vein,  which  is  drawn  aside,  and 
the  artery  is  then  ligatured"  (quoted  in  Bryant's  "Operative  Surgerv"). 
When  the  vessel  is  cleared  and  tied,  branches  of  the  inferior  cervical  ganglion 
are  damaged  and  possibly  included  in  the  Hgature,  and  as  a  consequence  the 
pupil  contracts.  Jacobson  tells  us  to  remember  that  the  phrenic  nerve  Hes 
on  the  scalene  muscle,  the  pleura  is  internal,  the  internal  jugular,  inferior 
thyroid,  and  vertebral  veins  are  over  the  vessel,  and  the  thoracic  duct  on  the 
left  side  crosses  it  from  within  outward. 

Results. — In  36  ligations  of  the  vertebral  artery  there  were  3  deaths 
(Joseph  D.  Bryant). 

The  Inferior  Thyroid  Artery.— Anatomy. — The  inferior  thyroid 
artery  is  a  branch  of  the  thyroid  axis.  It  ascends  the  neck,  passes  back  of 
the  carotid  sheath  and  the  sympathetic  nerve,  and  reaches  the  thyroid  gland. 
The  recurrent  laryngeal  nerve  lies  behind  the  artery.  The  phrenic  nerve 
is  external  to  the  artery  and  near  to  it  in  the  first  part  of  its  course  (up 
to  the  point  of  origin  of  the  ascending  cervical  branch).  The  ascending 
cervical  branch  takes  origin  just  before  the  artery  begins  to  dip  behind 
the  carotid.  In  front  of  the  beginning  of  the  inferior  thyroid  artery  of  the 
left  side  the  thoracic  duct  crosses.  The  artery  is  ligated  in  the  second 
part  of  its  course  (between  its  distribution  and  the  origin  of  the  above-named 
branch). 

Ligation. — The  position  of  patient  and  the  incision  are  the  same  as  for 
the  ligation  of  the  common  carotid  artery  in  the  triangle  of  necessity  (page 
348).  After  exposing  the  sternocleidomastoid  muscle  retract  it  outward, 
and  then  draw  outward  the  common  carotid  arter}'  and  also  the  internal 
jugular  vein.  The  inferior  thyroid  artery  will  be  found  a  little  below  the 
carotid  tubercle.  It  is  cleared  and  ligated.  Treves  advises  ligation  close 
to  the  level  of  the  carotid,  so  as  to  avoid  the  recurrent  laryngeal  nerve. 

Innominate  Artery. — First  successfully  ligated  by  Smythe.  of  New 
Orleans,  in  1S64.     It  is  an  extremely  fatal  operation. 

Anatomy. — The  innominate  artery  arises  from  the  beginning  of  the  trans- 
verse portion  of  the  arch  of  the  aorta,  passes  to  the  back  of  the  right  sterno- 
clavicular joint,  and  divides  into  the  common  carotid  and  subclavian 
vessels.  It  rests  upon  the  trachea.  It  has  upon  its  outer  side  the  pleura, 
the  right  innominate  vein,  and  the  jMieumogastric  nerve.  Ui)on  its  inner 
side  are  the  remnant  of  the  thymus  gland  and  the  beginning  of  the  left 
carotid  artery.  In  front  of  it  are  the  inferior  thyroid  veins  of  the  right  side, 
the  left  innominate  \ein,  the  sternohyoid  and  sternothyroid  muscles,  the 
remnant  of  the  thymus  gland,  and  sometimes  a  branch  from  the  right  pneumo- 
gastric  nerve. 

Ligation. — Place  tlie  ])atient  supine,  with  the  shoulders  a  little  raised, 
and  the  head  thrown  hack.  Carrv  an  incision  from  the  upper  margin  of 
the  sternum  for  three  inches  along  the  anterior  margin  of  the  sternomastoid. 


346 


Diseases  and   Injuries  of  the   Heart  and  Vessels 


Make  another  cut  of  the  same  length  along  the  upper  border  of  the  clavicle 
to  meet  the  first  cut.  Dissect  up  the  flap  of  skin  and  fascia.  Divide  the 
sternal  origin  and  a  part  of  the  clavicular  portion  of  the  sternocleidomastoid 
muscle,  and  cut  the  sternohyoid  and  sternothyroid  muscles  just  above  their 
sternal  origins  (Joseph  Bell).  Retract  the  inferior  thyroid  veins.  Divide 
the  dense  leaflet  of  cervical  fascia.  Find  the  common  carotid  artery,  and 
trace  back  along  this  vessel  until  the  innominate  comes  into  view.  Retract 
the  left  innominate  vein  downvi^ard.  The  needle  is  passed  from  without 
inward  to  avoid  the  right  innominate  vein  and  right  pneumogastric  nerve. 
If  the  needle  is  kept  close  to  the  artery,  the  pleura  and  trachea  will  not  be 
injured.* 

Results. — Three  cases  have  recovered  out  of  31  reported  (Burrell's, 
Banks's,  and  Smythe's).  Burrell  hgated  the  innominate  in  1895  and  the 
patient  lived  over  three  months,  dying  finally  from  cardiac  disease.  Mitchell 
Banks's  case  lived  over  three  months. 

Region  of  the  Neck. — Anatomy. — The  side  of  the  neck  is  that  space 
between  the  median  line  in  front  and  the  anterior  edge  of  the  trapezius  muscle 
behind,  which  space  is  limited  below  by  the  clavicle  and  above  by  the  body 
of  the  jaw  and  an  imaginary  line  running  from  the  angle  of  the  jaw  to  the 
mastoid  process.  The  sternocleidomastoid  muscle  divides  this  space  into  an 
anterior  and  a  posterior  triangle,  and  each  of  the  triangles  is  subdivided  by 
other  structures,  the  anterior  into  four  spaces  and 
the  posterior  into  two  (Fig.  136). 

Anterior  Triangle. — The  anterior  triangle  is 
bounded  in  front  by  the  median  line  of  the  neck, 
behind  by  the  anterior  margin  of  the  sternocleido- 
mastoid muscle,  and  above  by  the  body  of  the 
lower  jaw  and  an  imaginary  line  drawn  from  the 
angle  of  the  jaw  to  the  mastoid  process.  This 
space  is  subdivided  into  four  smaller  triangles — 
namely,  the  inferior  carotid,  the  superior  carotid, 
the  submaxillary,  and  the  submental. 

The  inferior  carotid  triangle  is  called  the  "  tri- 
angle of   necessity,"   because  the  common  carotid 
artery  in  this  region  is  ligated,   not   from  choice, 
but  through  force  of  necessity.     It  is  bounded  in 
front  by  the   median   line,  above   by  the   anterior 
belly  of  the  omohyoid  muscle  and  the  hyoid  bone, 
and    below   by   the  anterior  edge  of    the   sterno- 
mastoid    muscle.     The    floor    of    this    triangle    is 
composed  of  the  longus  colli,  the  scalenus  anticus, 
the  rectus  capitis  anticus  major,  the  sternohyoid, 
and  sternothyroid  muscles. 
The  superior  carotid  triangle  is  known  as  the  "triangle  of  election,"  be- 
cause, if  the  carotid  artery  must  be  tied,  the  surgeon,  whenever  possible, 
elects  or  chooses  to  tie  it  in  this  triangle.     In  this  region  the  carotid  is  super- 
ficial, and  there  can  be  lied  either  the  external,  the  internal,  or  the  common 

*See  the  exceedingly  clear  and  tense  account  in  that  excellent  bo(jk,  "A  Manual  of 
Surgical  Operations,"  by  Joseph  Bell. 


¥i<r.  136. — The  triangles  of 
the  neck,  rig-ht-sided  view:  i, 
Submaxillary  triangle  ;  2,  "  tri- 
angle of  election,"  or  superior 
carotid  triangle ;  3,  submental 
triangle;  4,  "triangle  of  neces- 
sity," or  inferior  carotid  tri- 
angle; 5,  occipital  triangle;  6, 
subclavian  triangle ;  7,  hyoid 
bone  (after  Keen). 


Common   Carotid  Artery  347 

carotid  artery,  as  ma\'  be  desired.  The  triangle  is  bounded  behind  by  the 
anterior  edge  of  the  sternocleidomastoid,  above  by  the  posterior  belly  of  the 
digastric,  and  below  by  the  anterior  belly  of  the  omohyoid  muscles.  Its 
floor  is  composed  of  the  inferior  and  middle  constrictors  of  the  pharynx  and 
the  thyrohyoid  and  hyoglossus  muscles. 

The  submaxillary  triangle  is  bounded  above  by  the  body  of  the  jaw  and 
an  imaginary  line  drawn  from  the  angle  of  the  jaw  to  the  mastoid  process, 
behind  by  the  posterior  belly  of  the  digastric  muscle  and  the  stylohyoid  muscle, 
and  in  front  by  the  anterior  belly  of  the  digastric  muscle.  Its  floor  is  composed 
of  the  mylohyoid  and  hyoglossus  muscles. 

The  submental  triangle  is  bounded  on  either  side  by  the  anterior  belly  of 
one  digastric  muscle;  its  base  is  the  hyoid  bone  and  its  floor  is  the  mylohyoid 
muscle. 

The  posterior  triangle  is  bounded  in  front  by  the  posterior  border  of  the 
sternocleidomastoid  muscle,  behind  by  the  anterior  edge  of  the  trapezius 
muscle,  and  below  by  the  clavicle.  The  posterior  belly  of  the  omohyoid 
muscle  subdivides  it  into  two  smaller  spaces,  the  occipital  and  subclavian 
triangles. 

The  occipital  triangle  is  bounded  in  front  b\'  the  posterior  edge  of  the 
sternocleidomastoid  muscle,  behind  by  the  anterior  border  of  the  trapezius 
muscle,  and  below  by  the  posterior  belly  of  the  omohyoid  muscle. 

The  subclavian  triangle  is  bounded  above  by  the  posterior  belly  of  the 
omohyoid  muscle,  below  by  the  clavicle,  and  in  front  by  the  posterior  border 
of  the  sternocleidomastoid  muscle.  Its  floor  is  formed  by  the  first  rib  and 
the  first  serration  of  the  serratus  magnus  muscle. 

Common  Carotid  Artery.— The  common  carotid  was  tied  to  arrest 
bleeding  by  Abernethy  in  1798,  and  was  first  ligated  successfully  for  aneu- 
rysm by  Sir  Astley  Cooper  in  1806.  The  line  of  the  common  carotid  artery 
is  from  the  sternoclavicular  articulation  to  midway  between  the  angle  of  the 
jaw  and  the  mastoid  process,  the  head  being  turned  toward  the  opposite  side. 

Anatomy  (PI.  4,  Fig.  3). — The  right  common  carotid  arises  from  the 
innominate  opposite  the  sternoclavicular  joint;  the  left  common  carotid  arises 
from  the  arch  of  the  aorta.  In  the  neck  the  two  carotids  possess  identical 
relations.  The  common  carotid  runs  upward  and  outward  from  behind 
the  sternoclavicular  articulation  to  a  level  with  the  upper  border  of  the  thyroid 
cartilage,  at  which  point  it  divides  into  the  external  and  internal  carotid. 
The  common  carotid  is  contained  in  a  sheath  derived  from  the  cervical  fascia. 
This  sheaih  also  contains,  in  separate  compartments,  the  internal  jugular 
vein  on  the  outer  side  of  the  artery  and  the  pneumogastric  ner\-e  between 
the  vein  and  artery,  but  more  deeply  placed.  The  anterior  edge  of  the  sterno- 
cleidomastoid muscle  lies  over  the  artery  and  is  a  guide.  Low  in  the  neck 
the  common  carotid  is  deep,  being  covered  by  skin,  superficial  fascia,  platysma, 
deep  fascia,  and  the  sternocleidomastoid,  sternohyoid,  and  the  sternothyroid 
muscles.  Above  the  omohyoid  muscle  the  vessel  is  more  superficial,  being 
covered  by  the  skin,  superficial  fascia,  platysma,  deep  fascia,  and  the  anterior 
edge  of  the  sternocleidomastoid  muscle.  Upon  the  sheath  (occasionally  within 
it),  above  the  crossing  of  the  omohyoid  muscle,  lies  the  descendens  noni 
nerve — the  descending  branch  of  the  ninth  pair  of  Willis  (the  hypoglossal). 
This  nerve  is  a  valuable  guide  to  the  sheath  in  the  triangle  of  election. 


34^  Diseases  and   Injuries   of  the   Heart  and   Vessels 

The  sternomastoid  branch  of  the  superior  thyroid  artery  crosses  the  carotid 
artery  a  httle  below  its  bifurcation,  and  the  superior  thyroid  vein  also  crosses 
it  in  this  region;  the  middle  thyroid  vein  crosses  the  artery  near  its  middle, 
and  the  anterior  jugular  \ein  crosses  low  down.  The  common  carotid  rests 
upon  the  longus  colli  and  rectus  capitis  anticus  major  muscles,  the  sympa- 
thetic nerve  lying  between  the  last-named  muscle  and  the  vessel,  outside  the 
carotid  sheath.  The  recurrent  laryngeal  nerve  passes  behind  the  carotid 
below  the  omohyoid  muscle,  and  the  inferior  thyroid  artery  passes  behind 
the  carotid  just  above  the  omohyoid  muscle.  The  common  carotid  is  in 
relation  internally  with  the  trachea,  thyroid  gland,  larynx,  and  pharynx. 
To  the  outer  side  are  the  pneumogastric  nerve  (which  is  on  a  posterior  plane) 
and  the  internal  jugular  vein.  On  the  left  side,  low  down  in  the  neck,  the 
jugular  vein  often  lies  in  "front,  or  partly  in  front,  of  the  artery. 

Ligation  in  the  Triangle  of  Necessity. — In  this  operation  the  patient  is 
placed  supine,  with  the  shoulders  raised,  a  sand-pillow  under  the  neck,  and 
the  head  turned  to  the  opposite  side,  with  the  chin  raised.  The  operator 
stands  upon  the  side  operated  upon.  The  incision,  three  inches  long,  at 
a  slight  angle  to  the  arterial  hne,  runs  from  the  level  of  the  cricoid  cartilage 
downward  and  inward  toward  the  sternoclavicular  joint,  following  the  inner 
border  of  the  sternocleidomastoid  muscle.  The  surgeon  opens  the  deep 
fascia,  draws  the  sternocleidomastoid  outward,  retracts  the  sternohyoid  and 
sternothyroid  muscles  inward,  and  feels  for  the  carotid  tubercle  of  Chas- 
saignac.  This  tubercle  is  the  costal  process  of  the  sixth  cervical  vertebra, 
and  lies  directly  under  the  artery.  The  tubercle  is  found  about  the  point 
at  which  the  omohyoid  crosses  the  carotid.  When  the  tubercle  is  found  we 
know  the  situation  of  the  artery,  and  that  the  triangle  of  necessity  is  below, 
and  the  triangle  of  election  above,  the  tubercle.  The  operator  draws  the 
omohyoid  muscle  upward,  opens  the  sheath  of  the  artery  on  its  inner  side, 
clears  the  vessel,  and  passes  the  needle  from  without  inward  to  avoid  the 
internal  jugular  vein,  remembering  that  the  pneumogastric  nerve  is  in  the 
.same  sheath  as  the  arter\'  and  \ein,  posterior  and  external  to  the  artery. 
In  this  operation  the  inferior  thyroid  veins  are  much  in  the  way,  the  anterior 
jugular  vein  crosses  low  down,  and  on  the  left  side,  at  the  root  of  the  neck, 
the  internal  jugular  vein  may  be  in  front  of  the  carotid  artery.  If  the  incision 
is  not  sufficiently  wide,  partially  divide  the  sternocleidomastoid  or  the  sterno- 
hyoid and  thyroid  muscles.  In  the  triangle  of  necessity  the  descendens  noni 
ner\e  floes  not  ser\e  as  a   guide  to  the  sheath  of  the  \-essels.     (See  PI.  4, 

F'K-  4-) 

LigiilioH  in  'lir  'I'ridiiglc  oj  lilcrlioii  (Fig.  137). — The  position  of  the  ])atient 
for  this  operation  is  the  same  as  in  the  jjreceding  one.  An  incision,  three 
inches  in  length,  is  made  along  the  anterior  edge  of  the  sternocleidomastoid 
muscle  in  the  line  of  the  arter\-,  the  middle  of  this  incision  being  opposite  the 
cricoid  cartilage  (Fig.  137).  In  cutting  the  superficial  fa.scia,  the  surgeon  axoids 
the  external  jugular  vein,  the  course  of  which  should  be  outlined  before  making 
the  incision.  The  line  of  the  external  jugular  is  from  the  angle  of  the  jaw  to 
the  middle  oi  the  clavicle.  The  operator  opens  the  deej)  fascia,  retracts  the 
sternocleidoma.stoid  muscle  outward,  feels  for  the  (arolid  Uibcn  le,  draws 
the  omohvoid  muscle  downward,  finds  the  de.scendens  noni  nerve  upon  the 
sheath,  opens  the  sheath  at  its  inner  side,  and  pa.s.ses  the  needle  from  without 


Internal   Carotid   Alter}-  349 

inward.  This  incision  permits  ligation  of  either  the  superior  thyroid  or  the 
external,  internal,  or  common  carotid,  and  if  it  be  extended  up  a  little  there 
can  be  tied  through  it  the  lingual,  and  even  the  facial  and  occipital,  arteries. 
(See  PI.  4,  Fig.  4.) 

Results. — In  from  20  to  25  per  cent,  of  cases  after  ligation  of  the  common 
carotid  artery  there  is  cerebral  softening  or  some  other  intracranial  com- 
plication. Crile  states  that  of  the  cases  that  develop  cerebral  trouble,  one- 
half  die.     The  operative  mortality,  according  to  Crile,  is  only  3  per  cent. 

External  Carotid  Artery.— Burke  ligated  the  external  carotid  in 
1827  (Treves,  from  Chelius).  The  line  of  the  external  carotid  artery  is  the 
upper  portion  of  the  common  carotid  line. 

Anatomy  (PI.  4,  Fig.  3). — The  external  carotid  artery,  which  is  one  of 
the  terminal  branches  of  the  common  carotid,  arises  on  a  level  with  the  upper 
border  of  the  thyroid  cartilage  and  runs  to  the  level  of  the  neck  of  the  condyle 
of  the  lower  jaw.  .\t  its  point  of  origin  it  is  covered  only  by  skin,  platysma, 
and  fascia,  and  the  edge  of  the  sternomastoid,  but  as  it  ascends  it  passes  be- 
neath the  digastric  and  stylohyoid  muscles  and  into  the  parotid  gland.  The 
glossopharyngeal  nerve,  styloid  process,  and  stylopharyngeus  muscle  lie  be- 
tween the  external  and  internal  carotid  arteries.  The  hypoglossal  nerve 
crosses  the  vessel  just  below  the  digastric  muscle,  and  the  facial  and  lingual 
veins  cross  it  a  littk  below  the  nerve.  The  first  branch  is  the  superior  thyroid, 
which  arises  from  the  very  beginning  of  the  trunk.  The  lingual  arises  on  a 
level  with  the  greater  cornu  of  the  hyoid  bone.  The  facial  and  occipital  take 
origin  above  the  lingual.  Each  of  them  can  be  hgated  through  the  incision 
made  for  ligation  of   the  external  carotid. 

Operation, — Place  the  patient  in  the  same  position  as  for  ligation  of  the 
common  carotid.  The  point  of  election  is  between  the  superior  thyroid  and 
the  lingual  arteries.  Make  an  incision  three  inches  in  length  at  a  slight  angle 
to  the  arterial  line,  from  near  the  angle  of  the  jaw  to  opposite  the  middle  of 
the  thyroid  cartilage.  Cut  through  the  skin,  superficial  fascia,  platysma, 
and  deep  fascia,  and  retract  the  sternocleidomastoid  muscle  outward.  Watch 
for  the  digastric  muscle,  find  the  hypoglossal  nerve,  and  feel  for  the  greater 
cornu  of  the  hyoid  bone.  Open  the  sheath  a  little  below  the  hvoid  cornu  and 
pass  the  needle  from  without  inward.  Ligation  of  the  external  carotid  ha? 
been  neglected  because  hgation  of  the  common  carotid  is  easier. 

Results. — Crile  believes  the  operative  mortality  to  be  2  per  cent. 

Internal  Carotid  Arter>-.— The  internal  carotid  was  tied  by  Keith. 
of  Aberdeen,  in  1851  (.Ashhurst's  "International  Encvclopedia  of  Surgery"). 
The /me  of  the  internal  carotid  is  parallel  with  and  half  an  inch  external  to 
the  line  of  the  external  carotid. 

Anatomy  (PI.  4,  Fig.  3). — The  internal  carotid  arterv.  the  other  terminal 
branch  of  the  common  carotid,  arises  on  a  level  with  the  upper  border  of  the 
thyroid  cartilage  and  enters  the  carotid  canal.  The  first  inch  of  the  artery 
is  the  only  point  where  a  ligature  is  ever  applied,  tin's  ])oint  being  covered 
only  by  skin,  platysma,  fascia,  and  the  sternocleidomastoid  muscle;  higher  uj) 
it  is  more  deeply  placed.  It  rests  upon  the  vertebra'  and  the  rectus  capitis 
anticus  major  muscle.  The  internal  jugular  vein  is  in  the  same  sheath  and 
external  to  the  artery:  the  pneumogastric  is  in  the  same  sheath,  between  the 
artery  and  the  vein,  but  posterior  to  both.     The  superior  cervical  ganglion 


350  Diseases  and  Injuries  of  the   Heart  and  Vessels 

of  the  sympathetic  hes  behind  the  origin  of  the  internal  carotid,  and  between 
the  ganglion  and  the  artery  is  the  superior  laryngeal  nerve. 

Operation. — In  this  operation  the  position  of  the  patient  is  the  same  as 
for  hgation  of  the  external  carotid.  The  incision  is  of  the  same  length  and 
direction  as  that  for  ligation  of  the  external  carotid,  and  is  half  an  inch 
external.  The  sternocleidomastoid  muscle  is  drawn  outward,  the  external 
carotid  artery  is  found  and  drawn  inward,  the  internal  carotid  is  found  and 
cleared,  and  the  needle  is  passed  from  without  inward.  The  internal  carotid 
is  known  by  its  more  external  position  and  by  the  fact  that  it  gives  otT  no 
branches. 

Results. — There  is  the  same  danger  of  cerebral  complications  after  this 
operation  as  after  ligation  of  the  common  carotid.  The  operative  mortality 
is  probably  as  great. 

Superior  Thyroid  .Artery  (PL  4,  Fig.  3).— This  branches  off  from 
the  external  carotid  below  the  level  of  the  greater  cornu  of  the  hyoid  bone,  in 
the  triangle  of  election.  It  is  primarily  superficial,  runs  first  upward  and 
inward,  next  downward  and  forward,  passes  underneath  the  omohyoid, 
sternohyoid,  and  sternothyroid  muscles,  and  reaches  the  thyroid  gland. 

Ligation. — The  position  of  the  patient  and  of  the  surgeon  is  the  same  as 
for  ligation  of  the  carotid.  The  artery  may  be  reached  through  the  incision 
employed  for  ligation  of  the  external  carotid.  Gross  made  an  incision  be- 
ginning at  the  edge  of  the  hyoid  bone,  and  running  downward  and  outward 
to  the  sternomastoid  muscle.  The  skin  and  superficial  and  deep  fascia?  are 
divided,  and  the  artery  is  found  deeply  placed  in  the  triangle  of  election  be- 
tween the  carotid  sheath  and  the  thyroid  gland. 

Lingual  Artery. — Charles  Bell  ligated  the  first  part  of  the  lingual 
artery  in  1814.  The  operation  beneath  the  hyoglossus  muscle  was  devised 
by  Pirogoff  in  1836.     (See  Treves's  "Manual  of  Operative  Surgery.") 

Anatomy  (PI.  4,  Fig.  3). — The  lingual  artery  arises  from  the  external 
carotid  opposite  the  greater  cornu  of  the  hyoid  bone,  passes  beneath  the  di- 
gastric and  stylohyoid  muscles,  reaches  the  margin  of  the  hyoglossus  muscle, 
passes  under  that  muscle,  and  emerges  from  beneath  it  to  run  along  the  under 
surface  of  the  tongue.  The  place  of  election  for  ligation  is  where  the  artery 
is  beneath  the  hyoglossus  muscle.  Its  guide  is  the  hypoglossal  nerve,  which 
lies  upon  the  muscle,  but  at  a  slightly  higher  level  than  the  artery. 

Operation. — In  this  operation  the  patient  is  placed  recumbent  with  the 
shoulders  raised  and  the  face  turned  away  from  the  side  to  be  operated  upon. 
The  surgeon  stands  upon  the  affected  side.  A  curved  incision  is  made  from 
a  little  external  to  the  symphysis  of  the  lower  jaw,  downward  and  outward, 
to  just  above  the  greater  cornu  of  the  hyoid  bone,  and  upward  and  outward 
to  ju.st  in  front  of  the  facial  artery  at  the  lower  edge  of  the  lower  jaw.  The 
skin,  the  superficial  fascia  and  f)latysma,  and  the  deep  fascia  are  incised. 
The  submaxillary  gland  is  cleared  and  retracted  well  upward.  The  fascia 
below  the  gland  is  divided  by  a  transverse  incision.  The  posterior  edge  of 
the  mylohyoid  muscle  and  the  bellies  of  the  digastric  muscle  are  sought  for 
and  identified.  One  of  the  digastric  tendons  is  retracted  down  and  out 
(Treves).  The  hyoglossus  muscle  is  cleared  with  a  dissector;  the  hypo- 
glossal nerve  and  ranine  vein  are  found  and  drawn  a  little  upward.  The 
hyoglossus  muscle  is  divided  transversely  a  little  above  the  hyoid  bone  and 


Occipital  Artery- 


SSI 


below  the  level  of  the  hypoglossal  nerve.     The  artery  is  found  under  the 
muscle  and  the  needle  is  passed  from  above  downward. 

Facial  Artery. — Anatomy  (PL  4,  Fig.  3). — Arises  from  the  external 
carotid  a  little  above  the  lingual,  runs  upward  and  forward  beneath  the  body 
of  the  inferior  maxillary  bone,  passes  along  a  groove  in  the  posterior  and  upper 
surface  of  the  submaxillary  gland,  crosses  the  body  of  the  lower  jaw  at  the 
lower  anterior  edge  of  the  masseter  muscle,  and  passes  forward  and  upward 
to  the  angle  of  the  mouth  and  side  of  the  nose. 

Ligation  (PI.  4,  Fig.  4). — The  facial  artery  is  rarely  ligated  in  the  cervical 
portion,  but  may  be  reached 
through  the  incision  em- 
ployed for  ligation  of  the  ex- 
ternal carotid.  The  vessel 
may  be  tied  before  it  crosses 
the  submaxillary  gland,  the 
stylohyoid  and  digastric  mus- 
cles being  drawn  aside  The 
vessel  is  reached  in  the  facial 
portion  of  its  course  by  a 
one-inch  cut  at  the  anterior 
edge  of  the  masseter  muscle 
(Fig.  137).  Branches  of  the 
facial  nerve  are  pushed  aside. 
The  needle  is  passed  from 
behind  forward  to  avoid  the 
vein  (Jacobson). 

Temporal     Artery.— 

The  line  of  the  temporal 
artery  passes  "upward  over 
the  root  of  the  zygoma,  mid- 
way between  the  condyle  of 
the  jaw  and  the  tragus" 
(Jacobson). 

Anatomy.  —  The      tem- 
poral artery  arises  from  the  external  carotid  behind  the  condyle  of  the  jaw 
and  in  the  parotid  gland,  passes  over  the  zygoma,  and  divides  into  two  termi- 
nal branches. 

Ligation. — The  patient  is  placed  recumbent  and  the  head  is  turned  to 
the  opposite  side.  An  incision  an  inch  in  length  is  made  (Fig.  137),  the 
superficial  structures  and  dense  fascia  are  divided,  the  vein  is  retracted  back- 
ward, and  the  needle  is  passed  from  behind  forward. 

Occipital  Artery. — Takes  origin  from  the  posterior  surface  of  the 
external  carotid,  below  the  digastric  muscle  and  opposite  the  point  of  origin 
of  the  facial  artery.  It  ascends  beneath  the  digastric  and  stylohyoid  muscles 
and  parotid  gland;  the  hypoglossal  nerve  hooks  around  it  from  behind  for- 
ward. It  crosses  the  internal  carotid  artery,  the  internal  iugular  vein,  the 
pneumogastric  and  spinal  accessory  nerves;  passes  between  the  mastoid  process 
of  the  temporal  bone  and  the  atlas;  grooves  the  temporal  bones;  penetrates 
the  trapezius  muscle,  and  ascends  over  the  occiput. 


Fig.  137. — Position  of  the  lines  of  incision  of  temporal, 
facial,  lingual,  common  carotid  (above  the  omohyoid),  sub- 
clavian, axillary  (first  portion),  and  internal  mammary  arte- 
ries (MacCormac). 


352  Diseases  and   Injuries  of  the   Heart  and  Vessels 

Ligation. — This  vessel  can  be  ligated  near  its  origin  through  the  same 
incision  as  is  employed  to  reach  the  external  carotid.  The  hypoglossal  nerve 
is  avoided.  To  tie  back  of  the  mastoid  process,  place  the  patient  in  the  same 
position  as  for  ligation  of  the  carotid.  Carry  an  incision  from  the  tip  of  the 
mastoid  upward  and  backward,  reaching  a  point  midway  between  the  mastoid 
and  the  occipital  protuberance  (Jacobson).  Cut  the  skin,  the  fascia,  the 
sternocleidomastoid,  the  splenius  capitis,  and  possibly  a  portion  of  the  trachelo- 
mastoid  muscles.  Bring  the  head  toward  the  operator  in  order  to  relax  the 
structures,  retract  the  edges  of  the  wound,  and  clear  the  artery  where  it  lies 
between  the  mastoid  process  and  the  transverse  process  of  the  atlas  (Jacob- 
son).  An  electric  forehead  light  is  of  great  assistance  in  finding  the  vessel. 
Pass  the  needle  away  from  the  \'ein  or  veins  (there  are  often  several). 

Dorsalis  Pedis  Artery. — The  line  of  the  dorsalis  pedis  artery  is 
from  the  middle  of  the  front  of  the  ankle-joint  to  the  middle  of  the  base  of  the 
first  interosseous  space. 

Anatomy  (PI.  5,  Fig.  i). — The  dorsalis  pedis  is  a  continuation  of  the 
anterior  tibial  artery,  and  it  runs  from  the  bend  of  the  ankle  to  the  proximal 
extremitv  of  the  first  interosseous  space,  where  it  divides  into  the  dorsalis 
hallucis  and  the  communicating  arteries.  The  artery  rests,  from  above  down- 
ward, upon  the  astragalus,  scaphoid,  and  internal  cuneiform  bones,  and  at 
its  point  of  bifurcation  lies  between  the  heads  of  the  first  dorsal  interosseous 
muscle.  It  may  lie  in  some  persons  a  little  external  to  this  course.  It  is  held 
upon  the  bones  by  a  distinct  layer  derived  from  the  deep  fascia.  This  artery 
is  covered  by  skin,  by  superficial  and  deep  fascia,  and  by  the  annular  ligament 
above,  and  is  sometimes  partly  overlaid  by  the  extensor  proprius  pollicis 
muscle,  and  is  crossed,  just  before  its  bifurcation,  by  the  innermost  tendon 
of  the  extensor  brevis  muscle.  The  inner  tendon  of  the  extensor  communis 
digitorum  is  to  the  outer  side  of  the  vessel ;  the  tendon  of  the  extensor  proprius 
pollicis  is  to  the  inner  side,  and  is  a  guide.  The  artery  is  hgated  in  the  dorsal 
triangle  of  the  foot — a  space  which  is  bounded  above  by  the  lower  edge  of  the 
annular  ligament,  externally  by  the  inner  tendon  of  the  extensor  brevis,  and 
internally  by  the  tendon  of  the  extensor  proprius  pollicis.  The  artery  has 
venai  comites;  the  anterior  tibial  nerve  hes,  as  a  rule,  to  its  inner  side,  but  may 
be  found  upon  the  artery  or  to  its  outer  side,  and  the  inner  division  of  the 
musculocutaneous  nerve  is  external  to  the  vessel  in  the  superficial  parts. 

Operation  (PI.  5,  Fig.  2). — In  this  operation  the  patient  is  placed  supine 
with  the  leg  and  foot  extended.  Heath  flexes  the  leg  jxirtly  and  rests  the  sole 
of  the  foot  directly  upon  the  table.  The  surgeon  stands  below  the  extremity, 
and  cuts  from  above  downward.  Make  an  incision  two  inches  in  length 
along  the  arterial  line,  beginning  opposite  the  lower  edge  of  the  annular  liga- 
ment and  running  along  b}'  the  tendon  of  the  extensor  proprius  pollicis;  cut 
through  the  skin  and  superficial  and  deep  fascia;  have  the  toes  extended;  re- 
tract the  tendon  of  the  extensor  ])roj)rius  pollicis  inward,  and  the  tendon  of 
the  extensor  communis  digitorum  outward;  clear  the  artery,  find  the  nerve, 
try  to  se})arate  the  ven;e  comites,  and  pa.ss  the  needle  from  the  nerve. 

Anterior  Tibial  Artery. —  To  locate  the  line  of  the  anterior  tibial 
mark  a  point  midway  between  the  head  of  the  fibula  and  the  tuberosil}-  of  the 
tibia,  drop  one  inch,  and  firaw  a  line  from  the  second  point  to  the  middle  of 
the  front  of  the  ankle-joint. 


LIGATIONS. 


Plate  5. 


15    E 


Anterior  Tibial  Arteiy  353 

Anatomy. — The  anterior  tibial  artery  is  one  of  the  terminal  branches 
of  the  popliteal.  It  arises  opposite  the  lower  border  of  the  popliteus  muscle, 
passes  forward  between  the  two  heads  of  the  posterior  tibial  muscle,  comes 
to  the  front  of  the  leg  through  an  opening  in  the  interosseous  membrane,  and 
runs  down  to  the  middle  of  the  front  of  the  ankle-joint.  In  the  upper  two- 
thirds  of  its  course  it  rests  upon  the  interosseous  membrane,  to  which  it  is 
fastened  by  firm  fascia;  in  the  lower  third  it  hes  first  upon  the  front  of  the 
tibia  and  then  upon  the  anterior  ligament  of  the  ankle-joint.  For  its  upper 
two-thirds  the  artery  has  the  tibialis  anticus  muscle  just  external  to  it;  at  the 
junction  of  the  middle  and  lower  thirds  the  extensor  proprius  pollicis  comes 
from  the  outside  and  lies  either  upon  the  artery  or  to  its  inner  side  for  the 
rest  of  its  course.  Externally  in  its  upper  third  is  the  extensor  communis 
digitorum;  in  the  middle  third  is  the  extensor  proprius  pollicis;  in  the  lower 
third,  the  proprius  pollicis  having  crossed  to  the  inner  side,  the  extensor 
communis  digitorum  again  becomes  the  outer  boundary.  The  artery  is 
covered  by  skin  and  by  superficial  and  deep  fascia.  In  its  upper  third  it  is 
deeply  placed  between  the  muscles;  in  its  middle  third  it  is  less  overlaid  by 
muscle;  in  its  lower  third  it  is  superficial  except  where  it  is  crossed  by  the 
extensor  proprius  and  where  it  is  covered  by  the  annular  ligament.  The 
artery  has  vense  comites.  In  the  lower  three-fourths  of  its  course  it  is  accom- 
panied by  the  anterior  tibial  nerve,  which  in  its  course  in  the  upper  third  of 
the  leg  is  external  to  the  artery;  in  the  middle  third  it  is  external  and  a  little 
in  front  of  the  artery ;  and  in  the  lower  third  it  is  external  to  or  upon  the  arterv 
(PI.  4,  Fig.  5). 

Operations. — The  hgations  of  the  anterior  tibial  (PI.  4,  Fig.  6)  are  (i)  of 
the  lower  third;  (2)  of  the  middle  third;  and  (3)  of  the  upper  third.  In  all 
these  Hgations  the  patient  is  placed  recumbent  with  the  leg  extended,  and  the 
surgeon  stands  to  the  outer  side  of  the  extremity,  cutting  from  above  down- 
ward on  the  right  side  and  from  below  upward  on  the  left  side. 

Ligation  oj  the  Lower  Third. — Make  an  incision  three  inches  long  in  the 
line  of  the  artery  and  over  the  annular  ligament.  This  incision  is  external 
to  the  tibialis  anticus  muscle  and  half  an  inch  from  the  outer  border  of  the 
tibia  (Barker).  Divide  the  skin  and  fascia,  retract  the  tendon  of  the  tibialis 
anticus  inward,  and  the  tendon  of  the  extensor  proprius  pollicis  outward,  along 
with  the  tendons  of  the  extensor  communis.  Flex  the  ankle-joint  to  relax 
the  tendons,  and  clear  the  artery.  Draw  the  nerve  external  and  pass  the 
ligature  from  without  inward.  In  order  to  recognize  the  muscles  in  this  as 
in  other  ligations,  rely  largely  upon  the  finger  while  the  muscles  are  being 
moved. 

Ligation  of  the  Middle  Third. — In  this  operation  the  procedure  is  similar 
to  the  above.  Remember  that  the  nerve  lies  in  front  of  the  vessel  and  that 
the  extensor  proprius  polhcis  muscle  is  external.  The  nerve  is  retracted 
outward  and  the  needle  is  passed  from  the  nerve.  A  good  rule  for  detecting 
the  artery  is  to  find  the  outer  edge  of  the  tibia  and  by  this  locate  the  inter- 
osseous membrane,  and  then,  by  passing  out  along  this  membrane,  discover 
the  artery. 

Ligation  of  the  Upper  Third. — Make  an  incision  three  inches  long  in  the 
arterial  line.  On  opening  the  deep  fascia,  do  not  rely  on  the  eye  for  finding 
the  muscular  interspace,  as  often  the  latter  cannot  be  seen,  and  neither  a  white 
23 


354  Diseases  and  Injuries  of  the   Heart  and   Vessels 

nor  a  yellow  line  is  reliable.  Place  the  index-finger  deep  in  the  wound  and 
have  the  tibiahs  anticus  and  extensor  communis  digitorum  muscles  successively 
rendered  tense  by  an  assistant.  In  opening  the  interspace  use  the  handle 
of  the  knife.  Relax  the  muscles,  retract  the  tibialis  anticus  inward  and  draw 
'the  extensor  communis  digitorum  outward.  Find  the  interosseous  membrane 
where  it  is  attached  to  the  edge  of  the  tibia,  and  the  artery  will  be  found  upon 
this  membrane,  between  the  tibia  and  the  nerve.  Clear  the  vessel  and  pass 
the  ligature  from  without  inward  to  avoid  the  nerve. 

Posterior  Tibial  Artery.— The  line  of  the  posterior  tibial  is  from 
the  middle  of  the  popliteal  space  to  a  point  midway  between  the  tip  of  the 
inner  malleolus  and  the  point  of  the  heel  (PI.  5,  Figs.  5,  6). 

Anatomy. — The  posterior  tibial  is  the  larger  of  the  two  terminal  branches 
of  the  popliteal.  It  arises  opposite  the  lower  border  of  the  popliteus  muscle, 
passes  down  between  the  deep  and  superficial  flexor  muscles  to  midway 
between  the  tip  of  the  malleolus  and  the  point  of  the  heel,  and  divides  into  the 
external  and  internal  plantar  vessels.  In  the  upper  third  of  its  course  it  is 
very  deeply  placed  midway  between  the  tibia  and  fibula;  in  its  middle  third 
it  is  less  deep,  having  passed  inward;  and  in  its  lower  third  it  is  superficial. 
At  the  ankle  the  artery  is  beneath  the  annular  ligament.  From  above  down- 
ward the  posterior  tibial  artery  rests  upon  the  posterior  tibial  muscle,  the 
flexor  longus  digitorum  muscle,  the  posterior  surface  of  the  tibia,  and  the 
internal  lateral  hgament  of  the  ankle-joint.  For  the  first  inch  or  two  of  the 
course  of  the  artery  the  posterior  tibial  nerve  is  to  the  inner  side;  the  nerve 
then  crosses  to  the  outer  side,  and  remains  in  that  relative  position  throughout 
the  rest  of  the  course  of  the  artery.  When  the  knee  is  partly  flexed  and  the 
leg  is  laid  upon  its  outer  surface  the  artery  is  between  the  operator  and  the 
nerve,  and  the  nerve  is  between  the  artery  and  the  table.  Back  of  the  malleo- 
lus, in  the  first  compartment,  lies  the  posterior  tibial  muscle;  in  the  next  com- 
partment is  the  flexor  longus  digitorum  muscle;  in  the  next  compartment 
are  the  artery  and  nerve;  and  in  the  most  posterior  is  the  flexor  longus  pollicis 
muscle. 

Operations, — Ligation  Back  oj  the  Malleolus. — In  this  operation  the 
patient  is  placed  recumbent  with  the  thigh  abducted  and  the  leg  flexed  and 
resting  upon  its  outer  .surface.  The  surgeon  .stands  to  the  outer  side.  Make 
a  two-inch  semilunar  incision  corresponding  in  its  curve  to  the  malleolus  and 
half  an  inch  posterior  to  its  margin  (Fig.  140).  Cut  down  to  the  annular  liga- 
ment, incise  the  ligament,  and  find  the  artery  and  vena;  comites.  Clear  the 
vessel  and  pass  the  needle  from  behind  forward  (to  avoid  the  nerve,  which  is 
here  posterior  and  external).  Do  not  make  the  preliminary  incision  nearer  the 
malleolus  than  half  an  inch,  as  the  sheath  of  the  tibialis  posticus  muscle  will 
then  surely  be  opened.  In  closing  the  wound,  suture  the  ligament  by  buried 
sutures  of  catgut  before  closing  the  superficial  parts  (PI.  5,  Fig.  6). 

Ligation  in  the  Middle  oj  the  Leg. — In  this  operation  the  patient  is  placed 
in  the  same  position  as  for  the  ligation  back  of  the  malleolus.  Feel  for  the 
inner  ?jorder  of  the  tibia,  and  make  an  incision  four  inches  long  one  inch 
behind  the  osseous  border,  parallel  with  it,  and  extending  through  skin  and 
superficial  and  deef)  fascia  (Fig.  140).  Draw  the  gastrocnemius  muscle  out- 
ward. Incise  the  soleus  muscle,  but  not  the  fascia  beneath  the  soleus;  cut  this 
fascia,  after  rlropj>ing  the  handle  of  the  knife  so  that  the  blade   is  at  right 


Popliteal  Artery 


355 


angles  with  the  plane  of  the  tibia.  Clear  the  artery;  pass  the  needle  from 
without  inward  (PI.  5,  Fig.  6). 

The  popliteal  artery  is  almost  never  ligated  in  continuity.  It  can  be 
tied  at  the  upper  portion  of  the  popliteal  space,  at  the  lower  portion  of  the 
popliteal  space,  or  at  the  inner  side  of  the  thigh. 

Anatomy  (Fig.  138). — The  popliteal  artery  is  the  continuation  of  the 
femoral,  and  runs  from  the  opening  in  the  adductor  magnus  muscle  to  the 
lower  margin  of  the  popliteus  muscle.  This  vessel  runs  downward  and  out- 
ward behind  the  knee-joint  and  in  the  popliteal  space.  The  ham,  or  popliteal 
space,  is  a  lozenge-shaped  space,  which  above  the  joint  is  bounded  on  the 
outer  side  by  the  biceps  muscle,  and  on  the  inner  side  by  the  semitendinosus, 
semimembranosus,  gracilis,  and  sartorius  muscles,  while  below  the  joint  it 
is  bounded  externally  by  the  plantaris  and  outer  head  of  the  gastrocnemius 


Fiji;.  138. — Atial(jiiiy  of  popliteal  artery  (Bernard 
and  Huette). 


P^'g-  '39- — Ligation  of   popliteal    artery  in    its 
upper  third  (Bernard  and  Huette). 


muscles,  and  internally  by  the  inner  head  of  the  gastrocnemius  muscle.  The 
tloor  of  this  space  is  formed  by  the  surface  of  the  femur,  the  posterior  ligament 
of  the  knee-ioint,  the  end  of  the  tibia,  and  the  popliteus  fascia.  The  internal 
popliteal  nerve  passes  down  the  middle  of  the  popliteal  space;  it  is  superficial 
to  the  vessels  in  the  upper  half  of  the  space,  and  is  e.xternal  to  them;  it  is  inter- 
nal to  the  vessels  in  the  lower  half  of  the  space.  The  external  popliteal 
nerve  is  in  the  outer  side  of  the  space.  The  popliteal  vein  is  between  the 
nerve  and  the  artery.  Above  the  knee-joint  it  is  to  the  outer  side  of  the 
artery,  but  below  the  knee-joint  it  is  to  the  inner  side.  The  artery  lies  deeply 
in  the  space. 

Ligation  in  Upper  Third. — Place  the  patient  prone.  The  surgeon  stands 
to  the  outer  side  of  the  limb  and  makes  a  vertical  incision  three  inches  in  length 
along  the  outer  margin  of  the  semimembranosus  muscle,  exposes  the  popliteal 
nerve,  retracts  the  muscle  inward  and  the  nerve  outward,  exposes  the  artery, 


356  Diseases  and   Injuries  of  the   Heart  and  Vessels 

separates  it  from  the  other  structures,  and  passes  the  needle  from  without 
inward  (Fig.  139). 

Ligation  in  Lower  Third. — Make  a  three-inch  vertical  incision  between 
the  heads  of  the  gastrocnemius  muscle.  Avoid  the  external  saphenous  vein 
and  nerve,  and  retract  them  with  the  popliteal  nerve.  Separate  the  artery 
from  the  vein  and  pass  the  needle  from  within  outward. 

Femoral  Artery. — The  line  of  the  femoral  artery  is  from  midway 
between  the  anterior  superior  spine  of  the  ihum  and  the  symphysis  pubis  to 
the  adductor  tubercle  on  the  inner  condyle  of  the  femur,  the  thigh  being 
abducted  and  resting  upon  its  outer  surface  (PI.  5,  Fig.  3). 

Anatomy. — The  femoral  artery  is  the  continuation  of  the  external  iliac 
trunk;  it  extends  from  the  lower  border  of  Poupart's  ligament  to  the  opening 
in  the  adductor  magnus  muscle,  and  hence  occupies  the  upper  two-thirds  of 
the  thigh.  The  artery  for  its  first  five  inches  is  superficial,  lying  in  Scarpa's 
triangle,  a  space  which  is  bounded  externally  by  the  sartorius  muscle  and 
internally  by  the  adductor  longus,  its  base  being  Poupart's  ligament  and  its 
floor  being  composed  of  the  psoas,  iliacus,  pectineus,  and  adductor  longus 
muscles,  and  often  the  adductor  brevis.  The  artery  enters  the  triangle  as 
the  common  femoral,  but  after  a  two-inch  course  it  divides  into  the  profunda 
(which  passes  deeply)  and  the  superficial  femoral.  The  latter  vessel  is  the 
one  alluded  to  in  this  section. 

At  the  base  of  Scarpa's  triangle  the  vein  is  internal,  the  artery  is  between, 
and  the  nerve  is  external  (v.  a.  n.).  At  the  apex  of  the  triangle  the  vein  is 
internal  and  a  little  posterior.  At  the  apex  of  the  triangle  the  superficial 
femoral  passes  under  the  sartorius  muscle  and  enters  into  Hunter's  canal, 
which  occupies  the  middle  third  of  the  thigh  and  which  terminates  at  an 
opening  in  the  adductor  magnus  muscle.  Hunter's  canal  is  bounded  ex- 
ternally by  the  vastus  internus  muscle,  internally  by  the  adductors  longus 
and  magnus,  and  its  roof  is  fascia  which  stretches  from  the  adductor  longus 
to  the  vastus  internus.  In  Hunter's  canal  the  vein  is  behind  the  artery  in  the 
upper  part,  but  external  to  it  in  the  lower  part,  and  is  firmly  attached  to  the 
artery.  There  may  be  two  veins.  Inside  Hunter's  canal,  but  outside  the 
femoral  sheath,  is  the  long  saphenous  nerve,  which  crosses  the  artery  from 
without  inward. 

A  way  to  remember  the  relation  of  the  femoral  vein  to  the  femoral  artery 
is  to  recall  the  fact  that  the  relation  of  the  vein  to  the  artery  is  always  con- 
trary to  the  relation  of  the  sartorius  muscle  to  the  artery:  when  the  sartorius 
muscle  is  external  to  the  artery,  the  vein  is  internal,  as  at  the  base  of  Scarpa's 
triangle;  when  the  sartorius  muscle  is  crossing  in  front  toward  the  inside  of 
the  artery,  the  vein  is  passing  at  the  back  to  the  outside,  as  at  the  apex  of 
Scarpa's  triangle;  when  the  muscle  is  over  the  artery,  the  vein  is  back  of  it, 
as  in  the  upper  third  of  Hunter's  canal;  and  when  the  muscle  is  to  the  inside 
of  the  artery,  the  vein  is  to  the  outside,  as  in  the  lower  two-thirds  of  Hunter's 
canal.  In  a  ligation  at  the  apex  of  Scarpa's  triangle  the  inner  edge  of  the 
sartorius  is  the  guide.  In  a  ligation  in  Hunter's  canal  the  long  saphenous 
nerve  is  the  guide. 

Operations. — Ligalion  oj  the  Superficial  Femoral  at  the  Apex  oj  Scarpa'' s 
Triangle. — In  this  operation  the  position  of  the  patient  is  supine  with  the 
thigh  and  leg  partly  flexed,  and  the  thigh  abducted,  everted,  and  rested  upon 


Femoral  Arteiy 


357 


its  outer  surface  on  a  pillow.  The  operator  stands  to  the  outer  side  of  the 
extremity.  From  a  point  corresponding  to  the  middle  of  Scarpa's  triangle, 
and  two  and  a  half  inches  below  Poupart's  ligament,  make  a  three-inch  inci- 
sion in  the  arterial  line  (Fig.  140).  Cut  the  skin  and  superficial  fascia.  The 
saphenous  vein  will  not  be  seen  unless  the  incision  is  internal  to  the  arterial 
line;  if  this  vein  is  seen,  draw  it  inward.  Open  the  fascia  lata,  find  the  inner 
border  of  the  sartorius  muscle,  and  draw  it  outward.  The  fibers  of  this 
muscle  run  downward  and  inward,  thus  distinguishing  it  from  the  adductor 
Jongus,  whose  fibers  run  downward  and  outward.  Open  the  common  sheath 
for  the  artery  and  vein,  and  then  incise  the  individual  arterial  sheath.  Clear 
the  artery  and  pass  the  ligature  from  within  outward  (PI.  5,  Fig.  4). 

Ligation  oj  the  Superficial  Femoral  in  Hunter's  Canal. — This  operation 
was  first  performed  for  aneurysm  by  John  Hunter  in  1785.     In  this  operation 


Fig.  140. — The  lines  indicate  the  incision  to  he  made  for  the  ligature  of  the  common  femoral,  of 
the  femoral  in  Scarpa's  triangle  and  in  Hunter's  canal,  and  of  the  posterior  tibial  in  the  calf  and 
hehiiid  the  malleolus  (MacCormac). 


the  position  of  the  patient  is  the  same  as  in  the  ligation  at  the  ape.x  of  Scarpa's 
triangle.  Make  a  three-inch  incision  in  the  middle  third  of  the  thigh, 
parallel  with  the  arterial  line  and  half  an  inch  internal  to  it  (Barker) 
(Fig.  140).  Incise  the  skin  and  superficial  fascia,  look  out  for  the  internal 
saphenous  vein,  open  the  fascia  lata,  find  the  sartorius  muscle,  and  retract  it 
inward,  thus  e.xposing  the  roof  of  Hunter's  canal,  which  is  to  be  opened  for  an 
inch  or  more.  Within  the  canal  is  seen  the  long  saphenous  nerve,  usually 
upon  the  sheath.  Open  the  sheath  of  the  artery,  clear  the  vessel,  and  pass  the 
needle  from  without  inward. 

Results. — The  favorite  operation  at  the  present  time  for  popliteal  aneu- 
rysm is  ligation  at  the  apex  of  Scarpa's  triangle.  It  is  a  very  successful  pro- 
cedure, I  have  performed  it  twice  with  success  and  have  assisted  other 
operators  in  :;  successful  cases.  Syme  successfully  ligated  the  femoral  about 
its  middle  twenty-three  consecutive  times,  and  in  Guy's  Hospital  the  same 


35^  Diseases  and  Injuries  of  the  Heart  and  Vessels 

operation  was  done,  twenty-four  times  with  i  death  ("  Practice  of  Surgery," 
by  Thomas  D.  Bryant). 

Iliac  Arteries. — The  line  of  the  common  and  external  ihac  arteries 
is  from  a  point  half  an  inch  below  and  half  an  inch  to  the  left  of  the  umbilicus 
to  midway  between  the  anterior  superior  spine  of  the  ihum  and  the  pubic 
symphysis.  The  upper  third  of  this  line  represents  the  common  iliac,  and 
the  lower  two-th  rds  the  external  iliac  (PI.  2,  Fig.  4). 

Anatomy. — The  common  iliac  arteries  arise  from  the  aorta  opposite  the 
left  side  and  lower  border  of  the  fourth  lumbar  vertebra,  and  extend  to  the 
upper  margin  of  the  right  and  left  sacro-iliac  joints,  where  they  each  bifurcate 
into  an  external  and  an  internal  iliac.  The  common  ihac  arteries  lie  upon 
the  fifth  lumbar  vertebra,  are  covered  with  peritoneum,  and  are  crossed  by 
the  ureters.  In  women  the  ovarian  arteries  cross  the  common  iliacs.  Each 
common  iliac  vein  lies  to  the  right  side  of  its  associated  artery.  The  right 
common  iliac  artery  has  in  front  of  it,  besides  the  peritoneum  and  ureter  (in 
women  also  the  ovarian  artery),  the  ileum,  branches  of  the  superior  mesenteric 
artery,  and  branches  of  the  sympathetic  nerve.  The  left  common  iliac  artery 
has  in  front  of  it,  in  addition  to  structures  common  to  both  sides  (ureter, 
ovarian  artery,  sympathetic  branches),  branches  of  the  inferior  mesenteric 
artery  and  the  sigmoid  flexure  with  its  mesocolon.  The  internal  iliac  artery 
runs  from  the  sacro-iliac  joint  to  the  upper  margin  of  the  great  sacrosciatic 
foramen.  It  is  very  rarely  ligated  (only  for  gluteal  aneurysm,  for  uncontrol- 
lable hemorrhage  from  the  gluteal  or  sciatic  arteries,  or  to  produce  atrophy 
of  the  prostate  gland).  The  external  ihac  artery  runs  from  the  sacro-iliac 
joint  along  the  pelvic  brim,  upon  the  inner  edge  of  the  psoas  muscle,  to 
Poupart's  ligament.  The  external  iliac  vein  is  internal  to  the  artery.  On 
the  right  side,  high  up,  it  passes  behind  the  artery.  The  external  iliac  artery 
has  in  front  of  it  peritoneum  and  subserous  tissue  (Abernethy's  fascia).  The 
ileum  crosses  the  right,  and  the  sigmoid  flexure  crosses  the  left,  external  iliac 
artery.  The  genital  branch  of  the  genitocrural  nerve  crosses  the  artery  low 
down,  and  the  circumflex  iliac  vein  crosses  it  just  before  it  terminates  in  the 
femoral.  The  spermatic  vessels  and  the  vas  deferens  in  the  male,  and  the 
ovarian  vessels  in  the  female,  lie  upon  the  artery  near  its  termination.  Some- 
times the  ureter  crosses  the  vessel  near  its  point  of  origin. 

Ligation  of  the  Iliac  Arteries  after  Abdominal  Section. — The  best  method 
for  ligating  the  common,  the  external,  or  the  internal  ihac  is  by  abdominal 
section.  The  patient  is  placed  in  the  Trendelenburg  position.  The  abdomen 
is  opened  in  the  midline  below  the  umbilicus  or  in  the  semilunar  line  of  the 
diseased  side.  The  intestines  are  lifted  toward  the  diaphragm,  and  are  held 
up  by  gauze  pads.  The  edges  of  the  incision  are  retracted.  The  vessel  to 
be  ticfi  is  located  and  the  point  for  ligation  is  selected.  The  posterior  layer 
of  the  peritoneum  is  ()j)ened  over  the  selected  point,  the  vessel  is  cleared,  and 
the  thrcafled  Dupuytren's  aneurysm  needle  is  passed  in  a  direction  away 
from  the  vein.  In  ligating  either  common  iliac,  pass  the  needle  from  right  to 
left.  In  ligating  the  external  iliac,  pass  the  ligature  from  within  outward. 
It  is  not  nectary  to  suture  the  posterior  layer  of  peritoneum.  The  abdo- 
men is  closed  without  a  drain.  In  these  oj)erations  be  sure  to  push  the  ureter 
out  of  the  way.  This  method  of  o[)erating  is  indorsed  by  Dennis,  Hearn, 
Marmaduke  Shield,  Mitchell  Banks,  and  others  who  have  employed  it. 


Iliac  Arteries  359 

Results:  Bryant  ("Operative  Surgery")  alludes  to  5  reported  cases  of 
transperitoneal  ligation  of  the  common  iliac  artery  with  i  death. 

Ligation  oj  the  Common  Iliac  Artery  by  the  Extraperitoneal  Method. — The 
common  iliac  artery  was  tied  unsuccessfully  by  Dr.  Wm.  Gibson  in  181 2.  It 
was  first  successfully  ligated  by  Valentine  Mott  in  1827.  The  patient  is  placed 
recumbent  or  in  the  Trendelenburg  position.  The  body  is  then  turned  a  little 
to  the  opposite  side  and  the  thighs  are  partly  flexed.  Bryant  says  there  are 
two  linear  guides  for  this  artery.  Crampton's  hne  is  drawn  from  "  the  apex 
of  the  cartilage  of  the  last  rib  downward  and  a  little  forward  nearly  to  the 
crest  of  the  ilium,  then  carried  forward  parallel  with  it  to  a  little  below  the 
anterior  superior  spine"  ("Operative  Surgery,"  by  Joseph  D.  Bryant). 
McKees'  line  is  "  drawn  from  the  tip  of  the  cartilage  of  the  eleventh  rib  to  a 
point  an  inch  and  a  half  within  the  anterior  superior  spine,  then  curved  down- 
ward, forward,  and  inward,  and  terminating  abruptly  above  the  internal 
abdominal  ring"  ("Operative  Surgery,"  by  Joseph  D.  Bryant). 

The  incision  can  be  begun  just  external  to  the  internal  abdominal  ring 
,and  be  curved  upward  and  outward  as  in  ligation  of  the  external  iliac,  but 
Crampton's  incision  gives  more  room.  The  superficial  tissues  are  divided 
down  to  the  transversalis  fascia,  this  structure  is  nicked  and  divided,  and  the 
exposed  and  unopened  peritoneum  is  rolled  upward  and  inward.  The 
muscular  guide  is  the  inner  border  of  the  psoas  magnus  muscle.  By  its  side 
an  artery  is  felt.  If  the  sacrovertebral  prominence  is  above  the  vessel  touched, 
the  artery  is  the  external  iliac;  otherwise  it  is  the  common  iliac.  If  the  ex- 
ternal iliac  is  the  vessel  first  exposed,  follow  it  up  to  find  the  common  trunk. 
When  the  common  iliac  is  found,  separate  the  fatty  tissue  about  it  and  pass 
the  ligature  from  the  right  toward  the  left  in  order  to  avoid  the  associated 
vein. 

Results:  Jos.  D.  Bryant  tells  us  that  this  vessel  has  been  ligated  by  the 
extraperitoneal  method  sixty-nine  times  with  only  16  recoveries,  but  it  is  to 
be  remembered  that  many  of  these  operations  were  in  preantiseptic  days. 

Ligation  oj  the  Internal  Iliac  Artery. — This  operation  was  first  performed 
by  Stevens,  of  Vera  Cruz,  in  1812  ("Practice  of  Surgery,"  by  Thomas  Bry- 
ant). The  incision  and  the  method  of  exposing  the  vessel  are  identical  with 
like  steps  in  the  ligation  of  the  common  iliac. 

Results:  Of  26  ligations  of  this  vessel  recorded,  18  were  fatal,  but  only 
a  few  of  the  cases  were  done  antiseptically  (Joseph  D.  Bryant's  "  Operative 
Surgery"). 

Ligation  oj  the  External  Iliac  by  Abernethy's  Extraperitoneal  Method  (PI. 
2,  Fig.  4). — The  external  iliac  artery  was  first  ligated  by  Abernethy  in  1796. 
The  operation  failed,  but  he  did  the  first  successful  operation  in  1806.  The 
patient  is  placed  recumbent  with  the  thighs  extended  during  the  first  incisions; 
but  in  the  later  stages  of  the  operation  the  thighs  are  flexed  a  little,  to  relax 
the  abdominal  structures.  The  operator  stands  to  the  outer  side.  The 
surgeon  will  find  the  artery  by  the  side  of  the  psoas  muscle.  Mark  a  point 
one  inch  above  and  one  inch  external  to  the  middle  of  Poupart's  ligament, 
and  another  point  one  inch  above  and  one  inch  internal  to  the  anterior  superior 
iliac  spine  (Barker).  Join  these  two  points  by  a  curved  incision  four  inches 
long  and  convex  downward.  Cut  the  skin,  the  fat,  the  two  oblique  muscles,  and 
the  transversalis  muscle;  open  the  transversalis  fascia,  separate  the  peritoneum 


\6o 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


toward  the  vessels,  and  draw  it  inward  by  a  broad  retractor,  and  look  for  the 
artery  along  the  pelvic  brim.  The  anterior  crural  nerve  is  seen  to  the  outer 
side  of  the  artery,  the  external  ihac  vein  is  to  the  inner  side  of  the  artery,  and 
the  genitocrural  nerve  is  upon  the  artery.  Clear  the  artery  near  its  middle 
and  pass  the  ligature  from  within  outward.     In  Sir  Astley  Cooper's  method 


Fig.  J41. — ^,  Nephrotomy  :  rt,  last  dorsal  n. ;  i5,  latissimus  dorsal  m. ;  c,  serratus  post,  inferior 
m. ;  rf,  middle  layer  of  lumbar  fascia  ;  e,  outer  layer  ;  _/,  ext.  oblique  m.  ;  ^,  int.  oblique  m. ;  h,  peri- 
nephritic  (extraperitoneal)  fat ;  ?',  quadratus  lumborum  m.  ;  j,  erector  spinse  m.  B,  Nephrotomy  :  a, 
first  lumbar  n.  ;  d,  kidney  ;  c,  transversalis  fascia.  C,  Ligature  of  the  sciatic  and  internal  pudic 
arteries,  and  exposure  of  the  great  sciatic,  small  .sciatic,  and  internal  pudic  nerves  :  a,  glutseus  maxi- 
mus  m.  ;  d,  inf.  gluteal  n.  ;  r,  sciatic  a. ;  rf,  int.  pudic  a.  and  n.  ;  <■,  great  sciatic  n.  ;  J\  small  sciatic  n.  ; 
X',  pyriformis  m.  /.*,  Ligature  of  the  gluteal  artery  and  exposure  of  the  superior  gluteal  nerve  :  a, 
glut.eus  maximus  m.  ;  />,  gluteal  a.  ;  r,  superior  gluteal  n.  ;  d,  pyriformis  ni.  ;  c,  glutccus  medius  ni. 
f  Kocher). 


of  ligation  the  inguinal  canal  is  opened;  in  .Mjernethy's  method  the  inguinal 
canal  is  not  opened. 

The  Gluteal  Artery. — This  vessel  is  a  continuation  of  the  posterior 
division  of  the  internal  iliac.  It  emerges  from  the  great  sacrosciatic  foramen 
at  the  upper  border  of  the  pyriformis  muscle.  It  rests  upon  the  glutaeus 
minimus,  divides  into  three  branches,  and  is  covered  by  the  glutaeus  maximus 
muscle.     The  superior  gluteal  nerve  lies  inferior  to  the  artery  (Fig.  141). 


Sciatic  Artery 


361 


Ligation. — The  patient  should  be  prone.  The  surgeon  stands  to  the  outer 
side.  The  incision  corresponds  to  a  line  drawn  from  the  posterior  superior 
iliac  spine  to  the  upper  border  of  the  great  trochanter  (Fig.  142).  Divide  the 
skin,  fascia,  glutaeus  maximus  muscle,  and  the  fascia  over  the  glutaeus  medius 
muscle,  and  retract  the  glutaeus  medius  upward.  Feel  for  the  great  sacro- 
sciatic  foramen,  and  at  this 
point  the  artery  is  found 
above  the  pyriformis  mus- 
cle. Clear  the  vessel  and 
pass  the  needle  from  below 
upward  (see  Kocher's  "  Op- 
erative Surgery").  There 
is  practically  no  mortality 
from  this  operation. 

The  Sciatic  Artery. 

— This   artery  is  the  larger 

of  the  terminal  branches  of 

the  anterior  division  of  the 

internal    iliac    artery.       It 

passes  to  the  lower  portion 

of     the     great    sacrosciatic 

foramen,  lying  back  of  the 

internal   pudic  artery,  and 

resting     upon     the    sacral 

plexus  of  nerves  and  pyri- 
formis  muscle  (Gray).     It 

leaves  the   pelvis   between 

the  pyriformis   and   coccy- 

geus  muscles,    and    passes 

downward      between      the 

ischial  tuberosity  and  great 

trochanter.     It    is   covered 

by  the  glutaeus  maximus 
muscle,  rests  upon  the 
gemelli,  internal  obturator 
and  quadratus  femoris 
muscles,  has  the  great 
sciatic  nerve  external  to  it, 
and  the  small  sciatic  nerve 
external  and  posterior  (Fig. 
141). 

Ligation. — The  patient 
lies  prone.  The  surgeon 
stands  to  the  outer  side.  The  incision  "corresponds  to  llic  middle  two- 
thirds  of  a  line  extending  from  the  posterior  inferior  iliac  spine  to  the  base 
of  the  great  trochanter."*  MacCormac  advises  the  incision  shown  in 
Fig.  142.  Divide  the  skin,  fat,  fascia,  and  the  gluta-us  maximus  muscle. 
Find  the  artery  at  the  lower  border  of  the  pyriformis  muscle  and  trace  it  to 
*  Kocher's   "Operative  Surgery,"  by  Stiles. 


Fig.  142.— Position  and  direction  of  the  superficial  incisions 
which  must  be  made  in  order  to  secure  the  gluteal  artery  and 
the  sciatic  and  pudic  arteries  :  A ,  Posterior  superior  iliac  spine ; 
B,  great  trochanter;  C,  tuberosity  of  the  ischium  ;  D,  anterior 
superior  iliac  spine;  A  B.  iliotrochanteric  line,  divided  into 
thirds.  This  line  corresponds  in  direction  with  the  fibers  of 
the  glutseus  maximus  muscle.  The  incision  to  reach  the  glu- 
teal artery  is  indicated  by  the  darker  portion  of  the  line.  Its 
center  is  at  the  junction  of  the  upper  and  middle  thirds  of  the 
iliotrochanteric  line,  and  exactly  corresponds  with  the  point 
of  emergence  of  the  gluteal  artery  from  the  great  sciatic  notch. 
.4  C,  ilio-ischiatic  line.  The  incision  to  reach  the  sciatic 
arterv  and  internal  pudic  is  indicated  by  the  lower  dark  line. 
It  is  also  to  be  made  in  the  direction  of  the  fibers  of  the  glu- 
taeus maximus  muscle.  The  center  of  the  woinid  corresponds 
to  the  junction  of  the  lower  with  the  miiUllc  third  of  the  ilio- 
ischiatic  line  (MacCormac). 


362  Diseases  and   Injuries  of  the   Heart  and  Vessels 

its   point   of   emergence   from   the   pehds.     Pass   the   hgature   from   without 
inward.     There  is  practically  no  mortality  from  this  operation. 

Internal  Pudic  Artery.— This  artery  is  one  of  the  terminal  branches 
of  the  anterior  trunk  of  the  internal  ihac.  It  passes  to  the  lower  margin  of 
the  great  sacrosciatic  foramen,  and  leaves  the  pelvis  between  the  pyriformis 
and  coccygeus  muscles;  crosses  the  ischial  spine,  and  again  enters  the  pelvis 
by  the  lesser  sacrosciatic  foramen.  The  vessel  is  accompanied  by  the  internal 
pudic  nerve  (Fig.  141). 

Ligation. — The  position  of  the  patient  and  the  incision  are  the  same  as 
for  ligation  of  the  sciatic  artery  (Fig.  142).  The  artery  is  found  below  the 
ischial  spine.  Pass  the  needle  from  below  upward  to  avoid  the  nerve.  There 
is  practically  no  mortality  from  this  operation. 

Ligation  of  the  Abdominal  Aorta. — This  operation  was  first  per- 
formed bv  Sir  Astley  Cooper  in  181 7.  The  patient  hved  but  a  few  hours. 
Fifteen  cases  of  ligation  of  the  aorta  have  been  published,  and  there  were  15 
deaths,  but  only  4  of  these  cases  were  aseptic  operations.  The  patient  of 
Monteiro,  of  Rio  Janeiro,  lived  for  ten  days.  The  circulation  was  entirely 
restored  in  the  hmbs,  and  the  man  died  from  hemorrhage  resulting  from  the 
ulceration  produced  by  a  septic  ligature.  Keen's  case  lived  for  forty-eight 
days  after  ligation  just  below  the  diaphragm.  The  urinary  secretion  was 
plentiful  and  the  circulation  in  the  lower  extremities  was  restored,  death 
resulting  from  cutting  through  of  the  Hgature.  Robt.  T.  Morris  performed 
distal  ligation  below  an  aneurysm.  He  encircled  the  aorta  with  a  soft-rubber 
catheter  and  clamped  it  with  forceps.  Twenty-two  hours  after  operation 
the  aneurysm  began  to  shrink,  and  in  three  hours  more  had  apparently  dis- 
appeared. Twenty-seven  hours  after  operation  the  clamp  and  catheter  were 
removed.  The  patient  died  of  septicemia  fifty-three  hours  after  operation. 
The  necropsy  disclosed  gangrene  of  a  bit  of  intestine  which  had  been  in  con- 
tact with  the  forceps,  but  the  dissecting  aneurysm  was  filled  with  solid  clot, 
the  aorta  was  patent,  and  the  circulation  in  the  extremities  was  re-established 
C' Amer.  Jour,  of  Med.  Sciences,"  Sept.,  1900).  These  cases  prove  that  under 
certain  circumstances  the  operation  is  feasible,  and  in  desperate  cases  it  must 
be  considered  as  a  possible  means  of  treatment. 

Murray  Operation. — This  procedure  aims  to  avoid  opening  the  peritoneum. 
An  incision  is  made  from  just  below  the  tip  of  the  tenth  rib  to  a  point  one  inch 
internal  to  the  anterior  superior  iliac  spine.  The  peritoneum  is  separated 
from  the  abdominal  wall  until  the  vessel  is  reached.  Cooper's  operation  by 
abdominal  section  is  the  preferable  procedure. 

Operation  by  Abdominal  Section  (Cooper's  Operation);  Inslniments  Re- 
quired.— Those  used  in  any  ligation,  with  the  addition  of  an  aneurysm  needle 
with  a  large  curve  and  a  very  long  handle.  With  an  ordinary  instrument  it 
is  extremely  difificult  to  pass  the  hgature.  It  would  be  a  great  advantage  to 
use  an  instrument  which,  after  being  passed  under  the  vessel,  could  have  a 
central  eyed  shaft  projected,  as  is  the  center  shaft  of  a  Bellocq  cannula.  Floss 
silk  is  probably  the  best  ligature  material. 

If  the  patient  is  much  exhausted,  an  assistant  should  infuse  salt  solution 
in  a  vein  during  the  operation.  In  Keen's  case  there  was  profound  shock, 
but  the  moment  the  ligature  was  tightened  it  passed  away. 

Operation. — The  patient  should  be  placed  upon  his  back.     The  surgeon 


Abdominal  Aorta  363 

stands  to  the  right  of  the  patient  and  opens  the  abdomen  in  the  median  h'ne, 
a  Httle  above  the  level  of  the  aneurysm.  The  intestines  are  packed  aside, 
the  posterior  layer  of  the  peritoneum  is  divided,  the  surface  of  the  aorta  over 
a  small  area  is  cleared  of  nerves,  the  plexuses  being  separated  with  a  blunt 
dissector. 

The  needle  is  passed  from  right  to  left.  A  double  ligature  of  floss  silk 
should  be  passed  and  the  ends  should  be  tied  with  a  stay-knot.  The  wound  is 
closed  and  dressed. 

It  has  been  suggested — I  think  by  Wyeth — that  it  might  be  wise  to  only 
partially  tighten  the  ligature  at  first,  completing  the  occlusion  of  the  artery 
after  a  day  or  two.  Such  a  procedure  would  certainly  give  a  better  chance 
for  the  collaterals  to  dilate,  and  restore  circulation  in  the  legs. 

Unfortunately,  in  an  aneurysm,  the  vessel  will  usually  be  extensively 
diseased,  and  ligation  will  be  out  of  the  question.  If,  however,  a  normal 
region  is  found,  the  chance  of  success  in  a  case  of  aneurysm  will  be  greater 
than  in  a  case  of  hemorrhage  from  a  branch  of  the  aorta,  because,  in  a  case 
of  aneurysm,  the  probabilities  are  that  the  collaterals  are  somewhat  distended 
before  a  ligature  is  applied. 


364  Diseases  and  Injuries  of  Bones  and  Joints 

XIX.   DISEASES  AND  INJURIES  OF  BONES  AND  JOINTS. 

I.   Diseases  of  the  Bones. 

Atrophy  of  bone  is  a  diminution  in  the  amount  of  bony  matter  without 
change  in  osseous  structure.  It  arises  from  want  of  use  (as  seen  in  the  wasting 
of  the  bone  of  a  stump)  or  from  pressure  (as  seen  in  the  destruction  of  the 
sternum  by  an  aneurysm  of  the  aorta).  Eccentric  atrophy  is  the  thinning 
of  a  long  bone  from  within,  the  outer  surface  being  unchanged.  It  is  usually 
a  senile  change.  Concentric  atrophy  means  a  thinning  of  the  outer  surface 
of  the  shaft,  causing  a  lessened  diameter.  It  is  usually  linked  with  eccentric 
atrophy. 

Hypertrophy  of  bone  may  be  due  to  increased  blood-supply  (as  is 
seen  in  chronic  epiphyseal  inflammation),  the  bone  growing  much  more  than 
does  its  fellow.  It  may  arise  from  excessive  use  or  from  strain,  as  is  seen  in 
the  increased  size  of  the  fibula  when  the  tibia  is  congenitally  absent. 

Tumors  of  Bone. — Bones  give  origin  to  both  innocent  and  malignant 
tumors.  Myeloid  sarcoma  takes  origin  in  the  endosteum  and  expands  the 
bone.  The  fasciculated  sarcoma  is  a  periosteal  growth.  Besides  these 
growths  there  may  develop  an  osteoma,  a  chondroma  and  secondary  deposits 
of  cancer  and  sarcoma.  There  is  no  such  thing  as  primary  cancer  of  bone. 
A  bone  may  become  cystic,  and  occasionally  the  cysts  are  due  to  hydatids. 
Gummata  are  frequently  met  with. 

Cysts  and  Cystomata  of  Bone.— The  majority  of  bone-cysts  are 
produced  by  softening  of  solid  neoplasms  (sarcoma,  myxoma,  chondroma). 
Occasionally  ''  cysts  from  softening  arise  in  osteomalacia  and  osteitis  de- 
formans" ("An  American  Text-Book  of  Pathology").  Hydatid  cysts  and 
dermoid  cysts  are  sometimes  encountered.  A  true  cystoma  of  bone,  except 
in  one  of  the  jaws,  is  a  surgical  rarity.  In  the  maxillary  bones  dentigerous 
cysts  or  cystomata  are  not  very  uncommon. 

Actinomycosis  of  bone  is  most  usual  in  the  jaw,  but  may  attack  the 
orbit,  ribs,  sternum,  or  limbs  (see  page  221).  Actinomycosis  of  bone  may 
arise  secondarily  after  infection  of  superficial  parts  with  the  ray-fungus.  In  the 
jaw  the  fungus  obtains  entrance  to  the  interior  of  the  bone  through  a  tooth 
socket.  In  some  cases  of  bony  actinomycosis  the  fungus  reaches  the  bone  by 
the  blood.  Actinomycosis  leads  to  the  production  of  granulation  tissue,  the 
bone  is  expanded  and  becomes  carious,  and  a  quantity  of  new  bone  is  some- 
times produced.  In  vertebral  actinomycosis,  although  the  condition  resembles 
tuberculosis,  angular  deformity  does  not  occur. 

Tuberculosis  of  bone  tends  especially  to  appear  in  the  cancellous  ends 
of  long  bones;  a  tuberculous  area  is  apt  to  caseate  and  destroy  large 
amounts  of  bone.  The  bone  does  not  sclerose,  but  undergoes  alterations 
of  an  osteoporotic  nature  (see  page  182). 

Osteitis,  Periostitis,  and  Osteoperiostitis.— Osteitis,  or  inflam 
mation  of  bone,  may  be  due  U)  traumatism,  to  a  constitutional  malady 
or  diathesis,  to  the  extension  of  inflammation  from  some  other  structure,  or 
to  infection.  In  inflammation  of  bone  the  exudate  and  leukocytes  pass  into 
the  Haversian  canals,  spaces,  and  canaliculi.  The  bone-corpuscles  pro- 
liferate and  the  bone  undergoes  thinning  (rarefaction),  not  because  of  pressure, 


Osteitis,   Periostitis,   and  Osteoperiostitis  365 

but  because  of  absorption  by  voracious  leukocytes  and  osteoclasts.  This 
process  of  rarefaction  enlarges  all  the  bony  spaces,  and  by  destroying  septa 
throws  many  of  the  spaces  into  one.  If  the  surface  of  a  bone  inflames,  the 
periosteum  will  be  separated  more  or  less  by  the  exudation,  and  the  bone  will 
be  covered  with  little  pits  or  erosions  made  by  the  leukocytes.  Inflamed 
bone  is  so  soft  that  it  can  readily  be  cut  with  a  knife. 

Osteitis  may  terminate  in  resolution  or  it  may  terminate  in  sclerosis,  the 
mass  of  proliferating  cells  being  converted  first  into  fibrous  tissue  and  next 
into  dense  bone  which  contains  very  few  small  cancellous  spaces.  If  the 
exudation  is  under  the  periosteum,  the  bone  will  be  thickened  at  this  point, 
bone  stalactites  marking  the  points  of  passage  of  the  vessels.  Osteitis  may 
terminate  in  suppuration,  this  condition  being  often  called  caries.  In  tuber- 
culous osteitis  caseation  of  the  inflammatory  products  is  very  apt  to  arise  (tuber- 
culous or  strumous  caries).  Acute  osteitis  may  terminate  in  necrosis,  the 
inflammatory  exudate  compressing  the  vessels  in  their  bony  canals,  a  portion 
of  the  bone  being  in  consequence  deprived  of  nutritive  material.  The  portion 
cut  off  from  nutritive  fluid  dies  en  masse  (necrosis).  Osteitis  is  usually 
associated  with  more  or  less  periostitis.  A  simple  acute  periostitis  without 
involvement  of  the  bone  may  arise  from  traumatism  or  strain;  but  in  all 
severe  cases  of  periostitis,  in  all  chronic  cases,  in  all  cases  due  to  syphilis, 
rheumatism,  measles,  scarlatina,  or  enteric  fever  the  bone  is  involved  at  the 
same  time  or  subsequently.  In  syphilitic  states  gummatous  degeneration  fre- 
quently ensues. 

Symptoms  of  Osteitis  and  Osteoperiostitis, — As  a  chronic  process, 
osteitis  is  most  commonly  found  in  the  femur.  Its  history  usually  exhibits 
a  record  of  an  antecedent  injury  or  chilling  of  the  body.  Pain  is  severe, 
boring  or  aching  in  character,  deep-seated,  worse  at  night,  and  aggravated 
by  a  dependent  position  of  the  part.  The  symptoms  closely  resemble  those 
of  periostitis,  with  which  disease  it  is  almost  sure  to  be  linked.  Tenderness 
exists  on  percussion,  and  sometimes  on  pressure.  Subperiosteal  swelling, 
fusiform  in  shape,  is  noted;  cutaneous  edema  and  discoloration  are  observed 
if  a  superficial  bone  is  inflamed.  In  syphilis,  atrophic  osteitis  may  attack  the 
cranial  bones  and  produce  softening  or  even  perforation,  or  osteophytic 
osteitis  may  arise,  exostoses  being  formed.  Osteoperiostitis  may  be  acute 
or  chronic,  circumscribed,  or  diffused,  and  may  terminate  in  resolution, 
organization,  or  suppuration.  It  arises  from  cold,  blows,  wounds,  strains, 
the  spread  of  adjacent  inflammation,  specific  febrile  maladies,  pyogenic 
infection,  syphilis,  rheumatism,  or  tuberculosis.  The  symptoms  are  pain 
(which  is  worse  at  night  and  which  is  aggravated  by  motion,  pressure,  or  a 
dependent  position),  swelling,  edema,  and  discoloration  of  the  soft  parts. 
Pain  in  the  syphilitic  form  is  not  so  severe  as  in  other  varieties.  Acute  necrosis 
or  dipise  periostitis,  a  septic  inflammation  of  bone  and  periosteum,  is  com- 
monest in  boys  about  the  age  of  puberty.  It  is  usually  due  to  cold,  a  specific 
fever,  or  injury,  and  most  often  affects  the  tibia  or  femur;  the  symptoms 
locally  are  redness,  swelling,  and  severe  pain;  constitutionally  there  are  rigors, 
fever,  and  sometimes  convulsions.  Necrosis  is  apt  to  result.  Pyemia  is 
common.  In  simple  acute  periostitis  a  swelling  is  felt  upon  the  osseous  sur- 
face.    The  swelling  is  firmly  fixed  and  is  very  tender   but  the  bone  itself  is 


366  Diseases  and   Injuries  of  Bones  and  Joints 

not  enlarged.  There  is  some  local  heat,  discoloration,  often  fever,  and  the 
patient  complains  of  an  aching  pain,  which  is  worse  at  night. 

Periostitis  due  to  strain  demands  some  special  attention.  Sir  James  Paget, 
years  ago,  pointed  out  that  muscular  exertion  might  cause  periostitis.  C.  T. 
Dent  has  written  a  valuable  article  upon  this  subject.* 

It  is  common  to  hear  football  players  complain  of  some  swelUng  of  the 
knee-joint.  Examination  finds  tenderness  over  the  tubercle  of  the  tibia  with 
slight  swelling  of  the  joint.  Dent  points  out  that  pain  is  felt  on  straightening 
the  leg,  not  on  rotating  it.  The  same  observer  states  that  omnibus  drivers 
suffer  from  periostitis  of  the  fibula,  due  to  pressing  forcibly  against  the  foot- 
board; those  who  ride  may  develop  periostitis  of  the  adductor  insertion 
(riders'  bone) ;  the  victims  of  flat-foot  may  labor  under  periostitis  of  the  inner 
tuberosity  of  the  os  calcis;  bar-keepers,  from  working  a  beer-pump,  may  get 
periostitis  of  the  scapula,  pain  being  marked  on  contracting  the  biceps;  a 
housemaid  may  develop  periostitis  at  the  points  of  bony  origin  of  the  great 
pectoral  from  the  chest,  the  condition  being  due  to  sweeping  and  scrubbing.f 

Treatment  of  Osteitis  and  Osteoperiostitis. — In  syphilitic  forms  the 
local  treatment  consists  in  rest,  elevation  of  the  part,  the  application  of  iodin 
and  mercurial  ointment,  and  bandaging.  Specific  treatment  is  by  the  stom- 
ach or  hypodermatically.  Operation  is  rarely  justifiable.  In  other  forms, 
if  the  case  be  recent  and  severe,  put  the  patient  to  bed,  place  the  limb 
in  a  splint  and  elevate  it,  employ  cold,  apply  a  bandage,  and  give  salines 
and  iodid  of  potassium  internally.  Later  use  ichthyol  inunctions  locally 
and  apply  a  hot  water-bag.  Morphin  is  administered  for  pain.  If  these 
means  fail,  order  counterirritation  by  iodin  and  blue  ointment  or  bUsters, 
and  apply  heat  locally.  In  severe  cases  take  a  tenotome  and  slit  the  perios- 
teum subcutaneously  to  relieve  tension ;  this  procedure  often  quickly  relieves 
the  pain.  Some  cases  demand  a  longitudinal  osteotomy,  which  is  performed 
by  taking  Key's  saw  and  dividing  the  bone  longitudinally  into  the  medullary 
canal.     If  pus  forms,  drain  at  once. 

Diffuse  osteoperiostitis  requires  early  and  free  incisions,  antiseptic  irri- 
gation, drainage,  rest  and  elevation  of  the  limb,  and  strong  supporting  and 
stimulating  treatment.  Amputation  is  sometimes  demanded,  as  when  the 
patient  grows  weaker  and  weaker  even  after  incision,  and  when  a  joint  is 
seriously  involved.  If  the  necrosis  affects  the  entire  shaft,  which  separates 
from  its  epiphyses,  and  new  bone  has  not  yet  formed  from  the  periosteum, 
make  a  subperiosteal  resection  of  the  shaft. 

Chronic  periostitis  is  usually  syphilitic.  A  node  is  a  chronic  inflamma- 
tion of  the  deep  periosteal  layers.  Nodes  occurring  early  in  the  secondary 
stage  remain  soft  and  soon  pass  away  under  treatment,  but  those  occurring 
two  years  or  more  after  infection  are  apt  to  cause  a  bony  deposit.  A  node 
may  soften,  leaving  a  sinus,  at  the  bottom  of  which  is  a  piece  of  dead  bone. 
Gumma  of  the  [)eriosteum  is  one  form  of  node  which  is  a]Jt  to  produce  caries 
or  necrosis. 

Osteoplastic  periostitis  accompanies  chronic  osteitis  and  causes  the 
deposit  of  new  b(;ne,  which  undergoes  sclerosis.  The  chief  symptom  is  aching 
f)ain,  which  is  worse  when  the  patient  is  warm  in  bed,  and  is  aggravated  by 
damp  and  wet.     A  swelling  is  found  at  the  seat  of  pain  (often  over  the  tibia 

*  Practitioner,  Oct.,  1897.  f  Ibid. 


Chronic  Abscess  of  Bone 


■h^7 


ulna,  clavicle,  or  sternum).  The  soft  parts  are  uninflamed  and  move  freely 
unless  softening  or  suppuration  has  occurred.     Tenderness  is  manifest. 

Treatment  oj  Chronic  Periostitis  and  Osteoplastic  Periostitis. — For  the 
nodes  of  early  syphilis  administer  mercury  by  the  plan  usually  followed  in 
secondary  syphilis;  for  the  nodes  of  late  syphilis  give  mercury  and  large 
advancing  doses  of  iodid  of  potassium.  Blisters,  blue  ointment,  and  iodin 
are  used  locally  in  both  forms,  and  subcutaneous  division  of  the  periosteum 
is  of  value.     If  suppuration  occurs,  incise  antiseptically. 

Chronic   Abscess  of   bone,  or  Brodie's  Abscess.— This  condition 

is  usually  due  to  tuberculous  infection.  It  is  always  chronic,  never  acute.  A 
very  acute  inflammation,  such  as  is  induced  by  pyogenic  organisms,  causes 
acute  necrosis  rather  than  an  acute  abscess.  After  typhoid  fever  an  area  of 
suppuration  may  slowly  form  in  the  head  of  a  long  bone,  due  to  the  action 
of  typhoid  bacilli.  After  a  tuberculous  abscess  forms  mi.xed  infection  may 
take  place,  the  seat  of  abscess  being  a  point  of  least  resistance.  Chronic 
abscess  of  bone  was  first  described  by 
Sir  Benjamin  Brodie,  and  is  often  called 
Brodie's  abscess.  It  occurs  in  the  can- 
cellous structure  of  the  ends  of  bones — 
usually  in  the  head  of  the  tibia,  sometimes 
in  the  femur  (Fig.  143)  or  humerus.  A 
tuberculous  abscess  of  bone  may  follow  a 
slight  injury,  inducing  osteitis,  which 
constitutes  a  point  of  least  resistance. 
Bacteria  lodge  and  multiply;  bone  rare- 
faction leads  to  the  formation  of  a  cavity, 
the  inflammatory  products  caseate,  some- 
times suppuration  arises,  and  the  sur- 
rounding bone  thickens  and  hardens  be- 
cause of  growth  from  the  periosteum.  The 
abscess  is  apt  to  break  into  a  joint,  as  the 
joint-surface  is  not  covered  by  periosteum 
and  no  barrier  of  bone  is  there  formed. 
Brodie's  abscess  may  induce  necrosis. 

Symptoms. — The  symptoms  are  like  those  of  osteoperiostitis,  only  they 
are  localized  and  persistent.  These  symptoms  are  thickening  of  the  bone  and 
soft  parts,  edema  and  discoloration  of  the  skin  over  the  seat  of  trouble,  tender- 
ness, constant  pain  (subject  to  violent  exacerbations,  worse  at  night  when 
warm  in  bed,  and  made  worse  by  motion,  pressure,  or  a  dependent  position), 
and  attack  after  attack  of  synovitis  in  the  nearest  joint.  Irregular  fever  and 
sweats  may  be  noted. 

Treatment. — In  treating  bone-abscess,  trephine  the  bone  at  the  point  of 
greatest  tenderness,  and  if  the  abscess  is  missed,  follow  the  advice  of  Holmes 
and  perforate  the  wall  of  bone  with  the  trephine,  opening  in  several  directions 
to  discover  the  tuberculous  matter  or  pus.  It  is  often  easy  to  open  into  the 
abscess  with  a  chisel  or  gouge.  After  opening  the  cavity  scrape  its  walls 
thoroughly  dry  with  gauze,  touch  with  pure  carbolic  acid,  and  pack  with 
iodoform  gauze.  If  the  abscess  opens  into  a  joint,  trephine  the  bone  and 
open,  irrigate,  and  drain  the  joint. 


Fig.  143. — Abscess  in  the  great  tro- 
chanter ("  American  Te.\t-book  of  Sur- 
gery "). 


368  Diseases  and   Injuries  of  Bones  and  Joints 

Carles  was  a  term  used  formerly  to  signify  suppuration  or  molecular 
death  of  bone.  In  some  cases  caries  means  suppurative  osteitis;  in  others, 
tuberculous  osteitis;  in  still  others,  gummatous  osteitis.  Typhoid  fever  is 
occasionally  followed  by  a  carious  condition  of  bone.  Osteitis  is  apt  to 
become  purulent  when  the  bone  is  exposed  to  the  air,  when  rest  is  not  secured, 
when  the  health  of  the  individual  is  below  normal,  when  a  foreign  body  such 
as  a  bullet  is  in  the  bone,  or  when  tubercle  or  syphilis  exists.  The  term  is 
rarely  used  to-day  except  loosely,  and  then  usually  to  signify  tuberculous  dis- 
ease of  bone.  When  caries  arises,  the  softened  and  granulating  bone  breaks 
down  and  is  discharged  through  a  sinus.  After  drainage  is  secured  organiza- 
tion, sclerosis,  and  healing  may  result.  In  these  cases  new  bone  may  form, 
and  a  cure  result. 

Tuberculous  or  strumous  caries,  a  condition  produced  by  the  caseation 
of  the  products  of  a  tuberculous  osteitis,  shows  no  tendency  to  self-cure,  no 
organization  or  sclerosis  takes  place,  and  no  new  bone  forms  unless  an  opera- 
tion is  performed.  The  interior  of  bones,  especially  of  the  carpus  and  tarsus, 
is  entirely  softened  and  destroyed,  and  thin  shells  only  are  left. 

Caries  necrotica  is  a  condition  in  which  small  but  visible  portions  of  soft 
and  dead  bone  are  cast  off;  caries  sicca  is  molecular  death  of  bone  without 
suppuration. 

The  caseating  masses  in  tuberculous  caries  contain  the  tubercle  bacillus. 
If  a  tuberculous  collection  is  evacuated  and  infection  with  pus  organisms 
occurs,  genuine  suppuration  takes  place,  and  constitutional  infection  causes 
septic  fever,  and  may  cause  death.  Purulent  osteitis  may  affect  any  part  of 
any  bone;  but  caseous  osteitis  (tuberculous  caries)  tends  to  arise  especially 
in  cancellous  structures  (heads  of  long  bones,  vertebral  bodies,  ribs  and 
sternum,  and  bones  of  the  carpus  and  tarsus).  Tuberculous  osteitis  of  the 
shaft  of  a  long  bone  occasionally,  but  rarely,  arises.  Tuberculous  osteitis  is 
apt  to  cause  tuberculous  disease  in  an  adjacent  joint.  Tuberculous  osteitis 
may  be  followed  by  the  formation  of  a  cold  abscess. 

Symptoms. — In  the  beginning  the  evidences  of  caries  are  usually  those 
of  osteitis,  but  the  first  sign  noted  may  be  a  fluctuating  swelling  due  to  pus 
or  to  caseated  tubercle.  After  a  time,  at  any  rate,  a  fluctuating  swelling  is 
discovered.  If  not  opened,  the  softened  mass  breaks  externally,  voids  its 
contents,  and  leaves  a  sinus  from  which  flows  caseated  matter  which  after 
a  time  becomes  thin,  reddish,  and  irritating  to  the  skin,  contains  small  por- 
tions of  gritty  bone,  and  has  a  foul  smell.  The  opening  of  the  sinus  fills  up 
with  edematous  granulations.  A  probe  carried  to  the  bottom  of  the  sinus 
finds  bone  which  is  sieve-like  (worm-eaten),  and  which  on  being  struck  gives 
a  muffled  note  rather  than  the  clear,  sharp  note  of  necrosis;  the  bone  is  rough, 
is  bared,  and  is  so  soft  that  the  probe  can  usually  be  stuck  into  it.  In  old 
cases  of  caries  amyloid  disease  may  arise. 

Treatment. — If  syphilis  exists,  give  iodid  of  potassium  in  advancing  doses 
and  a  mild  mercurial  course.  If  tubercle  exists,  give  iodid  of  iron,  arsenic, 
cod-liver  oil,  and  nourishing  foods,  and  recommend  a  change  of  air.  Locally, 
in  all  cases,  insist  on  rest  and  at  once  secure  drainage,  enlarging  the  opening, 
if  necessary,  and  inserting  a  tube,  and  even  making  additional  openings; 
syringe  often  with  antiseptic  fluids  and  dress  antiseptically.  If  the  case  is 
seen  before  spontaneous  evacuation  has  occurred,  open  under  strict  antiseptic 


Necrosis 


369 


precautions.  When  a  chronic  sinus  exists  there  arises  the  question  of  opera- 
tion. Incomplete  operations  are  worse  than  useless,  for  they  may  be  followed 
by  diffuse  tuberculosis  or  pyemia.  If  the  gouge  is  used,  try  to  remove  all 
carious  bone.  The  diseased  bone  is  white,  crumbles,  and  does  not  bleed; 
the  non-carious  bone  is  pink  and  vascular.  Scrape  away  all  granulations; 
swab  the  cavity  with  pure  carbolic  acid  and  pack  it  with  iodoform  gauze. 
Instead  of  gouging  away  bone,  there  may  be  used  the  actual  cautery,  sulphuric 
acid,  or  hydrochloric  acid.  In  severe  cases  excision  is  required,  and  in  some 
rare  cases  amputation  may  be  necessary.  Caries  of  the  spine  is  considered 
under  Diseases  of  the  Spine. 

Necrosis  is  the  death  of  visible  portions  of  bone  from  circulatory  im- 
pediment. It  is  analogous  to  gangrene.  One  cause  of  necrosis  is  traumatism 
(such  as  the  tearing  off  of  periosteum)  which  deprives  the  bone  of  blood. 
Inflammation  of  the  periosteum  further  lessens  the  nutrition.  Acute  inflam- 
mation in  bone  causes  necrosis,  the  excessive  exudation  in  the  canals  and 
spaces  occluding  the  blood-vessels  by  pressure.  The  occlusion  of  vessels 
by  septic  thrombi  may  lead  to  necrosis,  or  the  direct  action  of  toxins  may 
first  inflame  and  finally  destroy  a  portion  of  the  bone.  A  thin  shell  of  bone 
only  may  necrose  from 
periosteal  separation,  or  an 
entire  shaft  may  die  from 
acute  pyogenic  osteomye- 
litis or  diffuse  infective 
periostitis.  Osteomyelitis 
is  the  most  usual  cause  of 
necrosis.  Necrosis  is  most 
frequently  met  with  in  the 
diaphyses  of  the  long  bones, 
caries  in  the  cancellous 
tissue  of  bones.  The  ribs 
may  become  carious,  but 
very  rarelv  become  necrotic.  A  sequestrum  may  form  in  a  vertebral  body, 
in  the  carpus,  or  in  the  tarsus,  but  rarely  does;  hence,  we  conclude  that 
sequestra  do  not  often  result  from  tuberculous  osteitis.  A  fragment  of  dead 
bone  is  a  foreign  body;  the  healthy  bone  adjacent  to  it  inflames  and  softens; 
granulations  form,  and  this  line  of  granulation,  like  the  line  of  demarcation 
of  gangrene,  separates  the  dead  part  from  the  living,  the  white  dead  bone 
being  surrounded  by  the  red  zone  of  granulation  tissue.  A  bit  of  dead  bone 
is  called  a  "sequestrum,"  and  Nature  tries  to  cast  it  oft".  A  superficial 
sequestrum  is  known  as  an  "exfoliation." 

Nature's  method  of  casting  off  a  sequestrum  is  as  follows:  suppuration 
takes  place  at  the  line  of  demarcation,  osteitis  extends  for  a  considerable 
distance  around  this  line,  the  periosteum  .shares  in  the  inflammation,  and 
new  bone  forms.  A  cavity  is  thus  made  within  by  suppuration,  and  a  box 
or  case  forms  without  by  ossification,  the  now  entirely  loo.sened  sequestrum 
being  so  encased  that  it  cannot  escape.  The  pus  finds  its  way  through  the 
new  bone,  and  there  is  presented  the  condition  .so  often^seen  by  the  surgeon 
— namely,  a  case  of  new  bone  known  as  the  "  involucrum,"  a  cavity  containing 
pus  and  the  dead  fragment  or  sequestrum,  and  a  discharging  sinus  or  "  cloaca" 
24 


Fig.  144. — Diagram  illustiatiiig  the  formation  of  a  se- 
questrum :  A,  Sound  bone;  B,  new  bone;  C,  granulations 
lining  involucrum;  /?,  cloaca  ;  £■,  sequestrum. 


370  Diseases  and   Injuries  of  Bones  and   Joints 

(Fig.  144).     Nature   may  eventually  get  rid  of' the  fragment,  but  the  surgeon 
should  not  wait  for  the  completion  of  this  slow  process. 

When  a  portion  of  the  bone  surrounding  the  medullary  canal  dies,  the 
condition  is  called  "  central  necrosis."  In  some  rare  cases  necrosis  occurs 
without  apparent  suppuration,  a  painless  swelling  of  bone  simulating  sarcoma. 
This  condition  is  known  as  quiet  necrosis,  and  has  been  described  by  Sir  James 
Paget  and  Mr.  Morrant  Baker.  Mercury  is  an  occasional  cause  of  necrosis. 
The  fumes  of  phosphorus  may  cause  necrosis  of  the  lower  jaw  in  those  with 
decayed  teeth.  Necrosis  may  be  produced  also  by  frost-bites  and  burns. 
Many  fevers  (measles,  typhoid,  scarlet  fever,  etc.)  are  occasionally  followed 
bv  necrosis.     Syphilis  and  tuberculosis  are  occasional  causes. 

Symptoms. — The  symptoms  of  necrosis  are  at  first  those  of  osteitis  or 
osteomyelitis.  The  abscess,  when  formed,  opens  of  itself  or  is  opened  by  the 
surgeon,  and  a  sinus  or  sinuses  form  in  the  soft  parts  as  happens  in  caries. 
A  probe  introduced  into  the  sinus  strikes  upon  hard  bone  with  a  clear,  ringing 
note,  and  often  finds  a  sinus  or  sinuses  in  the  bone.  In  superficial  necrosis 
the  discharge  is  slight  and  the  probe  shows  the  limitations  of  the  disease. 
In  extensive  necrosis  the  discharge  is  profuse,  much  new  bone  forms,  several 
sinuses  appear  far  apart,  and  the  probe  must  pass  through  a  considerable 
thickness  of  new  bone  before  it  finds  the  bit  of  dead  bone.  The  surgeon 
should  not  operate  until  the  dead  bone  is  separated  from  the  hving  by  a  line 
of  demarcation,  and  until  the  sequestrum  is  loose.  In  youth  dead  bone 
loosens  quickly,  but  in  old  age  slowly.  An  exfoliation  becomes  loose 
sooner  than  the  sequestrum  of  central  necrosis.  In  diffuse  periostitis  the 
necrosed  shaft  loosens  quickly.  Necrosed  portions  of  the  upper  extremity 
loosen  more  rapidly  than  those  of  the  lower.  In  a  young  adult  two  or  three 
months  will  be  required  to  loosen  a  necrosed  fragment  in  the  lower  extremity, 
and  from  six  weeks  to  two  months  in  the  upper.  A  loose  sequestrum  may 
be  moved  bv  the  probe,  and  when  struck  gives  a  hollow  note.  In  protracted 
cases  of  necrosis  there  is  always  danger  that  amyloid  disease  may  arise. 

Quiet  necrosis  is  a  rare  condition  which  has  led  to  some  deplorable  but 
pardonable  mistakes,  because  it  resembles  ossifying  sarcoma.  It  follows 
injury,  particularly  fracture.  The  bone  enlarges  greatly.  There  is  little 
or  no  pain  and  no  fever.  The  diagnosis  can  only  be  made  by  exploratory 
incision,  and  it  may  even  be  necessary  to  remove  portions  for  microscopic 
study  before  a  conclusion  can  be  reached. 

Postfebrile  necrosis  is  most  usually  met  with  after  tyi^hoid  fever.  The 
bacilli  of  typhoid  cause  osteomyelitis,  and  this  is  followed  by  necrosis.  Scarlet 
fever,  measles,  and  other  febrile  processes  may  also  induce  necrosis.  It  is 
certain  that  bacilli  accumulate  in  the  bones  during  typhoid  fever.  They  may 
promptly  induce  disease;  they  may  remain  for  long  periods  apparently  in- 
active and  finally  pass  away;  or  after  a  slight  strain  or  injury  these  organisms 
may  induce  bone  disease  months  or  even  years  after  the  primary  infection. 
Typhoid  bone  disease  is  often  multiple,  many  bones  being  involved  succes- 
sively.* Not  unusually  after  typhoid  fever  muscle  strain  causes  periostitis 
and  osteitis,  and  at  such  a  point  necrosis  may  occur.  Either  exfoliation  or 
central  necrosis  may  follow  typhoid  fever.  The  tibia  is  involved  more  often 
than  other  bones. 

*  Keen's  "Surgical  (  omplications  of  Tyjilioid  I'ever." 


Necrosis 


371 


Treatment. — An  exfoliation  should  be  removed  as  soon  as  it  becomes 
loose,  the  seat  of  trouble  should  be  touched  with  pure  carbolic  acid,  and  pack- 
ing of  iodoform  gauze  should  be  inserted.  The  treatment  of  central  necrosis 
comprises  free  incisions  for  drainage,  antiseptic  dressing,  frequent  cleansing, 
rest,  nourishing  food,  stimulants,  and  tonics.  When  the  sequestrum  becomes 
loose,  the  involucrum  should  be  broken  through  with  the  chisel,  gouge,  and 
rongeur.  The  dead  bone  should  be  removed  and  the  cavity  scraped,  irrigated 
with  hot  salt  solution,  dried,  painted  with  pure  carbolic  acid,  and  packed  with 
iodoform  gauze.  This  operation  is  known  as  "sequestrotomv."  The  simple 
removal  of  a  sequestrum — /.  e.,  the  operation  of  sequestrotomv — often  fails 
to  effect  a  cure.  "The  involucrum  always  contains  pyogenic  germs  that  may 
live  in  its  small  foramina  and  crevices  almost  indefinitely.  For  this  reason, 
and  on  account  of  the  denseness  of  bony  structure,  it  is  well-nigh  impossible 
to  disinfect  it"  (Dr.  J.  Shelton  Horsley.  in  the  "Medical  Record,"  Oct.  20, 
1900).  Because  of  the  difficulty  of  curing  a  case  when  an  involucrum  has 
formed.  Dr.  Gushing,  of  Baltimore,  has  warmly  advocated  early  operation 
in  osteomyelitis;  that  is,  operation  before  an  involucrum  has  formed,  and  when 
the  osteoblasts  of  the  periosteum  are  extremely  active.  He  points  out  that 
if  an  involucrum  has  formed,  the  sequestrum  and  involucrum  should  be  re- 
moved after  stripping  the  periosteum  from  this  region.  If  the  periosteum 
is  found  not  to  be  infected,  it  may  be  stitched  together  at  the  gap  where  the 
bone  has  been  removed,  so  that  a  periosteal  cord  exists  between  the  two  ends 
of  the  bone;  and  the  soft  parts  above  this  may  be  closed.  If  the  periosteum 
is  found  to  be  infected,  we  agree  with  Gushing  that  the  cavity  should  be  packed 
with  gauze.  The  cavity  that  is  left  by  the  removal  of  a  sequestrum  and  the 
chiseHng  of  the  walls  of  the  involucrum,  if  large,  may  be  filled  by  various 
methods,  more  or  less  satisfactorv. 

The  surgeon  may  try  to  fill  it  by  taking  flaps  of  skin  and  fastening  them 
to  the  bottom  with  nails  (Neuber's  operation),  by  breaking  the  edges  of  the  in- 
volucrum and  turning  them  in,  or  by  inserting  bone-chips.  Bone-chips  are 
obtained  from  the  compact  part  of  the  tibia  or  femur  of  an  ox,  and  are  de- 
calcified by  being  placed  for  a  couple  of  weeks  in  a  10  per  cent,  aqueous  solution 
of  hydrochloric  acid  (which  is  renewed  every  day) ;  they  are  well  washed  in  a 
weak  alkali  and  then  in  water,  are  cut  into  strips,  are  soaked  for  two  days  in  a 
I  :  1000  solution  of  corrosive  sublimate,  and  are  kept  until  needed  in  a  satu- 
rated ethereal  solution  of  iodoform.  The  cavity  is  made  sterile  and  is  well 
dusted  with  iodoform,  the  bone-chips  are  dried  and  inserted  into  the  cavity,  a 
capillary  drain  is  employed,  the  periosteum  is  stitched  over  the  opening,  and 
the  soft  parts  are  sutured;  but  if  this  cannot  be  done,  iodoform  packing  is 
used  to  keep  the  chips  in  place.  This  method  we  owe  to  the  genius  of  Senn. 
Attempts  have  been  made  to  fill  bone-cavities  with  gutta-percha,  plaster 
of  Paris,  etc.  Schleich  uses  formalin-gelatin  to  fill  bone-cavities.  The 
difficulty  is  to  completely  asepticize  the  walls  of  the  cavity.  Dressman  has 
advised  for  this  purpose  the  use  of  boiling  oil,  but  it  is  apt  to  cause  superficial 
necro.sis.  In  some  cases  the  cavity  has  been  healed  by  the  insertion  of  a 
Thiersch  skin-graft.  This  method  has  been  advocated  by  J.  P.  Lord  ("Jour. 
Am.  Med.  Assoc,"  May  31,  1902).  Many  attempts  have  been  made  to  fill 
the  defect  by  bone-grafting.  The  first  case  of  satisfactory  transplanting  irom 
the  lower  animals  with  the  leaving  of  a  vascular  attachment  was  reported  by 


J/- 


Diseases  and  Injuries  of  Bones  and  Joints 


A.  W.  Morton  in  "American  Medicine,"  July  12,  1902.  The  patient  suffered 
from  a  compound  comminuted  fracture  of  both  bones  of  the  right  leg.  The 
fracture  in  the  fibula  united,  but  the  tibia  underwent  necrosis,  and  it  was  neces- 
sary to  remove  five  inches  of  the  lower  end  of  the  bone.  Some  days  later,  the 
periosteum  was  raised  from  the  ends  of  the  bone  and  these  ends  were  freshened. 
The  left  leg  of  a  dog  was  amputated  just  above  the  tarsus,  the  bones  being 
sawed  so  that  the  ulna  was  one  inch  longer  than  the  radius.  The  lower  end 
was  partlv  bared  of  periosteum,  and  the  ulna  of  the  dog  was  forced  into  the 
cavitv  of  the  tibia  of  the  man,  and  wired  to  that  bone  with  silver  wire. 
The  incision  in  the  man's  leg  was  then  sutured,  and  powerful  tendons  in 
each  leg  of  the  dog  were  divided.  Each  of  the  dog's  other  legs  was  wrapped 
separately  in  a  plaster  of  Paris  bandage,  and  the  entire  animal  and  the  leg  of  the 
man  were  then  put  up  in  a  plaster  of  Paris  dressing.  Five  weeks  later  the  cast 
was  removed,  and  the  bones  were  sawed  and  placed  in  contact  with  the  astra- 
galus. Union  took  place,  and  the  man  was  fortunate  enough  to  obtain  a  useful 
leg.  In  some  cases  of  widespread  necrosis  due  to  diffuse  infective  osteoperios- 
titis or  to  osteomyelitis  extensive  resection,  or  even  amputation,  may  be  neces- 
sary. 

Acute  osteomyelitis  is  an  acute  and  diffuse  inflammation  of  the  bone- 
marrow  due  to  pyogenic  organisms.  Infection  from  staphylococci  may  be 
limited  to  a  portion  of  one  bone.  Streptococcus  infection  causes  widespread 
involvement  of  a  bone  or  of  several  bones.  Acute  osteomyelitis  may  be  due  to 
mixed  infection  with  baciUi  of  typhoid  and  pyogenic  organisms,  or  bacilli  of 
tubercle  and  pyogenic  organisms,  a  typhoid  process  or  a  tuberculous  process 
serving  to  establish  a  point  of  least  resistance.  The  gonococcus  and  the 
pneumococcus  occasionally  produce  acute  osteomyelitis.  In  a  case  of  gonor- 
rheal arthritis  in  which  I  resected  the  wrist-joint  cultures  of  gonococci  were 
obtained  from  the  interior  of  the  bone  removed. 

The  pyogenic  organisms  may  gain  entrance  directly  by  way  of  a  wound 
(a  gunshot-wound,  a  compound  fracture,  an  amputation).  The  causative 
organisms  may  reach  the  bone  by  way  of  the  blood,  having  entered  the  blood 
originally  through  the  lymphatic  system  or  from  a  focus  of  suppuration  in 
the  skin,  the  subcutaneous  tissue,  or  a  deeper  part. 

Pus  organisms  may  pass  into  the  blood  from  the  tonsils  or  respiratory 
organs  (Kraske);  the  intestinal  canal  (Kocher);  the  genito-urinary  tract;  or 
from  excoriations,  bruises,  or  small  wounds  in  the  skin  (Warren).  Certain 
fevers  strongly  predispose  to  the  disease  by  preparing  the  soil  as  it  were  for 
the  growth  of  pyogenic  bacteria.  Typhus  fever,  smallpox,  malarial  fever, 
scarlet  fever,  measles,  and  diphtheria  lessen  the  vital  resistance  of  bone- 
marrow.  Typhoid  fever  is  not  unusually  followed  by  a  chronic  osteomyelitis, 
due  solely  to  typhoid  bacilli.  If  mixed  infection  with  pus  organisms  occurs, 
acute  osteomyelitis  arises.  Vital  resistance  of  marrow  is  lessened  by  exhausting 
diseases,  overexertion,  unhealthy  and  especially  ])utrid  food.  When  organisms 
gain  entrance  directly  b\-  a  wound  (as  in  a  com[)Ound  fracture),  the  endos- 
teum,  the  medulla,  and  the  cancellous  tissue  inflame  and  suppurate,  and  the 
entire  length  and  thickness  of  the  bone  may  be  involved.  The  periosteum 
becomes  infiltrated,  detached  from  the  bone,  and  retracted  from  the  edges 
of  the  wound  in  the  bone.  The  soft  tissues  around  the  bone  may  inflame, 
suppurate,  or  slough.     More  or  less  necrosis  inevitably  occurs. 


Acute  Osteomyelitis  373 

Acute  osteomyelitis  without  a  wound  is  often  called  acute  epiphysitis  or 
acute  infantile  arthritis.  This  condition  is  most  common  in  infants  or  children 
of  one  or  two  years  of  age,  but  occasionally  arises  in  older  children  (from  ten 
to  fourteen  years)  or  even  in  adults.  It  is  most  common  during  the  period 
of  active  growth  of  bone.  It  is  frequently  preceded  by  one  of  the  predis- 
posing causes  before  mentioned.  In  many  cases  a  strain  or  bruise  is  followed 
by  pyogenic  infection,  because  the  damaged  tissue  extends  a  hospitable 
welcome  to  micro-organisms  which  are  traveling  in  the  body-fluids  and  pass 
through  the  injured  area.  In  some  cases  chilling  of  the  surface  of  the  body 
is  a  predisposing  cause.     In  others  no  predisposing  cause  is  discoverable. 

The  compact  bone  suffers  secondarily,  but  is  never  attacked  primarily. 
New  tissue  is  more  susceptible  to  infection  than  old  tissue,  and  the  disease, 
as  a  rule,  begins  near  the  epiphyseal  line,  where  new  bone  is  being  formed. 
This  point  was  spoken  of  by  Oilier  as  "the  zone  of  election  of  pathological 
processes."  Warren  points  out  that  in  a  growing  bone  near  the  epiphyseal 
cartilage  there  exists  a  newly  formed  spongy  tissue,  very  vascular  and  con- 
nected with  the  cartilage  by  a  spongy  layer  of  tissue,  which  is  not  }-et  bone, 
but  which  does  not  possess  a  cartilaginous  structure.  It  is  in  this  portion 
of  the  skeleton  that  the  most  active  changes  take  place  during  the  period  of 
growth.  The  medullary  substance  is  very  vascular  at  this  point;  it  is  red  and 
without  fatty  tissue.  It  communicates  with  the  medullary  canal  and  with 
the  periosteum  by  a  number  of  vascular  channels.  The  epiphyseal  cartilage 
itself  is  intimately  blended  with  the  periosteum.  The  diaphyseal  side  of  the 
cartilage  produces  much  more  bone  than  is  found  in  the  epiphyseal  margin. 
There  is  also  an  active  growth  of  bone  in  the  periosteum,  and  it  is  in  these 
regions  and  in  the  medullary  canal  that  the  inflammatory  process  originates.* 
The  lower  end  of  the  femur  and  the  upper  end  of  the  tibia  are  the  regions 
most  commonly  attacked;  but  the  upper  end  of  the  femur  and  the  lower  end 
of  the  tibia  may  suffer,  and  other  bones  may  be  attacked,  especially  the 
humerus,  radius,  ulna,  and  inferior  maxilla.  The  adjacent  .joint  not  unusu- 
ally becomes  involved.  Though  the  inflammation  begins  in  the  spongy 
tissue  or  medulla,  it  passes  to  the  canals  and  spaces  of  the  compact  bone. 
The  inflammatory  exudate  in  the  canals  compresses  the  vessels  and  cuts  off 
nutrition  from  certain  areas.  Suppuration  begins,  clots  form  in  the  medulla 
from  thrombophlebitis,  and  the  clots  in  the  vessels  of  the  Haversian  canals 
become  septic.  A  small  sequestrum  forms  at  the  seat  of  origin  of  the  disease, 
and  the  pus  about  the  sequestrum  is  apt  to  empty  into  the  medullary  canal, 
causing  diffuse  osteomyelitis,  or  into  the  adjacent  joint,  causing  suppurative 
inflammation  of  the  articulation. 

Marked  constitutional  symptoms  arise  from  absorption  of  toxins  (sup- 
purative fever),  and  sometimes  true  septic  infection  or  even  pyemia  arises. 

Very  extensive  necrosis  may  follow  osteomyelitis  if  the  patient  recovers. 

Symptoms. — Osteomvelitis  secondary  to  a  wound  may  occur  in  a  person 
of  any  age.  If  a  wound  exists, — for  instance,  a  compound  fracture. — the 
diagnosis  is  evident.  The  constitutional  symptoms  of  septic  absorption  are 
])ositi^■e:  there  is  a  profuse,  offensive,  purulent  discharge  containing  bone- 
fragments  and  tissue-sloughs;  the  periosteum  is  red,  thick,  and  .separated; 
there  are  swelling  over  the  bone,  great  tenderness,  and  violent  boring,  gnawing, 
*  Warren's  "Surgical  Pathology." 


374  Diseases  and  Injuries  of  Bones  and  Joints 

or  aching  pain.  Osteomyelitis  occurring  without  a  wound,  the  condition 
known  as  acute  epiphysitis,  occurs  in  the  young,  and  particularly  in  children 
under  three  years  of  age. 

The  symptoms  of  acute  epiphysitis  usually  come  on  suddenly  and  espe- 
cially at  night,  and  the  attack  may  be  so  acute  as  to  cause  death  by  systemic 
poisoning  before  a  diagnosis  is  arrived  at.  The  disease  is  generally  ushered 
in  by  a  chill,  which  is  followed  by  septic  febrile  temperature.  The  history  will 
sometimes  contain  the  statement  that  a  blow  had  been  received,  that  a  febrile 
process  had  existed,  or  that  the  patient  had  been  suddenly  chilled  after  having 
been  overheated  (sitting  in  a  draft  or  in  a  cellar  on  a  hot  day,  possibly  swimming 
when  very  warm,  etc.).  There  is  violent  aching  pain  in  the  bone  and  acute 
tenderness  near  the  joint ;  the  soft  parts,  which  at  first  are  healthy  in  appear- 
ance, after  a  time  discolor,  swell,  and  present  distended  veins,  and  may  become 
glossy  and  edematous  because  pus  is  gathered  below.  An  abscess  sometimes 
reaches  the  surface  and  may  break  spontaneously.  The  neighboring  joint 
swells,  and  may  become  filled  with  pus;  the  periosteum  and  the  shaft  are 
involved  for  a  considerable  distance;  each  epiphysis  may  become  affected, 
the  shaft  between  being  comparatively  uninvolved,  and  the  epiphyses  may 
separate,  displacement  and  shortening  taking  place.  This  disease  is  often 
mistaken  for  rheumatism  because  of  the  joint-swelling,  occasionally  for 
typhoid  fever  because  of  the  fever,  and  in  some  cases  for  erysipelas  because 
of  the  redness  of  the  skin.  It  gives  a  very  grave  prognosis.  Sometimes  an 
epiphysitis  shows  milder  symptoms  and  is  slower  in  progress  (subacute). 
These  cases  are  very  often  mistaken  for  rheumatism.  But  in  rheumatism 
the  joint  is  the  part  involved  from  the  beginning,  while  in  epiphysitis  the  joint 
is  involved  secondarily  after  obvious  evidence  of  inflammation  well  clear  of 
the  articulation.  Further,  the  symptoms  of  rheumatism  will  be  rapidly 
improved  by  the  use  of  the  alkalies  or  the  sahcylates. 

Treatment. — If  a  wound  exists,  apply  a  tourniquet,  sterilize  the  parts, 
enlarge  the  wound,  expose  and  curet  the  medullary  cavity,  remove  loose 
fragments  of  bone,  irrigate  the  medullary  cavity  with  a  hot  solution  of  corro- 
sive sublimate  or  hot  salt  solution,  scrape  it  with  bits  of  gauze  held  in  the 
bite  of  a  forceps,  paint  with  pure  carbolic  acid,  pack  hghtly  with  iodoform 
gauze,  dress  with  hot  antiseptic  fomentations,  and  secure  rest  for  the  parts 
by  splints  and  bandages.  The  constitutional  treatment  is  the  same  as  that 
for  septicemia.  Acute  osteomyelitis  without  a  wound  is  a  most  serious  con- 
dition, rapidly  progressive,  apt  to  be  quickly  fatal,  and  requiring  prompt  and 
radical  treatment.  In  treating  it  do  not  wait  for  fluctuation,  but  incise  at 
once;  break  through  the  bone  at  one  or  more  points  with  a  gouge  or  chisel; 
chisel  away  the  diseased  bone,  and  if  necessary  curet  the  medullary  canal; 
irrigate  with  hot  corrosive  sublimate  .solutions  or  hot  salt  solution;  swab  with 
pure  carbolic  acid;  u.se  iodoform  plentifully;  pack  with  iodoform  gauze; 
dress  with  hot  antiseptic  fomentations;  drain  the  joint  if  it  is  involved;  employ 
rest,  anodynes,  strong  suj^porting  treatment,  and  other  remedies  advised  in 
septicemia.  Remove  dead  hone  subse(|uently  when  it  becomes  loose.  Am- 
putation may  be  required  in  either  form  of  the  di.sease. 

Chronic  osteomyelitis  is  usually  linked  with  osteitis.  It  may 
eventuate  in  (osteosclerosis  with  fjiling  up  of  the  medullary  canal,  in  limited 
suppuration,  in  caseation  of  the  cancellous  tissue  (Brodie's  abscess),  or  in 


Acromegaly  375 

necrosis.  A  tuberculous  inflammation  is  one  form  of  chronic  osteomyelitis. 
.Syphilis,  typhoid  fever,  etc.,  may  cause  it,  and  it  can  be  caused  by  glanders, 
leprosy,  and  actinomycosis. 

The  typhoid  bacillus  is  pyogenic.  Frankel  taught  this  some  years  ago, 
and  Keen  seems  to  prove  it  in  his  work  on  the  surgery  of  typhoid  fever.  Osteo- 
myelitis due  purely  to  typhoid  bacilli  is  chronic.  When  the  medulla  contains 
typhoid  bacilli  pus  infection  is  apt  to  take  place,  and  if  such  a  mixed  infection 
arises  acute  osteomyelitis  develops. 

In  chronic  osteomyelitis  there  are  pain,  tenderness,  and  swelling,  but  no 
marked  constitutional  symptoms.  In  some  cases  the  real  trouble  is  not 
identified  until  an  abscess  forms  (see  Necrosis). 

Treatment. — If  an  abscess  exists,  at  once  evacuate  it  by  incising  the  soft 
parts  and  chiseling  the  bone.  Do  not  wait  for  an  involucrum  to  form,  but 
incise  and  disinfect  promptly,  and  drain.  If  dead  bone  is  present  it  must 
be  removed. 

Osteomalacia,  or  Mollities  Ossium. — In  this  disease  the  bones 
are  partly  decalcified,  and  consequently  soften  and  bend.  Masses  of  new 
uncalcified  bone-tissue  are  formed.  Many  bones  are  usually  involved,  but 
the  head  is  not  obviously  aftected.  It  is  commoner  beyond  than  before 
middle  age,  though  it  may  occur  in  infancy;  it  is  more  frequently  met  with 
in  women  than  in  men,  and  pregnancy  seems  to  bear  more  than  a  casual 
relation  to  its  production.  In  osteomalacia  the  medulla  increases  in  bulk 
and  becomes  more  fatty,  and  the  osseous  matter  is  absorbed  gradually,  first 
from  the  cancellous  tissue  and  then  from  the  compact  tissue.  Some  observers 
believe  that  this  curious  condition  is  due  to  lactic  acid  in  the  blood,  an  ab- 
normal amount  of  acid  having  been  produced  and  absorbed  because  of  disorder 
of  the  primary  assimilation.  Volkmann  asserts  that  some  inflammatory  con- 
dition disturbs  the  blood-supply  of  the  medulla,  and  von  Recklinghausen 
asserts  that  arterial  hyperemia  is  responsible. 

Symptoms. — The  symptoms  of  osteomalacia  are  as  follows:  many  points 
of  pain  which  are  often  thought  to  be  due  to  rheumatism;  deformities' from 
twisting  and  bending  of  bone ;  and  a  large  excess  of  calcium  salts  in  the  urine. 
Fractures  occur  from  very  slight  force.  In  the  majority  of  cases  the  disease 
is  not  cured,  but  grows  progressively  worse  until  the  patient  dies,  after 
many  years,  from  exhaustion.  In  some  cases  the  process  is  arrested  and 
the  osteoid  tissue  is  calcified. 

Treatment. — In  treating  osteomalacia  in  women  insist  that  pregnancy 
must  not  occur.  Put  braces  and  supports  upon  distorted  limbs  to  prevent 
fracture.  Advise  hygienic  surroundings  and  nourishing  food,  and  insist  on 
the  value  of  fresh  air.  Among  the  medicines  that  can  be  used  may  be  men- 
tioned cod-hver  oil,  lime  salts,  preparations  of  phosphorus,  and  bofie-marrow. 
In  women  the  removal  of  the  ovaries  sometimes  produces  cure.  It  has  been 
asserted  that  the  production  of  anesthesia  by  means  of  chloroform  may  be  of 
benefit. 

Acromegaly. — This  is  a  disease  which  causes  progressive  and  often 
great  enlargement  of  both  the  bones  and  soft  parts  of  the  extremities,  which 
enlargement  is  symmetrical.  The  cranium  is  triangular  in  shape,  with  the 
base  below.  The  lower  jaw  projects  in  advance  of  the  upper  jaw,  the  nose 
becomes  prominent  and  thick,  the  supra-orbital  ridges  are  accentuated,  and 


176 


Diseases  and  Injuries  of  Bones  and  Joints 


the  costal  cartilages  and  inner  ends  of  the  clavicles  become  })rotuberant. 
Later  the  larynx,  ribs,  shoulder-blades,  and  vertebrae  become  involved,  and 
the  back  becomes  markedly  humped  (cervicodorsal  hump).  The  hands 
and  feet  are  affected  in  advanced  cases.  As  a  rule,  the  thyroid  gland  is  en- 
larged, and  a  post-mortem  examination  may  detect  an  enlarged  pituitary 
gland.  Severe  and  uncontrollable  headache  is  sometimes  a  distressing 
feature  of  the  disease.  Treatment  is  futile.  The  disease  slowly  but  surely 
causes  death. 

Leontiasis  Ossium  (Virchow's  Disease).— This  is  a  symmetrical 
hypertrophy  limited  to  the  facial  and  cranial  bones,  and  which  begins,  as 
a  rule,  in  the  superior  maxills.  The  hypertrophy  progressively  increases, 
causes  difficulty  of  mastication,  and  is  accompanied  by  headache.  It  produces 
distinct  deformity  of  the  jaw  like  a  tumor,  whereas  acromegaly  enlarges  all 

of  the  proportions  of  a  bone 
(Fig.  145).  It  may  produce 
blindness,  new  bone  pressing  upon 
the  o])tic  nerves.  Treatment  is 
not  satisfactory,  as  a  rule.  Re- 
cently Horsley  has  obtained 
amelioration  by  operating  and 
removing  masses  of  bone. 

Ostitis  Deformans  (Paget's 

Disease).  — This  disease  was 
first  described  by  Paget  in  1877, 
and  in  the  neighborhoocJ  of  100 
cases  have  been  reported.  Pack- 
ard and  Steele  ("  Amer.  Jour,  of 
Med.  Sciences,"  Nov.,  1901)  point 
out  that  many  of  the  reported 
cases  are  not  genuine  instances 
of  the  disease,  some  being  ordi- 
nary osseous  tumors,  others  being 
cases  of  enlargement  after  frac- 
ture, and  still  others  being  in- 
stances of  mollities  ossium.  They 
think  that  67  of  the  reported 
cases  are  genuine  instances  of  the  disease.  In  this  disease  great  quantities 
of  new  bone  are  formed,  but  calcification  does  not  occur.  The  material 
undergoes  absorption,  and  the  medullary  substance  of  the  bone  becomes 
extremely  vascular  and  filled  with  white  blood-cells,  and  also  with  giant- 
cells.  The  fact  that  the  new  bone  does  not  calcify  leads  to  various 
deformities  of  the  long  bones,  on  account  of  the  weight  of  the  body;  but 
fracture  is  not  jjarticularly  apt  to  occur.  Numbers  of  bones  may  be 
decidedly  thickened.  The  underlying  cause  of  this  curious  condition  is  en- 
tirely unknown,  but  it  is  assumed  to  be  tr()])hic.  It  is  claimed  that  it  has 
occasionally  arisen  after  an  injury  to  a  long  bone,  and  has  been  excited  into 
activity  by  heat  and  (okl.  It  is  extremely  rare  before  the  age  of  forty,  and 
u.sually  begins  between  forty  and  fifty.  The  enlargement  of  the  bones  may 
be  first  detected  in  the  cranium,  but  is  more  often  first  seen  in  some  other  bone 


Fig.  145. — Leontiasis  ossium. 


Fractures 


377 


— for  instance,  the  clavicle,  the  tibia,  the  spine,  or  the  radius.  In  fact,  in  some 
cases  the  bones  of  the  head  do  not  enlarge  at  all;  but,  taking  all  the  reported 
cases,  the  skull  is  affected  more  frequently  than  any  of  the  other  bones.  In 
some  cases,  the  enlargement  of  the  bones  seems  to  be  symmetrical;  in  others, 
it  is  not.  In  the  disease  known  as  leontiasis  ossium,  the  chief  enlargement 
is  manifested  in  the  face;  in  Paget's  disease  there  is  no  enlargement  of  the 
bones  of  the  face,  or  else  these  bones  are  trivially  involved.  Packard  and 
Steele  point  out  that  the  diagnosis  is  extremely  difficult  when  but  a  single  bone 
is  involved;  but  that  if  two  or  more  bones  are  involved,  we  should  think  of 
Paget's  disease  as  the  condition,  especially  if  we  are  able  to  exclude  syphilis, 
cancer,  and  sarcoma.  In  mollities  ossium  the  head  is  not  involved  at  all; 
and  there  is  not  nearly  so  much  thickening  of  the  bone.  The  two  authors 
before  quoted  show  that  in  acromegaly  the  cranium  is  a  triangle  with  its 
base  below  the  lower  jaw,  the  orbital  arches  being  chiefly  involved;  but  that 
in  Paget's  disease  the  involvement  is  chiefly  of  the  calvarium.  In  this  curious 
•malady  there  may  or  ma}'  not  be  pain.  The  patient  actually  diminishes  in 
height.  The  chest  becomes  deformed.  There  is  angular  curvature  in  the 
dorsocervical  region.  The  lower  extremities  are  usually  bent;  and  the  pelvis, 
as  a  general  thing,  is  broadened.  In  the  67  cases  collected  by  Packard  and 
Steele,  3  suffered  with  cancer  and  5  with  sarcoma. 

Treatment. — Treatment  is  practically  useless.  No  known  expedient 
diminishes  the  size  of  the  bones,  although  iodid  of  potassium  is  said  occa- 
sionally to  mitigate  the  pain. 

2.  Fractures. 

Definition. — A  fracture  is  a  solution,  by  sudden  force,  of  the  continuity 
of  a  bone  or  of  a  cartilage.  Clinically,  under  this  head  are  placed  epiphyseal 
separations  and  the  tearing  apart  of  ribs  and  their  cartilages. 

Varieties  of  Fractures. — The  varieties  of  fractures  are  as  follows: 
Simple  fracture  is  a  subcutaneous  fracture,  or  one  in  which  there  is  no 


Fig.  146. — Fracture  of  the  lea;  complicated  with  wouiul  aiul  commiiiution  of  the  botie. 


wciund  extending  from  the  surface  to  the  seat  of  l)one-injur\-.     This  corre- 
s])onds  to  a  contusion  of  the  soft  parts. 

Compound  jracture  is  an  open  fracture,  or  one  in  which  an  open  wound 
extends  from  the  surface  to  the  seat  of  bone-injury  or  in  which  a  wound  opens 
up  a  passage  from  the  fracture  to  the  surface.  This  corresponds  to  a  contused 
or  lacerated  wound  of  the  soft  parts  (Fig.  146).     The  opening  may  be  through 


378 


Diseases  and  Injuries  of  Bones  and  Joints 


the  skin;  through  a  mucous  membrane,  as  in  some  fractures  of  the  base  of  the 
skull  and  pelvis;  through  the  drum  of  the  ear,  as  in  some  fractures  of  the 
middle  fossa  of  the  base  of  the  skull;  through  the  lung,  as  when  a  broken  rib 
penetrates  that  organ;  or  through  the  bowel  or  bladder,  as  in  some  fractures 
of  the  pelvis. 

A  primary  compound  jracture  is  one  in  which  the  breach  in  the  soft  parts 


a  h  c  d 

Fig.  147.— Complete   fractures  :  a,  Transverse  ;  d,  spiral  ;  c,  dentated  ;  d,  oblique  or  multiple. 


is  produced  at  the  time  of  the  accident,  either  by  the  direct  violence  of  the 

injury  or  by  the  forcing  of  a  bone  or  bones  through  the  tissues. 

A  secondary  compound  jracture  is  one  in  which  the  breach  in  the  soft  parts 

occurs  after  the  accident,  either  from  sloughing  of  damaged  tissues,  from 
ulceration  because  of  the  pressure  of  ill-adjusted 
fragments,  or  from  the  forcing  of  a  bone  or  bones 
through  the  soft  parts  because  of  rough  handling, 
neglect,  or  the  tossing  of  delirium. 

Complicated  jracture  is  a  fracture  plus  the  com- 
plication of  a  joint-injury,  arterial  or  venous  damage, 
or  injury  to  the  nerves  or  soft  parts.  When  a  frac- 
tured rib  injures  the  lung  or  when  a  broken  vertebra 
damages  the  cord  a  complicated  fracture  exists.  The 
term  is  unfortunate,  as  it  conveys  no  definite  meaning, 
and  ts  use  is  no  more  justifiable  than  it  would  be  to 
speak  of  "complicated  pneumonia"  or  "complicated 
typhoid,"  for  the  comphcation  should  be  named  in 
any  case.  It  must  be  remembered  that  damage  to 
the  soft  parts  not  sufficiently  severe  to  produce  a 
wound  reaching  from  the  surface  to  the  .seat  of  frac- 
ture does  not  make  the  case  a  compound  fracture, 
but  rather  complicates  a  simple  fracture.  Remember 
also  that  even  superficial  areas  of  tissue-destruction 
must  be   treated  anti.septically,  otherwise  absorption 

of  pyogenic  bacteria  and  their  deposition  at  the  seat  of  injury  may  cause 

diffuse  osteomyelitis. 

Complete  jracture  is  that  which  extends  through  the  whole  thickness  of 

a  bone  or  entirelv  across  it  (Fig.  147). 


Fig.       148.  —  Longitudinal 
and  oblique  fracture. 


Fractures 


379 


Incomplete  jractiire  is  that  which  extends  only  partially  through  the  thick- 
ness of  a  bone  or  only  partially  across  it. 

A  linear,  hair,  capillary,  or  fissured  jractitre,  or  a  fissure,  is  a  crack  in  a  bone 
with  very  little  separation  of  the  edges.  This  is  an  incom- 
plete fracture,  but  may  be  associated  with  a  complete  break. 
A  green-sfick,  hickory-stick,  willow,  or  bent  jracture  is  a 
true  incomplete  break  (Fig.  149).  The  bones  most  frequently 
broken  are  the  radius,  ulna,  clavicle,  and  ribs.  It  arises  from 
indirect  force,  and  it  is  very  rare  after  the  age  of  sixteen.  In 
rickets  green-stick  fractures  are  very  common.  It  is  called 
"green-stick"  because  the  bone  breaks  like  a  green  stick  when 
forced  across  the  knee,  first  bending  and  then  breaking  on  its 
convex  surface.  The  bone,  being  compressed  between  two 
forces,  bends,  and  the  fibers  on  the  outer  side  of  the  curve  are 
pulled  apart,  while  those  on  the  concavity  are  not  broken,  but 
are  compressed.  In  correcting  the  deformity  such  fractures 
are  often  made  complete.  The  permanent  bending  of  a  bone 
without  a  break  may  possibly  occur  in  youth.  In  children  a 
portion  of  a  bone  of  the  skull  may  be  bent  inward,  causing 
depression.  In  some  cases  such  a  depression  is  permanent: 
in  others  it  is  temporary,  the  bone  returning  to  its  proper 
level. 

Depression-fracture  occurs  when  a  portion  of  the  thickness 
of  a  bone  is  driven  in  by  crushing.  Fracture  by  depression  is 
a  result  of  the  bending  in  of  a  bone  (as  the  parietal),  a  frag- 
ment breaking  off  from  the  side 
toward  which  the  bone  is  bending. 
A  depressed  fracture  is  complete,  not 
incomplete,  and  by  this  term  is 
meant  an  injury  in  which  a  fragment  of  the  entire 
thickness  of  the  bone  is  driven  below  the  level  of 
the  surrounding  surface. 

Splinter-  and  Strain-fracture.  —  The  breaking 
off  of  a  splinter  of  bone  (splinter-fracture)  or  of 
an  apophysis  constitutes  a  form  of  incomplete  frac- 
ture. A  strain  upon  a  ligament  or  a  tendon  may 
tear  off  a  shell  of  bone,  and  this  injury  is  the 
'"strain-fracture"  or  "sprain-fracture"  of  Callender. 
Longitudinal  jracture  is  a  fracture  whose  line  is 
for  a  considerable  distance  parallel,  or  nearly  so,  with 
the  long  axis  of  the  bone.  Such  fractures  are  com- 
mon in  gunshot-injuries  (Fig.  148). 

Oblique  fracture  is  a  fracture  the  direction  of 
which  is  positivel}"  oblique  to  the  long  axis  of  the 
bone.  Most  fractures  from  indirect  force  are 
oblique  (Fig.  147,  (/). 

Transverse  fracture  is  a  fracture  the  direction  of 
which  is  nearly  transverse  to  the  long  axis  of  the  bone  (no  fracture  is 
mathematically  transverse)  (Fig.  147,  a).    The  cause  is  often,  but  not  invari- 


Fig.    149. — Green- 
stick  fracture. 


Fig.  150. — Appearances    of 
the  eiid.s  of  fragments. 


l8o 


Diseases  and  Injuries  of  Bones  and  Joints 


ablv.  direct  force.  The  "  jnniitre  en  rave''  (radish-fracture,  so  called  because 
the  bone  breaks  as  does  a  radish)  is  transverse  at  the  surface,  but  not  within. 
Toothed  or  dentate  jractitre  is  a  form  of  fracture  in  which  the  end  of  each 
fragment  is  irregularly  serrated  and  the  fragments  are  commonly  locked  to- 
gether; hence  it  is  difficult  to  correct  the  deformity  (Fig.  147,  c,  and  Fig. 
150).     Most  simple  fractures  from  direct  force  are  serrated. 


Fig.  151. — Impacted  fracture  of  the 
neck  of  the  femur. 


Fig.  152. — Impacted  fracture  of  the 
neck  of  the  femur. 


Wedge-shaped,  V-shaped,  cuneated,  or  ciineijorni  jractitre  ("  fracture  oblique 
spiro'ide,"  "fracture  en  V"  of  Gosselin,  "fracture  en  coin")  is  one  the  lines  of 
which  take  the  shape  of  a  V,  which  may  be  entire  or  may  lack  the  point.  It 
occurs  at  the  articular  e.xtremity  of  a  long  bone,  and  a  fissure  usually  arises  from 
its  point  and  enters  the  joint.     If  complete,  it  is  a  "comminuted   fracture." 

T-shaped  jracture  is  a  fracture  which  presents 

a  transverse  or  oblique  line  and  also  a  longitudinal 

or  vertical   line.       It  occurs  at  the  lower  end   of 

either  the  humerus  or  femur,  the  transverse  hne 

being  above,  and  the  vertical  line  (intercondyloid) 

between,  the  condyles.     If  complete,  it  is  in  reality 

a  form  of  comminuted  fracture. 

Multiple   or    composite   jracture  is  a  condition 

in    which    a    bone    is 

Ijroken       into      more 

than  two   pieces,   the 

lines  of  fracture   not 

i  n  tercommunicating, 

or   a  cond  i  t  i  on   i  n 

which  two  or  more 
bones  are  Ijrokeii.  Multi])le  fractures  of  one  bone 
are  divided  into  double,  treble,  quadruple,  etc. 
Comminuted  jracture  is  a  condition  in  which 
a  bone  is  broken  into  more  than  two  jjieces, 
the  lines  of  fracture  intercommunicating  (Figs. 
153  and  154).  The  bone  may  be  broken  into  many  small  fragments,  there 
may  be  much  splintering,  or  the  osseous  matter  may  actually  be  ground  up. 
Impacted  jracture  is  one  in  which  one  fragment  is  driven  into  the  other 
and  solidly  wedged  (Figs.  151,  152,  and  155). 


Fig.  153. — Comminuted  frac- 
ture of  the  lower  extremity  of 
radiu.s. 


154. — Comminuted  fracture  of 
the  upper  part  of  femur. 


Fractures 


381 


Fracture  with  crushing  or  penetration  is  a  fracture  in  which  one  bone  is 
driven  into  the  other,  the  encasing  bone  being  so  splintered  that  the  impacting 
bone  is  not  firmly  held. 

Pathological,  spontaneous,  or  secondary  fracture  is  one  occurring  from  a 
very  insignificant  force  acting  on  a  bone  rendered  brittle  by  disease. 

Ununited  fracture  is  a  fracture  in  which  bony  union  is  absent  after  the 
passage  of  the  period  normally  necessary  for  its  occurrence. 

Direct  fracture  is  one  occurring  at  the  point  at  w  hich  the  force  was  pri- 
marily applied. 

Indirect  fracture  is  one  occurring  at  a  point  distant  from  the  area  of 
j)rimary  application  of  force. 

Stellate  or  starred  fracture  (fracture  par  irradiation)  is  one  in  which 
several  fissures  radiate  from  a  center.  If  the  fractures  be  complete,  the 
condition  is  in  reality  a  form  of  comminuted  fracture. 


Fig-  155- — Impacted  fracture  of  neck  of  femur  (Conner). 


Helicoidal,  spiral,  or  torsion  fracture  is  a  fracture  resulting  in  a  long  bone 
from  twisting. 

Fracture  by  contrecoup  is  a  fracture  of  the  skull  which  is  on  the  opposite 
.side  of  the  head  to  that  which  was  the  recipient  of  the  force. 

Epiphyseal  Separation  or  Diastasis. — This  injury  occurs  only  before  the 
age  of  twenty-five.  In  order  of  frequency,  the  bones  chiefly  subject  to  epiphy- 
seal separation  are:  the  upper  end  of  the  humerus,  the  lower  end  of  the 
radius,  the  lower  end  of  the  femur,  and  the  lower  end  of  the  tibia  (John 
Poland,  in  the  "Practitioner,"  Sept.,  1901).  This  injury  induces  deformity, 
which  is  often  difficult  to  reduce,  and  by  damaging  the  cartilage  may  retard 
or  inhibit  a  further  lengthening  of  the  limb  by  growth.  Occasionally,  after 
damage  to  an  epiphysis  suppuration  will  occur,  sometimes  thickening  takes 
place.  Non-union  is  very  rare.  After  a  sprain  of  an  epiphysis  tubercu- 
lous disease  sometimes  develops,  but  very  rarely  after  a  separation. 


382  Diseases  and  Injuries  of  Bones  and  Joints 

Inira-uterine  fractures  are  usually  due  to  injuries  of  the  mother's  abdomen 
sustained  toward  the  end  of  pregnancy.  Some  hold  that  they  can  arise  as 
a  consequence  of  the  force  of  violent  uterine  contractions.  Many  so-called 
"intra -uterine"  fractures  are  wrongly  named,  as  they  result  from  injury 
during  deUvery.  In  sporadic  cretinism  the  bones  are  fragile  and  ill-ossified, 
and  many  fractures  may  occur  m  utero. 

Designation  According  to  Seal  oj  Fracture. — A  fracture  may  be  desig- 
nated according  to  its  anatomical  seat;  for  instance,  fracture  of  the  upper 
third  of  the  shaft  of  the  femur,  fracture  of  the  olecranon  process  of  the  ulna, 
fracture  of  the  middle  third  of  the  clavicle,  and  fracture  of  the  body  of  the 
lower  jaw.  Intra-articular  fracture  is  one  e.xtending  into  a  joint;  intracapsular 
fracture  is  one  within  the  capsule  of  either  the  shoulder-  or  hip-joint;  and 
extracapsular  fracture  is  one  just  without  the  capsule  of  either  the  shoulder- 
or  hip-joint. 

Causes  of  Fracture. — The  causes  of  fracture  are  (i)  exciting,  imme- 
diate or  direct,  and  (2)  predisposing  or  indirect. 

Exciting  causes  are  (a)  external  violence  and  {b)  muscular  action. 

External  violence  is  the  most  usual  exciting  cause.  Two  forms  are  noted: 
(i)  direct  violence  and  (2)  indirect  force. 

Fractures  from  direct  violence  occur  at  the  point  struck,  as  when  the  nasal 
bones  are  broken  with  the  fist.  In  such  fractures  the  soft  parts  are  injured; 
they  may  be  destroyed  at  once  in  part,  they  may  be  damaged  so  severely 
that  a  portion  sloughs,  or  they  may  be  damaged  so  slightly  that  they  do  not 
lose  vitality;  hence  fractures  by  direct  violence  may  be  compound  from  the 
start,  may  become  so,  or  may  remain  simple.  In  fractures  by  direct  force 
discoloration,  due  to  effused  blood,  usually  appears  at  the  point  struck  soon 
after  the  accident.  In  compound  fractures  by  direct  violence  the  soft-part 
injury  is  so  great  that  primary  tissue-union  cannot  occur. 

Fractures  from  indirect  force  do  not  occur  at  the  point  of  application  of 
the  force,  but  at  a  distance  from  it,  the  force  being  transmitted  through  a 
bone  or  a  chain  of  bones,  as  when  the  clavicle  is  broken  by  a  fall  upon  the 
extended  hand.  Such  fractures  tend  to  occur  in  regions  of  special  predi- 
lection. If  they  are  not  compound,  there  is  no  injury  of  the  surface  over 
the  fracture.  If  they  become  compound  by  projection  of  fragments,  primary 
union  may  still  occur.  Discoloration  over  the  seat  of  fracture  is  usually 
not  present  soon  after  the  accident,  but  may  occur  later.  Discoloration 
rapidly  appears  in  soft  parts  at  the  point  where  the  force  was  first  applied. 

Muscular  action  is  rather  an  unusual  cause.  Fractures  thus  produced 
result  from  sudden  or  violent  muscular  contraction.  Bones  so  broken  are 
usually  diseased.  Violent  coughing  may  fracture  the  ribs;  attempting  to 
kick  may  fracture  the  femur;  saving  one's  self  from  falling  backward  may 
fracture  the  patella;  throwing  a  stone  may  fracture  the  humerus;  and  sudden 
extension  of  the  forearm  may  fracture  the  olecranon  process  of  the  ulna. 

Predisposing  Causes. — There  are  two  clas.ses  of  predisposing  causes, 
namely:  (i)  physiological,  natural  or  normal,  and  (2)  pathological  or  abnor- 
mal. 

Natural  Predisposing  Causes. — Under  this  head  is  considered  the  liability 
to  fracture  yjossessed  by  individual  bones  Vjecau.se  of  their  shape,  structure, 
function,  or  position.     Those  jtredispositions  occasioned  by  special  ages  are 


Fractures  383 

also  considered.  In  youth  epiphyseal  separation  is  commoner  than  fracture 
and  a  fracture  is  apt  to  be  incomplete.  Fractures  are  commonest  between 
the  ages  of  twenty-five  and  sixty.  From  two  to  four  years  of  age  a  child 
is  more  liable  to  fracture  than  later,  because  he  is  then  learning  to  walk 
(Malgaigne).  The  bones  of  the  old  are  easily  broken,  but  the  normal  lack 
of  activity  of  the  aged  saves  them  from  more  frequent  injury.  Thus  the 
predispositions  of  age  are  in  part  due  to  habits  and  in  part  to  bony  structure. 
The  bones  of  the  young,  being  elastic,  bend  considerably  before  they  break; 
the  bones  of  the  old,  being  brittle  and  inelastic,  break  easily,  but  do  not 
bend.  In  old  age  the  bones  become  lighter  and  more  porous,  though  they 
do  not  diminish  in  size.  Absorption  takes  place  from  the  interior  of  a 
bone,  particularly  at  its  articular  head,  the  medullary  canal  increases  in 
size,  the  cancellous  spaces  become  notably  larger,  and  portions  of  the  re- 
maining bone  of  the  interior  show  a  fatty  change.  There  is  no  increase  in 
the  amount  of  mineral  salts  present,  as  was  long  taught.  These  alterations 
occur  earlier  in  women  than  in  men.*  The  change  of  age  is  a  diminution 
in  the  amount  of  bone  present,  and  sometimes  a  fatty  change  in  a  portion 
of  what  remains.  If  the  atrophy  of  bone  is  other  than  that  normal  to  senility, 
it  constitutes  a  pathological  predisposing  cause  of  fracture.  Normal  predis- 
posing causes  include  the  person's  weight  (which  determines  the  force  of 
a  fall),  muscular  development,  habits,  se.x,  occupation,  and  the  season  of  the 
year. 

Pathological  Predisposing  Causes. — Hereditary  fragility,  a  form  of  jragili- 
las  ossiiini,  is  a  condition  commonest  among  women,  often  existing  in  genera- 
tion after  generation,  and  in  this  condition  fractures  occur  from  a  very  slight 
force.  There  exists  in  these  cases  bony  rarefaction — in  fact,  a  premature 
senility.  Fragihtas  ossium  may  result  from  senihty,  from  wasting  diseases, 
from  certain  nervous  disorders,  from  rickets,  from  osteomalacia,  and  from 
atrophy  due  to  disuse. 

Neri'oiis  Diseases. — Bony  nutrition  is  dependent  on  the  spinal  cord,  and 
the  trophic  influence  is  probably  exerted  through  the  posterior  nerve-roots 
(Gowers).  In  diseases  of  the  anterior  cornua  bony  growth  is  much  interfered 
with;  in  diseases  of  the  posterior  columns,  as  in  locomotor  ataxia,  a  true 
bony  atrophy  bespeaks  trophic  disorder.  Syringomyeha  causes  brittleness 
of  the  osseous  structures,  and  in  paralysis  agitans  bones  are  thought  to  break 
easily.  Trophic  changes  may  occur  in  the  bones  of  the  insane,  most  com- 
monly when  insanity  is  linked  to  organic  di.sease.  About  one-quarter  of 
paretic  dements  show  undue  l)rittleness  or  unnatural  softness  of  bones. f 
The  bones  of  maniacs  are  frequently  fragile.  Fractures  aniong  the  insane 
are  not  necessarily  an  indication  of  abu.se. 

Rickets. — Rickets  predisposes  to  fracture  because  of  altered  bone-structure 
and  the  great  liability  to  falls. 

OstcGmalacia  predisposes  to  fracture  of  the  long  bones,  sternum  and  ribs. 

Atrophy  of  Bone. — This  condition,  as  has  been  stated  (page  364),  is  nor- 
mal in  senility.  It  may  arise  from  want  of  use,  as  is  observed  in  the  bedfast 
in  the  wasted  femur  of  hip-joint  disease,  and  in  the  bones  of  a  stump.  It 
may  arise  from  pressure,  as  when  an  aneurysm  compresses  the  ribs,  sternum, 
or  vertebrae.     Among  other  of  the  pathological  predisposing  causes  are  to  be 

*  Humphrey  on  "  Old  Age."  f  "Manual  of  Insanity,"  by  Spitzka. 


384  Diseases  and  Injuries  of  Bones  and  Joints 

mentioned  cancer,  sarcoma,  hydatid  and  solitary  cysts  of  bone,  caries,  necrosis, 
gout,  scrofula,  syphilis,  mollities  ossium,  and  scurvy. 

Symptoms  of  Fracture. — History  of  an  Injury. — In  spontaneous 
fracture  there  may  be  no  record  of  violence;  for  instance,  a  bone  may  break 
while  an  individual  is  turning  in  bed.  In  investigating  the  history,  not  only 
seek  for  a  record  or  for  evidences  of  violence,  but  try  to  determine  exactly 
how  the  accident  happened. 

A  sound  oj  cracking  is  occasionally  audible  to  a  bystander  at  the  time 
of  the  injury.  The  patient  may  have  heard  it,  but  very  rarely  does.  A 
rupture  of  a  tendon  or  a  ligament  produces  a  similar  sound. 

Pain  is  usually,  but  not  invariably,  present  (absent  often  in  rickets). 
Malgaigne  says  that  in  some  fractures  the  pain  is  slight  or  absent,  in  others 
it  is  torturing,  and  in  most  it  is  severe  for  a  time  after  the  injury,  but  gradually 
abates  unless  reinduced  by  movement.  Pain  developed  at  the  time  of  the 
accident  is  far  less  important  as  a  symptom  than  that  which  can  subsequently 
be  produced  by  movement.  In  indirect  fracture  there  is  an  area  of  pain 
at  the  point  of  application  of  the  force,  and  another  at  the  seat  of  fracture. 
Pain  at  the  seat  of  fracture  can  be  greatly  aggravated  by  pressure  or  movement 
and  is  rather  narrowly  localized. 

Deformity  or  alteration  in  length  or  outline  is  due  in  part  to  swelling  and 
in  part  to  a  change  in  the  mutual  relation  of  the  fragments  (displacement). 
The  deformity  due  to  swelling  is  no  aid  to  diagnosis,  as  the  same  condition 
occurs  in  contusion,  and  often  hides  some  positive  symptomatic  distortion. 
The  swelling  is  due  first  to  blood  and  next  to  inflammatory  products  and 
pressure-edema,  and  is  very  great  in  joint-fractures.  The  deformity  of  dis- 
placement may  be  produced  by  the  violence  of  the  injury  (as  is  the  depression 
in  a  skull-fracture),  by  the  weight  of  an  extremity  (as  is  the  falling  of  the 
shoulder  in  a  fracture  of  the  clavicle),  or  by  muscular  action  (as  is  the  pulling 
upward  of  the  superior  fragment  of  a  fractured  olecranon  process). 

The  varieties  of  displacement  are  (1)  transverse  or  lateral,  where 
one  fragment  goes  to  the  side,  front,  or  back,  but  does  not  overlap  the  other; 
(2)  angular,  the  bony  axis  at  the  point  of  fracture  being  altered  and  the 
fragments  forming  with  each  other  an  angle;  (3)  rotary,  one  fragment  rotating 
in  the  bony  circumference,  the  other  remaining  stationary.  As  a  rule,  it  is 
the  lower  fragment  which  turns  on  its  long  axis,  the  limb  below  the  level 
of  the  break  rotating  with  it;  (4)  overlapping  or  overriding,  when  the  upper 
level  of  one  fragment  is  above  the  lower  level  of  the  other  fragment.  It  is 
usually  the  lower  fragment  which  is  drawn  by  the  muscles  above  the  upper, 
but  in  a  fracture  of  the  lower  extremity  the  body-weight  and  sliding  down 
in  bed  may  [)ush  the  upper  below  the  lower  fragment.  In  overriding  the 
ends  are  near  together  and  the  bones  are  usually  in  contact  at  their  periphery. 
It  is  obvious  that  overlapping  is  associated  with  transverse  displacement,  as 
one  fragment  must  go  front,  back,  or  to  the  side;  (5)  penetration  or  impaction 
when  one  fragment  is  driven  into  the  other,  thus  producing  shortening; 
(6)  separation  of  the  two  fragments  occurs  in  fracture  of  the  patella,  olecranon, 
OS  calcis,  certain  articulations,  and  in  some  breaks  of  the  humerus  when  the 
arm  is  not  supported. 

It  is  important  to  remember  that  a  dislocation  as  well  as  a  fracture  may 
produce   disj)lacemenl,   but   these   two   conditions   may   be  differentiated   by 


Fractures  385 

the  observation  that  the  displacement  of  fracture  tends  to  reappear  even 
after  complete  reduction,  while  the  displacement  of  dislocation  does  not 
reappear  after  correction.  A  displacement  is  diflficult  of  detection  in  a  flat 
bone  and  when  one  of  two  parallel  bones  is  broken. 

Loss  of  junction  may  be  shown  by  inability  to  move  the  limb  because 
of  the  break,  but  it  is  not  always  markedly  present,  though  some  degree 
invariably  e.xists.  It  is  slight  in  "green-stick"  and  impacted  fractures  (unless 
the  loss  of  power  arises  from  pain  or  nerve-injury).  A  person  can  walk 
when  the  fibula  alone  is  broken,  and  likewise  in  some  cases  of  intracapsular 
fracture  of  the  fernur,  and  can  often  put  the  hand  on  the  head  in  fractured 
clavicle  (Malgaigne).  The  pain  of  any  injury  or  the  loss  of  power  from 
nerve-traumatism  may  cause  loss  of  movement  in  the  limb.  This  symptom 
is  of  slight  diagnostic  value  in  most  fractures. 

Extravasation  oj  Blood. — A  contusion  of  the  surface  accompanied  by  skin- 
abrasion  indicates  merely  the  point  of  application  of  direct  external  violence. 
If  contusion  is  extensive  over  a  superficial  bone,  as  the  tibia  or  parietal, 
after  a  few  hours  it  often  stimulates  fracture  by  presenting  a  soft,  compressible 
center  surrounded  by  a  ring  of  hard,  condensed  tissues  and  coagulated  blood. 
Direct  external  violence  may  merely  occasion  ecchymosis,  and  in  fracture 
from  indirect  force  ecchymosis  may  occur  throughout  a  considerable  area. 
In  regard  to  this  symptom,  note  that  even  great  external  violence  may  occasion 
no  evident  contusion  or  ecchymosis,  and  in  any  fracture  this  symptom  may 
be  present  or  absent.  In  old  people,  anemic  subjects,  alcoholics  and  opium- 
eaters,  extravasation  of  blood  is  frequently  marked  and  persistent.  By  sug- 
gillation  is  meant  an  extravasation  of  blood  which  slowly  invades  wide  areas 
of  tissue  and  which  appears  at  the  surface  only  after  some  time,  and  then 
usually  as  a  yellowish  discoloration,  red  hemoglobin  having  been  changed 
to  yellow  hematoidin.  Linear  ecchymosis  has  been  esteemed  by  some  as  a 
sign  of  fissure,  and  it  is  often  noted  after  fracture  of  the  fibula.  Linear 
ecchymosis  over  the  line  of  the  posterior  auricular  artery  was  shown  by 
Battle  to  be  a  valuable  sign  of  fracture  of  the  posterior  fossa  of  the  base  of 
the  cranium. 

Preternatural  mobility  is  a  most  important  symptom,  which  is  pathogno- 
monic when  surely  found.  The  unbroken  bone  is  nowhere  mobile  in  con- 
tinuity. By  preternatural  mobility  is  meant  that  a  bone  is  mobile  in  con- 
tinuity or  that  there  is  abnormality  in  the  direction  or  extent  of  joint-mobility. 
In  some  fractures  this  symptom  does  not  exist  (impacted,  green-stick,  and 
locked  serrated  fractures) ;  in  others  it  cannot  be  found  (fractures  of  tarsus, 
carpus,  vertebral  bodies) ;  in  others  it  is  difficult  to  obtain,  but  at  times  can 
be  developed  (fractures  near  or  into  many  joints).  To  develop  this  symptom, 
try,  when  the  case  admits,  to  grasp  the  fragments  and  to  move  them 
in  opposite  directions.  In  a  fracture  of  the  shaft  of  the  femur  or  humerus 
fix  the  upper  fragment  and  carry  the  knee  or  elbow  in  various  directions 
to  develop  bending  at  the  point  of  fracture.  In  fracture  of  the  clavicle  push 
the  shoulder  downward  and  inward.  In  fractures  of  either  bone  of  the  fore- 
arm grasp  the  parallel  bone  with  four  fingers  of  each  hand  and  make  pressure 
on  the  suspected  bone  alternatelv  with  either  thumb,  and  the  same  procedure 
can  be  used  in  fractures  of  the  leg.  In  fracture  of  the  neck  of  the  femur 
the  altered  rotation-arc  of  the  great  trochanter  demonstrates  preternatural 
25 


386  Diseases  and  Injuries  of  Bones  and  Joints 

mobility  (Desault).  In  fracture  of  the  lower  end  of  the  radius  bend  the 
hand  back,  and  in  a  break  of  the  lower  end  of  the  fibula  evert  the  foot 
(Maisonneuve).  In  seeking  preternatural  mobility,  remember  that  the  elas- 
tic ribs  when  forced  in  give  a  sense  of  bending,  and  that  the  fibula  at  its 
middle  is  "normally  flexible"  (Dupuytren).  Some  rachitic  bones  may  be 
bent. 

Crepitus  or  crepitation  is  both  a  sensation  and  a  sound,  which  indicates 
the  grating  together  of  the  two  rough  surfaces  of  a  broken  bone.  This  symp- 
tom is  of  great  value,  but  it  is  not  always  present.  It  is  absent  in  locked 
serrated  fractures,  in  impacted  fractures,  in  cases  where  the  broken  ends 
cannot  be  approximated  (as  in  overlapping),  is  rare  when  a  fractured  surface 
is  against  the  side,  and  not  the  broken  face,  of  the  other  fragment,  and  is 
unusual  in  incomplete  fractures.  Crepitus  is  often  absent  in  epiphyseal 
separation,  in  softened  bones,  and  in  fractures  in  or  near  joints,  and  it  may 
be  prevented  from  occurring  by  blood-clot,  fascia,  synovial  membrane,  perios- 
teum, or  muscle  between  the  broken  surfaces.  The  grating  found  in  teno- 
synovitis must  not  be  mistaken  for  the  crepitus  of  fracture:  the  former  is 
diffuse,  large,  soft,  and  moist;  the  latter  is  limited,  small,  harsh,  and  dry. 
The  clicking  of  an  inflamed  or  eroded  joint  and  the  crackling  of  emphysema 
must  also  be  separated  from  bony  crepitus.  Crepitus  of  fracture  may  be 
present  at  one  moment,  but  absent  the  next.  It  is  often  not  detected  during 
the  time  swelling  is  marked,  and  cannot  be  discovered  after  organization 
of  the  callus  begins.  In  but  few  fractures  is  it  needful  to  try  to  hear  crepitus 
with  the  unaided  ear  or  with  a  stethoscope  upon  the  part,  but  in  doubt- 
ful cases  of  fractures  of  ribs  and  joints  this  evidence  should  be  sought  for. 

The  above-named  symptoms  are  known  as  "direct."  There  are  other 
symptoms  known  as  "circumstantial,"  such  as  the  flow  of  blood  and  cere- 
brospinal fluid  from  the  ear  after  some  fractures  of  the  middle  fossa  of  the 
skull;  emphysema  of  the  face  and  epistaxis  after  fracture  of  the  nasal  bones; 
hemoptysis  and  emphysema  after  crushes  of  the  chest;  discoloration  following 
the  line  of  the  posterior  auricular  artery  after  fracture  of  the  posterior  fossa 
of  the  skull;  and  subconjunctival  ecchymosis  after  fracture  of  the  anterior 
fossa  of  the  skull. 

Diagnosis. — Examine  as  soon  as  practicable  after  the  injury — before 
the  onset  of  swelling,  if  possible.  Expose  the  part  completely,  taking  off 
the  clothing,  if  necessary,  by  clipping  it  along  the  seams.  Attentively  scru- 
tinize the  part  and  compare  it  with  the  corresponding  part  on  the  opposite 
side.  If  any  deformity  be  present,  it  must  be  ascertained  that  it  did  not 
exist  before  the  accident.  If  the  nature  of  the  injury  be  uncertain,  if  the 
patient  be  very  nervous,  or  if  the  part  be  acutely  painful,  it  is  better  to  give 
ether  to  diagnosticate,  set,  and  dress.  In  injuries  of  the  elbow-joint  anesthe- 
tize before  examination,  unless  an  .v-ray  apparatus  is  accessible  to  settle 
the  diagnosis,  and  even  then  it  is  usually  well  to  anesthetize  in  order  to  facili- 
tate reduction  and  dressing. 

A  fracture  is  distinguished  from  a  dislocation  by  its  preternatural  mobility, 
its  easily  reduced  but  recurring  displacement,  and  its  crepitus,  as  contrasted 
with  the  preternatural  rigidity,  the  deformity,  difficult  to  reduce  but  remaining 
reduced,  and  the  absence  of  crepitus  of  a  dislocation.  Further,  in  dislocation 
the  bone,  when  rotated,  moves  as  one  piece,  whereas  in  fracture  it  does  not 


Fractures  387 

s(i  move;  in  dislocation  the  bony  processes  are  felt  occupying  their  proper 
relations  to  the  rest  of  the  same  bone,  while  in  fracture  some  of  them  present 
altered  relations.  In  dislocation  the  head  of  the  bone  is  found  out  of  its 
socket,  but  in  fracture  it  is  felt  in  place.  It  is  important  to  remember, 
moreover,  that  a  fracture  and  a  dislocation  may  occur  together,  and  that 
the  rubbing  of  a  dislocated  bone  against  an  articular  edge,  when  the  joint  has 
been  roughened  by  inflammation,  simulates  crepitus. 

Great  contusion,  by  inducing  extreme  tumefaction,  may  mask  charac- 
teristic deformity  and  obscure  crepitus.  When  only  a  contusion  exists, 
pain  is  apt  to  be  widespread;  but  if  a  fracture  has  occurred,  the  pain  is 
accentuated  at  some  narrow  spot.  In  many  cases,  before  he  can  give  a  certain 
opinion,  the  surgeon  must  wait  some  days  until  the  swelling  has  largely 
subsided.  In  such  a  case  it  is  best  to  assume  in  our  treatment  that  a  fracture 
exists  until  the  contrary  is  known.  Combat  swelling  by  rest,  the  use  of 
evaporating  lotions,  and  moderate  compression. 

In  impaction  the  diagnosis  is  difficult.  The  moderate  deformity  is  con- 
cealed by  swelling;  crepitus  and  preternatural  mobility  do  not  exist  unless 
the  fragments  are  pulled  apart,  and  there  is  not  necessarily  much  loss  of 
function.  A  conclusion  is  reached  largely  by  considering  the  nature,  direction, 
and  extent  of  the  violence,  the  seat  of  the  pain,  and  by  a  careful  study  of 
the  most  minute  deformity.  It  is  difficult  to  recognize  fissures.  They 
rarely  present  any  evidence  of  their  existence  except  a  localized  pain,  and 
possibly  a  linear  ecchymosis  appearing  after  a  few  days. 

In  green-stick  fractures  the  age,  the  deformity,  and  possibly  crepitus 
during  reduction  help  in  the  diagnosis,  although  in  many  cases  no  crepitus 
is  obtained.  Epiphyseal  separations  are  diagnosticated  by  the  age,  the 
preternatural  mobility,  the  pain,  the  swelling,  the  ecchymosis,  the  deformity, 
the  situation  of  the  injury,  and  the  absence  of  crepitus  or  the  presence  only 
of  a  soft  crepitus.  It  is  important,  however,  to  remember  that  an  epiphyseal 
separation  is  sometimes  incomplete,  and  even  when  it  is  complete  there 
may  be  no  displacement.  In  cases  without  displacement  the  .v-rays  will 
not  enable  us  to  make  a  diagnosis.  In  many  cases  of  complete  separation 
soft  crepitus  is  obtainable;  but  in  not  a  few  cases  it  is  not  to  be  found.  In 
incomplete  separation  crepitus  is  absent.  If  absent  in  complete  separation, 
probably  some  tissue  is  between  the  lines.  Fractures  are  often  difficult  to 
recognize  w^hen  occurring  in  a  group  of  bones  (which  are  firmly  joined  by 
dense  ligaments)  like  those  of  the  carpus  and  tarsus,  or  in  one  of  two  parallel 
bones.  There  is  not  always  a  certainty  that  a  fracture  exists,  and  Vi^hen, 
after  a  careful  examination,  there  is  still  an  uncertainty,  do  not  prolong 
the  efforts  or  use  great  force,  but  treat  the  case  as  a  fracture  until  a  cure 
ensues  or  the  diagnosis  becomes  apparent. 

In  a  child  the  diagnosis  of  fracture  is  sometimes  difficult.  Pain  may  be 
trivial.  Children  are  liable  to  a  form  of  fracture  in  which  the  periosteum 
is  but  slightly  torn  or  is  not  torn  at  all,  the  disability  and  pain  are  often  slight, 
and  the  fracture  may  be  easily  overlooked  (Cotton  and  Vose). 

We  have  recently  had  added  to  our  resources  a  method  of  incalculable 
value  in  diagnosticating  fracture;  that  is.  the  use  of  the  force  known  as  the 
.v-ray  or  the  Rontgen  ray.  We  can  look  through  a  part  with  a  fluoroscope 
and  see  the  bones  as  shadows,  or  we  can  take  a  negative  of  the  shadows 


388  Diseases  and  Injuries  of  Rones  and  Joints 

and  print  skiagraphs  from  it.  This  method  is  applicable  even  when  the 
parts  are  swollen,  and  even  when  a  limb  is  clothed  or  wrapped  in  dressings. 
It  is  possible  to  obtain  a  picture  of  a  fractured  skull  after  long  exposure; 
fractured  ribs  and  vertebrae  can  be  detected ;  and  the  process  is  of  the  greatest 
use  in  detecting  fractures  of  the  limbs.  It  is  not  infallible.  An  epiphyseal 
separation  may  not  be  detected,  and  a  slight  angling  of  the  plate  may  give 
a  deceptive  appearance  of  distortion.  An  .v-ray  picture,  to  be  useful,  must 
be  taken  by  an  expert  and  should  be  interpreted  by  a  surgeon.  This  method 
should,  if  possible,  be  resorted  to  in  doubtful  cases. 

Complications  and  Consequences.— Some  of  the  consequences  and 

complications  of  fractures  are — sloughing  of  the  soft  parts,  thus  making 
the  fracture  compound;  extravasation  of  blood,  causing  swelling  or  even  gan- 
grene; rupture  of  the  main  artery  or  vein  of  the  limb;  dislocation;  edema 
from  pressure  of  extravasated  blood,  from  inflammatory  exudation,  from 
tight  bandaging,  from  thrombosis,  or,  later,  from  the  pressure  of  callus; 
stiffness  of  joints  from  synovitis  with  adhesion,  from  displaced  fragments, 
or  from  intra -articular  callus;  stiffness  of  tendons  from  adhesive  thecitis  or 
from  the  pressure  of  callus;  paralysis  from  traumatic  neuritis,  the  pre.ssure 
of  callus  upon  nerve-trunks,  or  from  division  of  a  nerve;  muscular  spasm; 
painful  callus;  exuberant  callus;  embolism;  fat-embolism;  pulmonary  con- 
gestion; gangrene;  shock;  septicemia;  pyemia;  tetanus;  delirium  tremens; 
urinary  retention;  extensive  laceration  of  the  soft  parts;  rupture  of  large 
nerves;  and  involvement  of  joints.  A  fracture  may  fail  to  unite,  fibrous 
union  or  cartilaginous  union  only  being  obtained.  An  epiphyseal  separation 
may  arrest  the  future  growth  of  the  limb. 

Repair  of  Fractures. — Simple  Fracture. — In  a  simple  fracture  the 
bone  is  broken,  the  medullary  contents  are  lacerated,  the  periosteum  is  torn, 
and  the  overlying  soft  parts  are  damaged  to  a  considerable  degree.  The 
periosteum  is  stripped  more  or  less  from  each  fragment,  but  it  is  rarely  com- 
pletely torn  through,  an  untorn  portion  known  as  the  periosteal  bridge  re- 
maining. The  amount  of  blood  effused  is  usually  considerable,  and  it  forms 
a  decided  prominence  at  the  seat  of  fracture;  it  gradually  gathers  becau.se 
of  oozing,  and  soon  clots.  This  clot  hes  in  the  medullary  canal,  between  the 
fragments,  under  the  periosteum  at  the  ends  of  the  fragments,  and  in  the 
tissues  outside  of  the  periosteum.  Very  rapidly  after  the  accident  the  dam- 
aged parts  inflame  (bone,  endosteum,  periosteum,  and  the  torn  periosseous 
structures).  The  inflammatory  exudate  enters  into  the  blood-clot  and  the 
leukocytes  eat  up  and  destroy  the  clot.  The  clot  is  simply  dead  material 
and  in  no  way  contributes  to  repair.  The  cells  of  the  damaged  tissue  pro- 
liferate and  the  young  proliferating  cells  (fibroblasts)  enter  into  the  spaces 
in  the  blood  and  clot  eaten  out  by  the  leukocytes.  Finally  the  entire  clot  is 
replaced  by  fibroblasts  and  much  of  this  cellular  mass  quickly  becomes  vas- 
cularized (granulation  tis.sue). 

The  o.steoblasts,  which  exi.st  in  the  deeper  layers  of  the  periosteum  and 
in  the  tis.sue  of  the  medulla  itself,  begin  to  proHferate  actively  .soon  after 
the  fracture  has  taken  place.  The  fibrobla.sts  have  been  formed  by  the 
proliferation  of  the  ordinary  connective-tissue  cells,  and  the  proliferating 
o.steoblasts  .soon  enter  into  and  become  widely  distributed  through  this  mass 
of  fibroblasts.     Some  maintain  that  the  fibroblasts  themselves  are  directly 


Fractures  389 

transformed  into  bone;  other  observers  deny  this,  and  think  that  all  bone- 
formation  comes  from  the  osteoblasts.  Osteoblasts  may  form  bone  directly, 
or  may  form  cartilage  first  and  then  bone.  When  a  fracture  takes  place, 
a  bridge  of  periosteum  is  usually  left  untorn;  and  this  bridge  holds  the  frag- 
ments in  contact  at  some  point,  just  as  a  strap  nailed  to  a  trunk  and  also 
to  its  lid  might  hold  these  two  objects  in  contact  at  some  point.  The  new 
tissue  about  the  periosteal  bridge  always  becomes  cartilaginous  for  a  time; 
but  the  rest  of  the  callus  rarely  shows  the  development  of  cartilage,  and 
passes  directly  into  bone.  If,  however,  osteoblasts  fail  to  proliferate  with 
sufficient  activity,  the  mass  of  granulation  tissue  becomes  fibrous  tissue; 
bone  is  not  formed  at  all,  or  is  very  scantily  formed;  and  fibrous  union  occurs. 
If  the  osteoblasts  lack  activity,  but  are  more  active  than  in  the  case  just 
cited,  they  form  cartilage  extensively — but  cartilage  only;  consequently, 
cavrtilaginous  union  occurs.  During  the  process  of  the  repair  of  a  fracture 
the  ends  of  the  bony  fragments  are  always  softened,  and  some  of  the  bone 
is  absorbed  by  the  osteoclasts.  The  osteoclasts  are  really  large  osteoblasts 
that  have  lost  the  power  of  producing  bone  and  that  furnish  a  secretion  to 
absorb  bone  (the  elder  Senn).  After  bony  union  has  been  accomplished  the 
osteoclasts  absorb  the  superfluous  callus.  The  mass  of  new  tissue  around 
and  between  the  bone-ends  is  called  callus.  It  will  be  observed  that  the 
name  is  apphed  successively  to  fibroblastic  tissue,  granulation  tissue,  fibrous 
tissue,  and  bone.  Warren  tells  us  that  callus  has  no  well-defined  outline, 
and  "involves  not  only  the  bone  and  periosteum,  but  also  the  connective 
tissue  and  some  of  the  surrounding  muscular  tissue."  Within  a  few  days 
after  the  injury  the  inflammatory  mass  is  much  firmer  than  follows  inflamma- 
tion involving  other  structures,  and  the  bone-ends  are  deeply  imbedded  in  a 
dense  mass. 

During  the  second  week  the  callus  is  greatly  strengthened  by  the  formation 
of  dense  fibrous  tissue  in  and  below  the  periosteum,  of  less  dense  fibrous 
tissue  outside  the  periosteum,  and  of  cartilage  from  the  periosteal  bridge. 
The  newly  formed  tissue  contracts  decidedly.  During  the  third  week  ossi- 
fication begins  at  the  points  farthest  from  the  fracture,  and  in  the  course 
of  a  short  time  (from  three  to  six  weeks)  is  complete.  The  mass  of  ossified 
callus,  or  new  bone,  is  spindle-shaped  and  spongy. 

The  term  intermediate,  definitive,  or  perynanent  callus  is  used  to  describe 
the  material  which  forms  between  the  ends  of  the  broken  bone.  The  name 
provisional  or  temporary  callus  is  given  to  the  material  within  the  canal  (cen- 
tral callus)  and  external  to  the  bone  (ensheathing  callus).  The  amount  of 
provisional  callus  depends  directly  on  the  extent  of  separation  and  the  amount 
of  motion  between  the  fragments.  It  is  Nature's  splint,  and  when  the  break 
is  not  well  immobilized  a  large  amount  is  formed.  The  greater  the  amount 
of  motion,  short  of  a  degree  sufl&cient  to  cause  non-union,  the  larger  the 
amount  of  provisional  callus. 

The  ensheathing  callus  is  after  a  time  largely  absorbed,  and  the  central 
callus  in  the  course  of  a  long  time  may  also  be  absorbed,  with  the  restoration 
of  the  medullary  canal,  although  this  latter  result  is  rare.  An  excessive 
amount  of  provisional  callus  may  ossify  nearby  tendons,  may  unite  two 
parallel  bones  (radius  to  ulna,  tibia  to  fibula,  a  rib  to  its  neighbors),  may 
block  a  joint  just  as  a  stone  in  the  crack  of  a  door  will  block  a  door,  or  may 


390  Diseases  and  Injuries  of  Bones  and   Joints 

absolutely  abolish  a  joint.  Fragments,  even  if  entirely  detached,  often  unite, 
but  they  may  be  surrounded  by  provisional  callus;  sometimes  they  do  not 
cause  trouble,  but  sometimes  suppuration  takes  place.  It  takes  about  one 
year  for  Nature  to  remove  the  temporary  callus.  The  definitive  or  permanent 
callus  after  a  time  ceases  to  be  porous  and  becomes  very  dense  bone. 

Compound  fractures  without  much  destruction  or  bruising  of  soft  parts, 
if  treated  antiseptically,  become  at  once  simple  fractures  and  unite  as  such. 
If  the  wound  is  not  drained  and  asepticized  and  septic  inflammation  occurs, 
pus  forms,  and  union  by  granulation  is  the  best  that  can  be  obtained.  Com- 
pound fractures  by  direct  violence  will  not  heal  by  first  intention  because 
of  the  loss  of  vitality  of  a  large  area  of  the  soft  parts. 

Delayed  union  is  usually  due  to  imperfect  approximation  of  the  frag- 
ments. This  imperfect  approximation  may  result  from  failure  to  reduce 
the  fracture  (muscle,  ligament,  or  synovial  membrane  being  caught  between 
the  ends  of  the  bone);  the  use  of  unsuitable  splints;  too  tight  application  of 
bandages;  and  general  cau.ses  of  ill  health,  for  instance  anemia,  scurvy, 
Bright's  disease,  rickets,  syphilis,  and  pregnancy.  In  delayed  union  there  is 
pain  on  passive  motion;  in  non-union  there  is  not.  In  delayed  union  there 
is  loss  of  voluntary  motion;  in  non-union  there  is  power  of  voluntary  motion 
(A.  H.  Tubby,  in  "Brit.  Med.  Jour.,"  Dec.  7,  1901).  Delayed  union  is 
not  non-union,  but  may  eventuate  in  non-union. 

Non=union  of  Fractures. — An  ununited  fracture  is  a  fracture  in  which 
union  is  not  effected  at  all  or  in  which  it  is  not  brought  about  by  bone.  Non- 
union is  especially  common  in  fractures  of  the  upper  third  of  the  femur  and 
of  the  middle  third  of  the  humerus.  The  causes  are  local  and  constitutional. 
The  local  causes  are  (i)  want  of  approximation  of  fragments  (a  frequent 
cause  of  want  of  approximation  is  interposition  of  soft  tissues,  especially  mus- 
cle); (2)  want  of  rest;  (3)  want  of  blood-supply  (as  seen  in  the  heads  of  the 
humerus  and  femur,  or  when  a  nutrient  artery  is  torn,  or  when  a  thrombus 
forms  in  a  vein  near  the  fracture);  (4)  defective  innervation;  (5)  bone- 
disease;  (6)  the  use  of  unsuitable  splints;  (7)  tight  bandaging.  The  consti- 
tutional causes  are  debility,  scurvy,  Bright's  disease,  syphilis,  etc.  Sometimes 
union  fails  to  occur  for  no  appreciable  reason.  In  an  ununited  fracture  the 
broken  ends  of  the  bone  round  off  and  the  medullary  canal  of  each  fragment 
becomes  closed  by  bone.  The  fragments  may  not  be  held  together  by  any 
material,  or  they  may  be  held  by  very  thin  and  much-stretched  fibrous  tissue 
(memhranous  union),  or  by  strong,  thick,  fibrous  tissue  {ligamentous  or  fibrous 
union).  When  the  ends  of  the  bones  come  together,  are  held  by  a  fibrous 
capsule,  and  move  on  each  other,  there  exists  a  false  joint  or  pseudarthrosis. 
Such  a  joint  may  after  a  time  secrete  serous  fluid  for  lubrication. 

Vicious  union  is  union  with  great  deformity,  and  is  often  prcKkutive 
of  pain  and  loss  of  function.  It  arises  from  failure  to  coaptatc  the  fragments, 
from  a  recurrence  of  displacement  after  reduction,  or  from  yielding  of  callus 
after  the  removal  of  splints. 

Treatment  of  Fracture. — If  a  man  is  found  in  the  street  with  a 
fracture,  further  injury  must  be  i)revented  by  ai)i)lying,  after  cutting  off 
the  clothing  over  the  fracture,  .some  temporary  support.  If  an  ambulance 
or  patrol-wagon  cannot  be  obtained,  move  the  i)atient  by  iiand.  If  the 
lower  extremity  be  involved,  an  improvised  stretcher  (a  board  or  a  shutter)' 


Fractures  '  391 

is  placed  on  the  ground  beside  the  patient,  who  is  laid  on  the  stretcher, 
the  surgeon  lifting  the  injured  limb,  and  the  patient  is  then  carried  to  the 
hospital  and  carefully  transferred  to  a  fracture-bed,  or,  if  taken  home,  to 
a  small  ordinary  bed,  several  boards  being  placed  transversely  beneath  a 
rather  hard  but  even  mattress.  The  temporary  appliances  are  now  removed 
and  a  diagnosis  by  the  methods  before  given  is  proceeded  with.  After  de- 
termining the  nature  of  the  injury  the  fragments  must  be  adjusted.  This 
should,  if  possible,  be  done  at  once,  because  a  fracture  remaining  unreduced 
may  become  compound,  the  fragments  may  injure  important  structures,  and 
they  are  sure  to  cause  intense  pain.  Reduction  is  easily  effected  during 
shock,  as  the  muscles  are  in  a  state  of  relaxation.  If  there  is  great  swell- 
ing, reduction  may  be  impossible,  and  the  part  must  then  be  supported, 
moderate  cold,  sorbefacients,  and  gentle  pressure  being  used,  ice  and  tight 
bandaging,  which  predispose  to  gangrene,  not  being  employed.  Set  the  frac- 
ture at  the  first  possible  moment.  Velpeau's  a.xiom  was  to  reduce  fractures 
at  once,  regardless  of  pain,  spasm,  or  inflammation,  as  reduction  is  their  cure. 

If  the  patient  is  very  nervous,  if  the  pain  is  severe,  or  if  rigid  muscles 
antagonize  the  efforts  of  the  surgeon,  reduce  the  fracture  under  anesthesia.  In 
some  fractures  (as  those  of  the  clavicle)  adjustment  is  effected  by  altering 
the  position,  and  in  others  (as  those  of  the  femur)  by  extension  and  counter- 
extension;  in  some  by  tenotomy,  and  in  some  by  kneading,  bending,  and 
coaptation.  When  extension  is  employed,  always  endeavor  to  get  a  point 
of  counterextension.  The  extension  is  to  be  made  on  the  broken  bone  (if 
possible,  in  the  axis  of  the  bone),  is  to  be  steady,  and  neither  jerky  nor  violent. 
In  some  cases  complete  reduction  is  impossible.  This  may  be  due  to  spasm, 
to  swelling,  to  the  catching  of  soft  parts  between  the  fragments,  to  the  existence 
of  a  loose  fragment,  to  locking,  or  to  impaction.  An  impaction  by  rotation 
can  generally  be  released,  but  it  is  sometimes  undesirable  to  reduce  it.  If 
the  fragments  cannot  be  adjusted  without  violence,  retain  them  in  the  best 
attainable  position,  combat  the  antagonistic  cause,  and  set  them  properly  as 
soon  as  possible. 

After  adjusting  the  fragments  maintain  them  in  position  by  some  reten- 
tive apparatus.  Avoid  pressure  over  joints  or  bony  prominences,  and  par- 
ticularly guard  against  tight  or  improper  bandaging.  The  circulation  in  the 
fingers  or  the  toes  must  be  observed  as  an  index  of  circulation  in  the  limb; 
hence  leave  those  digits  exposed.  A  retentive  apparatus  should  prevent  the 
redevelopment  of  deformity,  and  not  be  itself  productive  of  pain  or  harm.  For 
the  first  few  days  of  treatment  of  a  simple  fracture  the  dressing  is  removed 
every  day,  to  make  sure  that  deformity  has  not  recurred,  and  if  it  does  recur  the 
fragments  must  at  once  be  reset.  The  splints  should  be  padded  thoroughly, 
especially  when  over  joints  or  bony  prominences,  and  they  should,  if  possible, 
fix  the  joints  immediately  above  and  below  the  break.  A  primary  roller  should 
never  be  used. 

Some  surgeons  at  once  apply  an  immf)vable  dressing.  This  proceeding  is 
safe  in  simple  fractures  without  much  displacement  or  soft-part  injury.  This 
dressing  is  valuable  in  military  practice,  for  the  old  and  feeble  whom  we  fear 
to  put  to  bed,  for  the  young  who  are  very  restless,  and  for  the  insane  or  the 
delirious.  If,  however,  there  is  great  deformity,  much  soft-part  injury,  or 
marked  swelling,  immovable  dressings  may  induce  sloughing,  edema,  gangrene 


392 


Diseases  and  Injuries  of  Bones  and  Joints 


or  faulty  union.  In  the  above-named  cases  use  splints  for  the  first  few  days; 
then,  if  it  is  desirable,  the  immovable  dressing  can  be  applied.  Plaster-of-Paris 
bandages. are  unsafe  in  very  young  children,  and  gangrene  may  occasionally 
result  from  their  application.  It  is  dangerous  to  keep  old  or  feeble  persons 
long  in  bed,  as  they  are  prone  to  develop  bed-sores  and  hypostatic  pulmonary 
congestion.  The  period  for  the  artificial  retention  of  the  fracture  varies  with 
the  seat  of  the  fracture  and  the  age  and  the  condition  of  the  patient.  Passive 
motion  is  to  be  made  in  most  fractures  in  from  two  to  three  weeks,  though  it  is 
sometimes  made  earlier  to  prevent  ankylosis  and  sometimes  later  because  of 
risk  of  non-union.  Landerer  strongly  advocates  massage,  believing  that  it 
hastens  union  and  prevents  wasting.     He  applies  it  as  soon  as  there  is  no 


Fig.  156. — Ambulatory  dressing  of  Plaster-of-Paris  for 
fracture  of  the  bones  of  the  leg  (Pilcher). 


Fig.  157. — Ambulatory  dressing  apparatus 
for  fracture  of  thigh  (Harting). 


danger  of  the  callus  bending  (in  from  eight  to  fourteen  days).  Massage  should 
not  be  used  when  great  edema  points  to  the  possibility  of  venous  thrombosis. 
The  movements  might  break  up  a  clot  and  cause  fatal  embolism.*  Very  early 
massage  may  cause  fat-embolism.  In  fracture  of  the  patella,  Barker  and 
many  others  believe  in  wiring,  and  some  surgeons  advocate  the  same  jjrocedure 
in  fracture  of  the  clavicle,  fracture  of  the  tibia,  and  fracture  of  the  upper 
third  of  the  femur.  If  fragments  cannot  be  approximated  or  retained,  an 
incision  should  be  made,  approximation  effected,  and  the  fragments  retained 
by  wire,  a  clamp,  or  a  bone  ferrule. 

The  plan  known  as  the  ambulatory  treatment  of  fractures  of  the  lower 
*  Cerne's  case,  in  "Normandie  med.";   I>nll.  med.,  1895,  No.  44. 


Fractures  393 

extremities  has  many  advocates.  Its  aim  is  not  only  to  get  the  patient  about 
on  crutches,  but  also  to  cause  him  to  use  the  limb.  It  is  held  that  this  plan  of 
treatment  greatly  lessens  the  patient's  sufferings  and  actually  favors  union  by 
the  stimulation  of  walking.  Bardeleben,  in  his  report  to  the  German  Surgical 
Congress,  gave  the  records  of  in  fractures  of  the  lower  extremity  thus  treated 
(77  simple  and  12  compound  fractures  of  the  leg;  17  simple  and  5  compound 
fractures  of  the  thigh).  The  patients  were  gotten  about  a  few  days  after  the 
accident,  were  able  to  attend  to  business,  had  excellent  appetites,  digested  their 
food  perfectly,  slept  well,  and  were  saved  from  muscular  atrophy.  Pilcher  has 
warmly  advocated  the  method.  It  can  be  used  in  fractures  as  high  up 
as  the  middle  of  the  femur.  The  apparatus  which  we  should  employ 
in  the  ambulatory  treatment  reaches  below  the  sole  of  the  foot,  and  is  supported 
firmly  above  the  seat  of  fracture,  the  weight  of  the  body  being  transferred 
from  above  the  fracture  to  the  firm  pad  below  the  sole  of  the  foot  on  which  the 
patient  walks  (Fig.  157).  This  appliance  in  a  fractured  thigh  is  put  on  about 
one  week  after  the  infliction  of  the  injury.  While  the  patient  sits  on  the  ischial 
tuberosities  extension  is  made  upon  the  leg.  The  seat  of  fracture  is  encircled 
with  a  thin  plaster  cast.  The  sole  of  the  other  foot  is  raised  by  a  cork  sole. 
Albers,  when  he  treats  a  fractured  thigh,  uses  plaster-of-Paris  strengthened  by 
bits  of  wood,  running  from  below  the  sole  of  the  foot  to  the  iliac  crest.  Krause 
says  in  fracture  of  the  ankle  carry  the  dressing  to  the  head  of  the  tibia;  in  frac- 
ture of  the  leg  carry  it  to  the  middle  of  the  thigh ;  in  fracture  of  the  lower  end  of 
the  femur  carry  it  to  the  pelvis.*  Bradford  warmly  advocates  the  use  of 
Thomas's  splint  often  combined  with  plaster-of-Paris. 

Prevention  and  Treatment  of  Complications. — In  every  case  of  fracture 
feel  for  the  pulse  between  the  periphery  and  the  seat  of  injury  in  order  to  be 
sure  the  artery  is  not  ruptured.  If  the  soft  parts  are  badly  contused,  try  to  pre- 
vent sloughing  by  employing  rest  and  relaxation,  and  by  applying  heat.  If  su- 
perficial sloughing  occurs,  treat  antiseptically,  remembering  that  even  a  superfi- 
cial excoriation  can  admit  bacteria  which,  carried  by  the  blood  or  lymph,  may 
infect  the  bones.  If  a  slough  leads  down  to  the  fracture,  treat  the  case  as  a 
compound  fracture.  If  there  be  great  blood-extravasation,  the  danger  is 
gangrene,  and  the  foot  of  the  bed  is  to  be  elevated,  or  the  extremity,  to  which 
splints  and  bandages  are  to  be  loosely  applied,  is  to  be  raised  and  surrounded 
with  hot  bottles.  If  a  bleb  forms,  it  is  to  be  opened  with  a  clean  needle  and 
dressed  antiseptically.  If  gangrene  occurs,  treat  by  the  usual  rules.  Fre- 
quently after  fracture  of  a  bone  blebs  containing  reddish  serum  form  on  the 
skin.  The  appearance  of  blebs  when  the  circulation  is  good  does  not  mean 
gangrene,  and  is  not  of  any  particular  consequence.  If  blebs  are  due  to  gan- 
grene, there  are  distinct  symptoms  of  circulatory  impairment. 

Edema  may  be  due  to  tight  bandaging.  If  it  is  due  to  phlebitis,  there  is 
danger  of  pulmonary  or  cerebral  embolism.  In  phlebitis  elevate  the  limb, 
remove  all  constriction,  and  employ  locally  ichthyol  ointment;  do  not  use  mas- 
sage, and  give  stimulants  by  the  mouth.  In  edema  due  to  weak  circulation  or 
venous  relaxation  use  daily  frictions  and  firm  bandaging.  If  the  fracture  in- 
volves a  joint,  carefully  adjust  the  fragments,  make  passive  motion  early,  and 
inform  the  patient  that  he  will  probably  have  a  stiff  joint. 

A  dislocation  occurring  with  a  fracture  is  reduced  at  once  if  possible.    To 

*Centralbl.  f.  Chir.,  vol.  xxii,  1895. 


394 


Diseases  and  Injuries  of  Bones  and   Joints 


do  this,  splint  the  Umb  and  give  ether,  and  try  to  reduce  while  the  limb  is  man- 
aged with  the  splint  as  a  handle.  Allis  is  often  able  to  reduce  a  dislocation 
accompanied  by  a  fracture.  He  uses  the  untorn  portion  of  periosteum  as  a 
hinge,  pulls  upon  the  lower  fragment,  and  thus  draws  down  the  upper  frag- 
ment and  pushes  it  in  place 
by  manipulation.  If  this 
fails,  it  is  best  to  incise  and 
pull  the  separated  end  in 
place  by  the  hook  of  Mc- 
Burney  and  Dowd  (Figs. 
158-160);  but  some  sur- 
geons say,  get  the  bones  in 
the    best    possible    position, 

Fia;.  isS. — Fracture-hook  (McBurnev  ami  Dowd).  ^    ^u  -j.  •  j 

"    ^  set  them,  await  union,  and 

then  treat  the  unreduced  dislocation.  A  rupture  of  the  main  artery  of  the 
limb  presents  the  symptoms  of  absent  pulse  below  the  rupture,  a  tumor 
which  may  pulsate,  and  possibly  a  whirring  sound,  or  an  aneurysmal  thrill 
and  bruit.  This  condition  demands  that  the  surgeon  should  apply  an 
Esmarch  bandage,  cut  down  upon  the  tumor,  turn  out  the  clot,  and  ligate  each 
end  of  the  vessel.  If  these 
measures  fail  or  if  gangrene 
appears,  amputate  at  once 
above  the  seat  of  the  frac- 
ture. 

Inflammation  is  to  be 
treated  by  compression,  rest, 
moderate  cold,  and  later  by 
a  50  per  cent,  ichthyol  oint- 
ment. Muscular  spasm  re- 
quires morphin  internally, 
firm  bandaging,  or  even 
tenotomy.  Fat-embolism  is  treated  by  stimulants  and  inhalation  of  oxygen, 
and  possibly  artificial  respiration.  Shock,  delirium  tremens,  urinary  retention, 
etc.,  are  treated  acc(^rding  to  the  ordinary  rules  of  surgery. 

Treatment  of  Compound  Fractures. — It  must  first  be  decided,  in  a  ca.se 
of  compound  fracture  of  a  limb,  if  amputation  is  necessary,  and  the  :x;-rays  are 

of  great  value  in  determin- 
ing the  condition  of  the 
bones  in  a  crushed  part. 
Amputation  is  demanded 
when  the  limb  is  completely 
crushed  or  pulpefied  through 
its  entire  thickness;  when  ex- 
tensive pieces  of  skin  are  torn 


Fig.  159.- 


Fracture-hook  applied  at  base  of  acromion  process 
(McBurnev  and  Dowd). 


FiK-  ifio.- 


-Fracture-hook  inserted  in  flisplaced  fraKment 
f  McBurney  and  Dowd). 


off ;  when  the  main  artery,  vein,  and  nerve  are  torn  through;  and  sometimes  when 
there  is  violent  hemorrhage  from  a  deep-seated  vessel  or  when  an  important 
joint  is  splintered.  What  is  to  be  done  is  to  some  extent  determined  by  the 
patient's  age  and  general  health.  In  a  healthy  young  f)erson,  if  in  rloubt,  give 
the  limb  the  benefit  of  the  df)ubt  and  try  to  save  it;  if  the  artery  or  vein  alone  is 


Fractures 


395 


ruptured,  cut  down  upon  it  and  tie  both  ends;  if  the  nerve  is  severed,  suture  it; 
if  a  joint  is  opened,  drain  and  asepticize.  If  an  attempt  is  made  to  save  the 
limb,  be  ready  at  any  time  to  amputate  for  gangrene,  secondary  hemorrhage 
(if  re-ligation  at  original  point  and  compression  high  up  fail),  extensive  cellu- 
litis, and  profuse  and  prolonged  suppuration.*  When  it  is  determined  to  try 
to  save  the  limb,  the  part  must  be  cleansed  thoroughly  by  the  antiseptic  method 
(in  no  injuries  is  this  more  important).  If  a  small  portion  of  bone  protrudes, 
cleanse  the  skin  of  the  extremity  and  the  protruding  bone,  push  the  spicule  out 
a  little  more  and  cut  it  off.  If  a  large  piece  of  bone  is  protruded,  it  must  not 
be  cut  away,  but  should  be  thoroughly  disinfected,  and  after  the  skin  wound 
has  been  enlarged  should  be  returned  into  place.  Hemorrhage  requires  a  free 
incision  to  permit  of  ligation  of  bleeding  points.  In  comminuted  fractures, 
fragments  which  are  completely  broken  otf  should  be  removed,  but  those  which 
are  only  partially  separated  should  be  retained.  In  all  cases  a  drainage-tube 
must  be  carried  down  to  the  seat  of  fracture,  and  in  some  cases  a  counter-open- 
ing must  be  made  and  the  tube  be  pulled  through  the  limb  (Fig.  i6i). 


Fig.  i5i.— Fenestrated  plaster-of-Pai'is  dressing:. 


After  inserting  the  tube  the  wound  is  sutured,  a  plentiful  antiseptic  dressing 
is  applied,  and  the  extremity  is  dressed  with  plaster.  The  plaster  can  be  ap- 
plied over  a  narrow  strip  of  wood,  trap-doors  being  cut  in  the  plaster  before  it 
sets  (Fig.  i6i).     The  wound  is  then  covered  with  gauze  and  a  bandage. 

The  bracketed  splint  is  a  better  dressing  than  the  one  just  described.  After 
the  wound  has  been  dressed  with  gauze,  plaster  is  at  once  applied  over  the  ends 
of  brackets  (Fig.  162).  The  above  methods  not  only  immobilize  the  fractured 
bones,  but  keep  the  parts  aseptic  and  afford  easy  access  to  the  wound.  The 
drainage-tubes  are  usually  removed,  if  suppuration  does  not  occur,  in  from 
forty-eight  to  seventy-two  hours.  The  wound  is  treated  as  any  other  wound. 
In  some  compound  fractures  there  is  difficulty  in  retaining  the  fragments  in 
apposition  (lower  end  of  femur,  upper  third  of  femur).  In  such  cases  the  ends 
of  the  bone  should  be  resected  and  the  bones  should  be  fastened  together  as  in 
a  case  of  united  fracture,  with  silver  wire,  aluminum  wire,  chromicized  catgut, 

*See  Howard  Marsh  on  "Fractures,"  in  Heath's  Dictionary  of  Practical  Surgery. 


396 


Diseases  and  Injuries  of  Bones  and  Joints 


or  kangaroo-tendon.  In  a  compound  fracture  of  the  patella  after  free  incision 
and  disinfection,  investigate  to  determine  the  gravity  of  the  injury.  In  an 
ordinary  case  in  which  there  are  two  or  three  fragments,  open  the  joint,  irrigate 
with  saiine  fluid,  drill  the  fragments,  and  fasten  them  with  silver  wire.  Very 
small  fragments  should  be  removed.  A  tube  is  carried  into  the  joint,  the 
wound  is  sutured  and  dressed,  and  the  limb  is  immobilized  in  extension. 

In  a  case  of  severe 
compound  commin- 
uted fracture  of  the 
patella,  after  disinfec- 
tion, the  loose  piece 
should  be  removed  and 
"the  remaining  por- 
tions made  smooth  with 
bone  forceps  and  the 
sharp  spoon."*  The 
wound  is  only  partially  sutured,  is  drained  and  dressed,  and  the  limb  is 
placed  on  a  straight  posterior  splint.  A  compound  fracture  of  the  skull 
demands  trephining.  If  a  fracture  of  a  rib  is  compound  internally,  resect  the 
rib ;  if  it  is  compound  externally,  dress  antiseptically. 

Compound  fractures  may  be  followed  by  gangrene,  sloughing,  periostitis, 
septicemia,  pyemia,  osteomyelitis,  necrosis,  etc.  The  treatment  of  these  con- 
ditions is  by  well-known  rules. 

Treatment  of  Delayed  Union  and  Ununited  Fracture. — When  delayed  union 
exists,  seek  for  a  cause  and  remove  it,  treating  constitutionally  if  required,  and 


Fig.  162.— Bracketed  plaster-of-Paris  dressing. 


Fig.   163. — Parkhill's  clamp  for  ununited  fracture. 


thoroughly  immobilizing  the  parts  by  plaster.  Orthopedic  splints  may  be  of 
value.  Use  of  the  limb  while  splinted,  percussion  over  the  fracture,  and  rub- 
bing the  fragments  together,  thus  in  each  case  producing  irritation,  have  all 
been  recommended.  Blistering  the  skin  with  iodin  or  firing  it  has  been  em- 
ployed. If  the  union  be  very  long  delayed,  forcibly  separate  the  fragments  and 
put  up  the  limb  in  plaster  as  we  would  a  fresh  break.  If  these  means  fail,  irri- 
tate hiy  subcutaneous  drilling  or  scraping,  or,  better,  by  laying  open  the  parts  and 
then  drilling  and  scraping  at  many  places.  Buechner  advocates  the  induction 
of  hyperemia  by  a  constricting  band,  just  as  Bier  induces  congestive  hyperemia 
in  treating  tuberculous  areas.  At  first  the  constriction  is  permitted  to  remain 
but  a  short  time,  but  the  period  is  lengthened  everyday,  until  in  a  few  days  it 
remains  almost  continuously  day  and  night.  He  claims  that  ten  days  of  almost 
continuous  application  cures  most  cases.  Helferich  devi.sed  this  method  in  1887. 
Lannelongue  and  Menard  inject  a  i  :  10  solution  of  zinc  chlorid  between  the 

*  Lilienthal's  "Imperative  Surgery." 


Fractures   of  Nasal   Bones  397 

fragments.  Leaving  acupuncture  needles  in  for  days  is  approved  by  some,  and 
electropuncture  is  advocated  by  others.  Cases  of  ununited  fracture  must  be 
treated  by  excision  of  the  bony  ends  and  fibrous  tissue,  securing  the  fragments 
together  by  periosteal  sutures,  by  pins,  by  screws  and  plates,  by  ivory  pegs,  by 
screws,  by  silver  or  aluminum  bronze  wire,  by  kangaroo-tendon,  by  Senn's 
bone-rings  or  bone-ferrules,  or  by  chromicized  catgut.  Delorme  makes  an  in- 
cision, removes  bone-splinters  and  fibrous  tissue,  smooths  off  one  end,  forces  this 
into  the  bored-out  medullary  canal  of  the  other  fragment,  and  sutures  the  peri- 
osteum. Gussenbauer's  clamp  will  often  give  a  good  result,  and  was  used  for 
years  by  Billroth.  Parkhill's  clamp  (Fig.  163)  secures  absolute  immobility  and 
is  a  very  useful  instrument  (see  Osteotomy  for  Ununited  Fracture). 

Treatment  of  Vicious  Union. — If  angular  deformity  results  from  faulty 
union,  it  can  be  corrected  by  moulding  the  part  into  shape  while  the  callus  is 
soft.  If  the  callus  has  become  hard,  the  bone  can  be  refractured.  If  faulty 
union  occurs  with  overriding,  an  osteotomy  can  be  performed. 

Special  Fractures. — Nasal  Bones. — The  nasal  bones,  because  of  their 
situation,  are  often  broken.  The  commonest  seat  of  fracture  is  through  the 
lower  third,  where  the  bones  are  thin  and  lack  support.  The  fracture  is  usually 
compound  externally  or  through  the  mucous  membrane  internally.  The 
cause  is  direct  violence.  Displacement  may  not  occur  at  all,  but  when  present 
it  arises  purely  from  force,  and  never  from  muscular  action,  no  muscle  being 
attached  to  these  bones.  If  the  force  is  from  the  front,  the  nose  is  flattened; 
if  from  the  side,  it  is  deflected.  Displacement  is  soon  masked  by  swelling. 
Crepitus  can  sometimes  be  elicited  by  lightly  grasping  the  upper  part  of  the 
nose  with  the  fingers  of  one  hand  and  moving  it  gently  below  from  side  to  side 
with  the  fingers  of  the  other  hand.  Preternatural  mobility  is  valueless  as  a 
sign,  because  of  the  natural  mobility  of  the  cartilages.  Nose-breathing  is  diffi- 
cult because  of  blocking  of  the  nostrils  by  blood-clot.  Diagnosis  may  be 
almost  impossible  when  deformity  is  absent. 

The  complications  that  may  be  noted  are  cerebral  concussion,  brain-symp- 
toms from  implication  of  the  frontal  bone  or  cribriform  plate  of  the  ethmoid 
bone,  and  extension  of  the  fracture  to  the  superior  maxillary  or  lachrymal  bones. 
Emphysema  of  the  root  of  the  nose,  the  eyelids,  and  the  cheeks  is  common,  and 
means  either  a  rent  in  the  mucous  membrane  of  Schneider  or  a  crack  in  the 
frontal  sinus.  There  may  be  much  discoloration  because  of  subcutaneous 
hemorrhage.  Epistaxis  is  usual,  and  is  recognized  from  the  epistaxis  pro- 
duced by  fracture  of  the  base  of  the  skull  by  the  facts  that  the  bleeding  in  the 
first  condition  is  profuse,  is,  as  a  rule,  soon  checked,  and  is  not  followed  by 
oozing  of  cerebrospinal  fluid,  whereas  in  the  second  condition  it  is  profuse,  con- 
tinued, and  followed  by  a  flow  of  cerebrospinal  fluid.  Fracture  of  the  bony 
septum  occasionally  complicates  nasal  fractures,  and  deviation  of  the  cartila- 
ginous septum  often  takes  place.  Suppuration  may  occur  and  necrosis  of  bone 
or  cartilage  may  follow.     The  prognosis  is  usually  good. 

Treatment. — After  cocainizing  the  nares  a  careful  inspection  should  be 
made  by  means  of  a  mirror  and  a  light  to  determine  if  there  is  any  injury  of  the 
septum.  This  point  must  be  determined  in  order  that  the  deformity  of  the 
septum  may  be  corrected  at  the  same  time  as  is  the  deformity  of  the  nasal  bones. 
When  there  is  no  displacement,  or  when  a  displacement  does  not  tend  to  be  re- 
produced after  reduction,  employ  no  retentive  apparatus  of  any  kind.     Order 


398 


Diseases  and  Injuries  of  Bones  and  Joints 


Fig.  164. — Mason's  pin 


the  patient  not  to  blow  his  nose  for  ten  days  and  syringe  it  daily  with  a  solu- 
tion of  bicarbonate  of  sodium.  If  deformity  be  noted,  correct  it  at  once,  as  the 
bones  soon  unite  in  deformity.  If  the  attempts  at  reduction  are  very  painful, 
or  if  the  subject  be  a  child,  a  woman,  or  a  nervous  man,  give  ether  to  obtain 
primary  anesthesia.  Reduction  is  effected  by  a  grooved  director  or  steel 
knitting-needle  wrapped  in  iodoform  gauze  and  passed  into  the  nostril;  the 
fragments  are  lifted  with  this  instrument,  and  the  fingers  externally  mould 
them  into  place.  A  rubber  dilator  can  be  used  in  reduction.  This  is  pushed 
into  the  nose  and  inflated  by  air  or  w^ater.  If  the  septum  is  deviated  and  can- 
not be  pushed  in  place  by  a  metal  sound,  it  must 
be  twisted  into  place  by  means  of  septum  for- 
ceps. If  bleeding  is  moderate,  check  it  with 
cold  ;  if  severe,  by  plugging.  "For  fractures 
high  up  with  displacement,  gauze  packing  car- 
ried well  up  will  be  required  to  retain  the  elevated 
bones.  For  lower  deviations  the  Asch  tube  will 
be  needed"  (Scudder,  on  "The  Treatment  of 
Fractures").  A  hollow  vulcanite  plug  is  inserted 
in  each  nostril  and  the  nose  is  moulded  into  cor- 
rect shape  over  the  plug.  The  patient  breathes 
through  the  hollow  plug.  A  thread  runs  from 
each  plug  and  is  fastened  to  the  cheek  by  adhe- 
sive plaster.  Once  or  twice  a  day  the  plugs  are 
removed,  cleaned,  and  greased  with  iodoform  ointment.  The  nose  is  cleared, 
and  the  plugs  are  reinserted.  If  flattening  tends  to  recur,  pass  a  Mason  pin 
(Fig.  164)  just  beneath  the  fragments,  through  the  line  of  fracture  and  out  the 
opposite  side.  Steady  the  fragments  by  a  piece  of  rubber  externally  caught 
on  each  end  of  the  pin,  or  w-ith  figure-of-eight  turns  around  the  ends  with 
silk.  Leave  the  pin  in  place  for  five  days.  The  instrument  of  Mason  is  a 
sharp,  strong,  nickel-plated  pin,  with  a  triangular  point. 

If  lateral  deformity  tends  to  recur,  hold  a  compress  over  the  fracture  or 
fix  a  moulded-rubber  splint  over  the  nose  by  a  piece  of  rubber  plaster  one  and  a 
half  inches  broad  and  long  enough  to  reach  well  across  the  face,  and  use  com- 
pression for  ten  days.  In  neither  of  the  above 
cases  is  the  nose  to  be  blown,  and  in  both  cases 
it  is  to  be  syringed  once  or  twice  a  day.  In 
fractures  rendered  compound  by  tears  in  the 
mucous  membrane  irrigate  with  normal  salt  so- 
lution f)r  boracic-acid  solution,  holding  the 
head  so  that  the   solution  will    not    run    into 

the  mouth;  plug  with  iodoform  gauze  around  a  small  rubber  catheter,  which 
instrument  permits  nose-breathing;  carefully  remove  the  gauze  daily  and 
syringe.  In  fractures  compound  externally  clean.se  antiscptically  externally, 
and  dress  with  a  film  of  cotton  soaked  in  iodoform  collodion  or  compound  tinc- 
ture of  benzoin,  or  apply  sterile  gauze.  Fractures  of  the  bony  .septum,  if  show- 
ing a  tendency  to  reyjroduction  of  deformity,  require  packing  as  above  explained 
or  the  use  of  a  special  splint  within  the  nostrils  (Fig.  165),  or  the  application 
of  vulcanite  plugs,  so  marie  that  the  patient  can  breathe  through  them,  and  that 
threads  can  be  attached  to  them.     Fractures  of  the  nasal  cartilages  are  to  be 


Fig.  i6f;. — Jones's  nasal  splint. 


Fractures  of  the  Superior  Maxillary  Bone  399 

pinned  in  place.  Fractures  of  the  nose  are  entirely  united  in  from  ten  to 
twelve  days. 

Fractures  of  the  Lachrymal  Bone. — The  lachrymal  bone  may  be  broken 
when  the  nasal  bones,  a  superior  maxillary  bone,  or  the  lateral  plate  of  the 
ethmoid  are  fractured,  and  union  is  solid  in  from  three  to  four  weeks.  The 
question  of  how  much  deformity  is  to  be  expected  is  always  uncertain,  and  in 
not  a  few  cases  obstruction  of  the  no.se  follows  fracture  becau.se  of  damage  to 
the  septum. 

Treatment. — Treat  the  chief  injury,  which  is  the  fracture  of  the  other  bone 
or  bones.  Maintain  the  patency  of  the  lachrymal  duct  by  frequently  pass- 
ing a  clean  probe. 

Fractures  of  the  Superior  Maxillary  Bone. — Although  a  fragile  bone, 
the  superior  maxillary  is  rarely  broken  except  through  the  alveolar  border. 
It  may  be  broken  by  transmitted  force  from  blow's  on  the  chin,  or  on  the  head 
when  the  chin  is  fixed;  but  direct  violence  is  the  usual  cause.  The  wall  of  the 
antrum  may  be  crushed  in.  Comminution  is  the  rule,  and  the  injury  is  often 
compound.  These  fractures  induce  great  swelling,  pain,  and  inability  to 
chew.  Mobihty  and  crepitus  may  be  detected.  Deformity  is  due  to  the  break- 
ing force,  and  not  to  the  action  of  any  muscle.  \\'hen  a  portion  of  the  alveolar 
arch  is  fractured,  as  may  occur  in  pulling  teeth,  the  small  fragment  is  de- 
pressed backward,  and  there  exist  irregularity  of  the  teeth  (some  of  which 
may  be  loosened)  and  inability  to  chew  food.  Fracture  of  the  nasal  process 
is  apt  to  injure  the  lachrymal  duct.  When  the  antrum  is  broken  in  there 
are  great  sinking  over  the  fracture,  depression  of  the  malar  bone,  and  emphy- 
sema. Transverse  fracture  of  the  upper  part  of  the  body  of  the  bone  may 
cause  no  deformity.  The  force  required  to  break  the  superior  maxillary 
bone  is  so  great  that  fractures  of  other  bones  almost  certainly  occur,  and  con- 
cussion of  the  brain  not  infrequently  exists.  Injury  of  the  infra-orbital 
nerve  is  not  unusual,  causing  pain,  numbness,  or  an  area  of  anesthesia  in- 
volving one-half  of  the  upper  lip,  the  alae  of  the  nose,  and  a  triangle  whose 
base  is  one-half  the  upper  lip  and  whose  apex  is  the  infra-orbital  foramen. 
There  is  also  loss  of  sensation  in  the  gums  and  upper  teeth  of  the  injured  side. 
Fractures  of  the  superior  maxillary  bone  occasionally  induce  fierce  hemor- 
rhage from  branches  of  the  internal  maxillary  artery;  and  if  this  occurs, 
watch  for  secondary  hemorrhage  (these  vessels  being  in  firm  canals). 

Treatment. — If  the  fracture  does  not  implicate  the  alveolus,  or  if  no  deform- 
ity exists,  apply  no  apparatus,  but  feed  the  patient  on  liquid  food  for  four 
weeks.  Reduce  deformity,  if  it  exists,  by  inserting  a  finger  in  the  mouth. 
If  the  antrum  is  broken  in,  put  the  thumb  in  the  mouth  and  push  the  malar 
bone  up  and  back.  In  certain  cases  of  deformity  make  an  incision  at  the 
anterior  border  of  the  masseter  muscle,  insert  a  tenaculum  or  aneurysm 
needle,  and  pull  the  bone  into  place  (Hamilton).  If  the  malar  bone  or  malar 
process  is  driven  into  the  antrum,  Weir  tells  us  to  incise  the  mucous  membrane 
above  and  external  to  the  canine  tooth  of  the  upper  jaw,  break  into  the  antrum 
with  a  bone-gouge,  insert  a  steel  sound,  lift  out  the  malar  bone,  and  pack  the 
antrum  with  gauze.  Loose  teeth  are  not  to  be  removed;  they  are  pushed 
back  into  place  and  held  by  wiring  them  to  their  firmer  neighbors.  Hem- 
orrhage is  arrested  by  cold  and  pressure.  If  hemorrhage  is  dangerously 
profuse  or  prolonged,  tie  the  external  carotid. 


400 


Diseases  and  Injuries  of  Bones  and  Joints 


If  the  line  of  the  teeth,  notwithstanding  the  wiring,  is  not  regular,  mould  on 
an  interdental  splint.  The  usual  splint  for  the  upper  jaw  is  the  lower  jaw  held 
firmly  against  it  by  the  Gibson,  the  Barton,  or  the  four-tailed  bandage.  There 
is  a  great  amount  of  dribbling  of  saliva  during  the  treatment,  and  a  dressing 
must  be  used  to  catch  this  fluid.  Every  day  remove  the  bandage  and  dressing, 
and  wash  the  face  with  ethereal  soap.  The  patient,  who  is  ordered  not  to  talk, 
is  to  live  on  liquid  food  administered  by  a  nasal  tube  or  by  pouring  it  into 
the  mouth  back  of  the  last  molar  tooth  by  means  of  a  tube  or  a  feeding- 
cup.  Never  pull  a  tooth  to  obtain  a  space;  but  if  a  tooth  is  lost,  utilize  the 
vacant  space  for  this  purpose.  After  every  meal  wash  out  the  mouth  with 
peroxid  of  hydrogen  followed  by  chlorate  of  potassium,  boracic-acid  or  nor- 
mal salt  solution,  and  thus  prevent  foulness  and  the  digestive  disorders  it 
may  induce.  Dispense  with  the  dressings  in  six  weeks,  and  let  the  patient 
gradually  return  to  ordinary  diet. 

In  fractures  compound  externally  do  not  remove  fragments,  antisepticize, 
arrest  bleeding  as  far  as  possible  by  ligature,  by  pressure,  or  by  plugging,  wire 
the  fragments  if  feasible,  dress  with  gauze,  and  wash  the  mouth  with  great 


Fig.  i66. — Hard-rubber  splint ;  wire  arms  and  chin-piece  held  together  by  metal  rods  and  nuts. 


frequency.     Fractures  compound  internally  are  treated  as  simple  fractures, 
except  that  the  mouth  is  w^ashed  more  frequently. 

The  malar  bone  is  rarely  broken  alone.  Hamilton  says  no  uncompli- 
cated ca.se  is  on  record.  The  malar  is  a  strong  bone  resting  on  a  fragile 
support,  and  hence  it  may  become  a  wedge  to  break  other  bones  and  yet  itself 
be  unfractured.  The  cause  of  fracture  is  violent  direct  force.  A  fracture  of 
the  orbital  surface  of  this  bone  causes  subconjunctival  hemorrhage  like  that 
encountered  in  fracture  at  the  base  of  the  skull,  and  may  produce  irritation 
of  the  infra-orbital  nerve.  Protrusion  of  the  eye  may  result  either  from  hem- 
orrhage or  from  crushing  in  of  the  malar  bone.  There  is  a  hollow  below  and 
to  the  inner  side  of  the  orbit.  Occasionally  the  line  of  fracture  is  detectable, 
but  mobility  and  crepitus  are  very  rarely  discoverable.  Chewing  is  apt  to 
cause  pain,  and  often  the  motions  of  the  lower  jaw  are  limited,  the  coronoid 
process  being  pressed  upon  by  a  depressed  malar  bone,  an  associated  fracture 
of  the  zygoma,  a  blood-clot  or  swollen  tissue.  (See  Scudder,  on  "  The  Treat- 
ment of  Fractures.") 


Fractures  of  the  Zygomatic  Arch 


401 


Treatment. — If  no  deformity  exists,  there  is  practically  nothing  to  be  done. 
If  deformity  exists,  try  to  correct  it  as  in  fractures  of  the  superior  maxiUary 
bone.  If  correction  is  impossible  by  ordinary  methods  and  the  movements 
of  the  lower  jaw  are  impeded  by  the  displaced  bone,  make  a  small  incision 
and  through  this  insert  an  instrument  and  endeavor  to  lift  the  bone  into 
place.  As  these  cases  are  almost  invariably  complicated  by  fracture  of  the 
upper  jaw,  they  are  treated  in  the  same  manner  as  the  latter  injurv.  The 
union  is  complete  in  three  weeks. 

Fractures  of  the  zygomatic  arch  are  very  rare.  The  causes  are  (i) 
direct  violence;  (2)  indirect  force  (from  depression  of  the  malar);  and  (3) 
forcing  foreign  bodies  through  the  mouth.  Direct  violence  is  the  usual 
cause.  Direct  violence  causes  inward  displacement,  and  indirect  force  may 
cause  outward  displacement.  The  usual  seat  of  fracture  is  at  the  smallest 
portion  of  the  process — that  is,  on  the  temporal  side  of  the  temporomalar 


Fig.  167. — Front  view  of  splint  (figure  i66),  with  mouth  closed  (Moriarty). 

suture  (Matas).  The  symptoms  are  pain,  ecchymosis,  swelling,  displacement, 
and  difficulty  in  moving  the  jaw  (because  of  injury  to  the  masseter  muscle). 
Treatment. — In  simple  fracture  give  ether  and  try  to  push  the  arch  in 
place.  Many  surgeons  do  not  make  an  incision,  as  depression  will  do  no 
harm  and  the  functions  of  the  jaw  will  be  restored.  Simply  dress  with  a  com- 
press, adhesive  strips,  and  the  crossed  bandage  of  the  angle  of  the  jaw.  Union 
will  take  place  in  three  weeks.  Matas*  advises  operation.  An  anesthetic 
is  administered,  and  the  parts  are  asepticized.  A  long  semicircular  Hagedorn 
needle  is  threaded  with  silk,  is  entered  one  inch  above  the  middle  of  the  dis- 
placed fragment,  is  passed  well  into  the  temporal  fossa,   and    is   made  to 

*New  Orleans  Med.  and  Surg.  Jour.,  Sept.,   1896. 
26 


402 


Diseases  and  Injuries  of  Bones  and  Joints 


emerge  half  an  inch  below  the  arch.  The  silk  is  used  to  pull  a  silver  wire 
around  the  fracture,  and  this  wire  is  employed  to  pull  the  bone  into  position. 
A  firm  pad  is  applied  externally  and  the  wire  is  twisted  over  the  pad.  Anti- 
septic dressings  are  applied,  and  on  the  ninth  or  tenth  day  the  wire,  splint, 
and  dressings  are  removed  permanently.  I  have  employed  this  plan  in  two 
cases  with  perfect  satisfaction. 

Fractures  of  the  inferior  maxillary  bone  may,  and  most  usually  do, 
affect  the  body,  although  they  occasionally  occur  in  the  rami.  Any  part  of 
the  body  may  be  fractured,  the  most  usual  seat  being  near  the  canine  tooth 
or  a  little  external  to  the  symphysis  (Pick).  A  portion  of  alveolus  may  be 
broken  off.  In  fractures  of  the  ramus  either  the  angle,  the  condyloid  neck, 
or  the  coronoid  process  may  be  broken.  In  fractures  of  the  body  the  posterior 
fragment  generally  overrides  the  anterior.  Fractures  of  the  lower  jaw  are 
often  multiple  and  are  almost  always  compound,  because  the  oral  mucous 
membrane  and  alveolar  periosteum  are  torn.     The  cause  is  usually  direct  vio- 


Fig.  i6S.— Hard-rubber  splint  in  position,  upper  teeth  resting  upon  it  (Moriarty). 


lence.  Indirect  violence  (lateral  pressure)  may  fracture  the  body  anteriorly. 
Fractures  near  the  angle  are  always  due  to  direct  violence.  Indirect 
violence  may  fracture  the  condyle  (falls  on  the  chin),  and  so  may  direct 
violence.  Fractures  of  the  coronoid  process  are  very  rare,  and  they  arise  from 
greatdirect  violence  (usually  a  gunshot-wound  or  some  other  penetrating  force). 
Symptoms. — In  fracture  of  the  body  preternatural  mobility  and  crepitus 
generally  exist.  The  gum  over  the  fracture  swells  rapidly  and  decidedly. 
There  is  bleeding  because  of  laceration  of  the  gum;  saliva  dribbles  constantly; 
after  two  or  three  days  some  of  the  cervical  lymph-glands  enlarge;  when  the 
fracture  is  open  through  the  mucous  membrane  suppuration  is  usual;  the  odor 
of  decomposition  soon  becomes  marked;  the  patient  suj)ports  the  jaw  with 
the  hand;  great  pain  exists  (possibly  from  injury  of  the  nerve);  and  deformity 


Fractures  of  the  Inferior  Maxillarv  Bone 


403 


— Hamilton's  bandage. 


is  present,  shown  by  inequahty  of  the  teeth  if  the  fracture  is  anterior  to  the 
masseter,  the  anterior  fragment  going  downward  and  backward  and  the  pos- 
terior fragment  going  upward  and  forward.  The  downward  displacement  is 
due  to  muscular  action  (action  of  the  digastric,  geniohyoid,  and  genio- 
hyoglossus).  The  backward  displacement  is  due  to  the  violence.  The  tem- 
poral muscle  draws  the  posterior  fragment 
upward  and  to  the  front.  In  fracture  of 
the  neck  of  the  condyle  the  jaw  is  drawn 
toward  the  injured  side,  and  the  condyle 
is  pulled  inward  and  forward  by  the  action 
of  the  external  pterygoid  muscle.  In  frac- 
ture of  the  coronoid  process  the  temporal 
muscle  pulls  the  small  fragment  upward. 

Complications. — The  complications 
are — digestive  disorders  and  diarrhea  from 
swallowing  foul  discharges;  loosening  of 
the  teeth ;  lodgment  of  loosened  teeth  be- 
tween the  fragments;  bleeding  (usually 
only  oozing  from  the  gum,  but  there  may 
be  hemorrhage  from  the  inferior  dental 
artery) ;  and  suppuration.  Necrosis  may 
follow  these  fractures,  an  abscess  of  the 
neck  may  develop,  or  a  sinus  may  form. 

Treatment. — Remove  a  tooth  if  it  lies  between  the  fragments,  but  replace 
it  in  its  socket  after  reducing  the  fracture.  Correct  deformity  with  great  care 
and  be  sure  to  bring  the  teeth  into  normal  alinement.     As  a  rule,  push  loose 

teeth  into  place  and  put  back  detached 
ones;  but  occasionally  a  tooth  obstinately 
prevents  perfect  approximation,  and  if  it 
does  it  must  be  removed.  Wash  the 
mouth  with  hot  water  to  clean  it  and  to 
check  bleeding.  If  bleeding  is  very  severe, 
compress  the  carotid  artery  for  a  time. 
The  fracture  can  be  dressed  with  a  pad 
of  lint  over  the  chin  and  Hamilton's  four- 
tailed  bandage  (Fig.  i6g).  A  common 
plan  is  to  take  a  splint  of  pasteboard,  felt, 
or  gutta-percha;  pad  it  lightly  with  cotton, 
mould  it  to  the  part,  and  hold  it  in  place 
with  a  Barton  or  a  Gibson  bandage.  If 
apposition  of  the  fragments  cannot  be 
maintained  by  the  above  methods,  fasten 
the  teeth  together  with  wire,  wire  the 
fragments  together,  or  have  a  dentist  apply  an  interdental  splint  (Figs. 
170,  171).  Fracture  of  the  lower  jaw  can  often  be  most  satisfactorily  treated 
by  Angle's  bands.  These  bands  are  of  great  value  in  complicated  cases, 
in  which  two  or  more  fractures  exist.  Each  band  consists  of  thin  metal  and 
a  screw  and  a  nut  to  fit  the  screw.  The  band  is  adjusted  around  a  firm  tooth 
and  a  nut  is  applied  so  as  to  hold  the  band  tightly.     Several  bands  are  placed 


Fig.  170. — Vulcanite  splint  with  boxes 
vulcanized  on  each  side.  If  the  jaw  is 
fractured  in  the  region  of  the  molars,  con- 
siderable pressure  is  required  to  get  the 
liarts  in  position  ;  therefore  it  is  best  to 
vulcanize  on  to  the  sides  of  the  vulcanite 
splint  hoxe^into  which  wire  arms  can  be 
inserted  (Pilcher). 


404 


Diseases  and  Injuries  ot  Bones  and   Joints 


Fig.  171. — Interdental  splint. 


upon  teeth  in  both  jaws.  Silver  wire  or  silk  is  thrown  around  the  pins  of  the 
bands  so  as  to  catch,  and  the  jaws  are  thus  held  firmly  together.  The  patient 
is  to  be  fed  on  liquid  food  (see   Fracture  of  the  Upper  Jaw),  the  mouth 

is  to  be  washed  frequently  with  peroxid 
of  hydrogen,  followed  by  boric-acid  solu- 
tion or  normal  salt  solution,  and  the  dress- 
ings are  to  be  changed  every  second  day. 
The  union  should  be  complete  in  five  weeks. 
Though  these  fractures  are  usually  compound, 
they  do  not  endanger  life. 

Fractures  of  the  Hyoid  Bone. — These 
fractures  are  uncommon  injuries,  and  are 
caused  by  hanging,  by  throttling,  and  by 
falls  in  which  the  neck  strikes  some  ob- 
stacle. If  the  bone  breaks  by  throttling,  it 
is  its  body  which  fractures  (indirect  force).  Fractures  by  muscular  action 
are  most  unusual. 

Symptoms. — -The  symptoms  are — a  sensation  of  something  breaking; 
bleeding  from  the  mouth  if  the  mucous  membrane  be  lacerated;  pain,  which 
is  worse  on  opening  the  jaws  or  on  moving  the  head  or  tongue;  difficulty  in 
swallowing;  muffled,  hoarse  voice  or  aphonia;  swelling,  and  frequently  ecchy- 
mosis,  of  the  neck.  There  are  observed  occasionally,  though  rarely,  harsh 
cough  and  dyspnea,  irregularity  of  bony  contour,  and  crepitus.  Always  look 
into  the  mouth  and  see  if  there  can  be  detected  ecchymosis  or  laceration  of 
the  mucous  membrane  or  projection  of  a  bony  fragment.  The  displacement 
is  due  to  the  middle  constrictor  of  the  pharynx  contracting.  A  fracture  of 
the  hyoid  bone  may  destroy  life. 

Treatment. — For  dyspnea,  be  ready  to  perform  intubation  or  tracheotomy 
at  a  moment's  notice.  Edema  of  the  glottis  is  a  great  danger.  Try  to  restore 
the  fragments  with  one  hand  externally  and  with  a  finger  in  the  mouth. 
Put  the  patient  to  bed  and  have  him  lie  back  upon  a  firm  rest  so  that  his 
shoulders  are  elevated.  His  head  is  to  be  placed  between  extension  and 
flexion,  a  pasteboard  splint  or  collar  is  moulded  on  the  neck,  and  a  bandage 
is  applied  around  the  forehead,  neck,  and  shoulders  to  keep  the  head  immobile. 
The  patient  must  not  utter  a  word  for  a  week;  he  must  at  first  be  fed  by 
enemata,  and  then  for  some  time  on  liquid  diet,  which  is  given  through  a 
tube  early  in  the  case.  Endeavor  to  control  the  cough  by  opiates.  A  frac- 
tured hyoid  bone  recjuires  about  four  weeks  to  unite. 

Fractures  of  laryngeal  cartilages  are  caused  by  direct  violence,  as 
throttling,  blows,  or  kicks.  They  are  rare  in  young  persons,  and  are  com- 
monest when  the  cartilages  have  begun  to  ossify.  They  are  very  grave  in- 
juries, death  tending  to  occur  from  obstruction  to  the  entrance  of  air. 

Symptoms. — The  symptoms,  which  are  .severe,  are  pain,  aggravated  by 
attempts  at  swallowing  or  speaking;  .swelling,  ecchymosis  it  may  be,  and 
€mphy.sema  of  the  neck;  cough;  aphonia;  intense  dy.spnea;  and  bloody  ex- 
pectoration if  the  mucous  membrane  is  ruptured.  There  can  be  detected 
inequality  of  outline  (flattening  or  projection)  and  perhaps  moist  crepitus. 
The  usual  seat  of  the  injury  is  the  thyroid  cartilage. 

Treatment. — Cases  without  dyspnea  require  quiet,  avoidance  of  all  talking. 


Fractures  of  the  Ribs  405 

feeding  with  a  stomach-tube,  the  apphcation  of  compresses  and  adhesive 
strips  over  the  fracture,  and  the  use  of  remedies  to  quiet  cough.  The  surgeon 
must  be  ready  to  operate  at  any  moment.  In  most  cases  dyspnea  exists, 
due  to  projection  of  the  fragments  or  submucous  extravasation.  When  there 
is  dyspnea,  emphysema,  or  spitting  of  blood,  at  once  practise  intubation, 
or,  if  unable  to  do  this,  open  the  larynx  or  trachea  below  the  seat  of  fracture. 
If  laryngotomy  or  tracheotomy  is  performed,  try  to  restore  to  proper  position 
displaced  fragments.  If  the  fragments  will  not  remain  reduced,  introduce 
a  Trendelenburg  cannula  or  a  tracheotomy-tube,  and  pack  gauze  around 
it.  Take  out  the  packing  in  four  days,  and  remove  the  tube  as  soon 
as  the  patient  breathes  well,  when  the  opening  may  be  allowed  to  close. 
In  these  cases  feed  with  a  stomach-tube  and  keep  the  patient  absolutely 
quiet.     Union  takes  place  in  four  weeks. 

Fractures  of  the  Ribs. — The  ribs,  owing  to  their  shape,  elasticity,  and 
mode  of  attachment,  readily  bend  and  as  readily  recover  shape,  and  thus 
withstand  considerable  force  without  breaking.  Notwithstanding  these  facts, 
the  situation  of  the  ribs  so  exposes  them  that  in  16  per  cent,  of  all  cases  of 
fractures  noted  by  Gurlt  these  bones  were  involved.  In  children  fracture 
of  a  rib  seldom  occurs  and  is  usually  incomplete;  it  is  common  in  adults  and 
the  aged,  and  in  them  is  generally  complete.  It  is  more  frequent  among 
men  than  among  women.  The  ribs  commonly  broken  are  from  the  fifth 
to  the  ninth,  the  seventh  being  the  one  that  most  frequently  sufifers.  Fracture 
of  the  first  rib  alone  is  an  excessively  rare  accident.  The  eleventh  and  twelfth 
rjbs  are  seldom  broken.  A  rib  may  be  broken  in  several  places,  and  several 
ribs  are  often  broken  at  the  same  time.  Fracture  of  a  single  rib  is  not  nearly 
so  common  as  fracture  of  several  ribs.  These  fractures  may  be  compound 
either  through  the  skin  or  through  the  pleura,  a  damaged  lung  permitting 
pneumothorax.  Compound  fractures  are  very  rare,  however,  except  from 
bullet-wounds. 

Causes. — Direct  force,  as  buffer  accidents,  kicks,  blows  with  heavy  instru- 
ments, or  being  jumped  on  while  recumbent,  may  produce  these  injuries. 
A  fracture  from  direct  violence  occurs  at  the  point  struck,  and  the  ends, 
projecting  inward,  may  damage  a  viscus.  Indirect  force,  as  great  pressure 
or  blows  which  exaggerate  the  natural  bony  curves,  tends  to  produce  fractures 
near  the  middle  of  the  ribs  or  in  front  of  their  angles  and  to  force  the  ends 
outward.  A  number  of  ribs  are  apt  to  be  broken.  Muscular  action,  as  in 
coughing  or  parturition,  occasionally,  but  very  rarely,  is  a  cause. 

Symptoms. — In  connection  with  the  history  of  the  accident  the  symptoms 
are:  acute  localized  pain  (a  stitch)  on  breathing,  increased  by  pressure  over 
the  seat  of  pain,  pressure  backward  over  the  sternum,  cough,  and  forcible 
inspiration  or  expiration;  respiration  is  largely  diaphragmatic,  the  patient  en- 
deavoring to  immobilize  the  injured  .side;  cough  is  frequent  and  is  sup- 
pressed because  of  pain.  Crepitus  is  often  but  not  invariably  found.  The 
surgeon  seeks  for  it,  first,  by  resting  the  palm  of  his  hand  over  the  seat  of 
pain  while  the  patient  takes  long  breaths;  second,  by  placing  a  thumb  before 
and  one  behind  the  seat  of  pain  and  making  alternate  pressure;  and  third, 
by  auscultation.  It  should  be  remembered  that  incomplete  fractures  are  the 
rule  in  children;  hence  in  them  do  not  e.xpect  crepitus.  Deformity  is  usually 
trivial  unless  several  ribs  are  broken,  because  shortening  cannot  occur  and  the 


4o6  Diseases  and  Injuries  of  Bones  and  Joints 

intercostal  attachments  prevent  vertical  displacement.  Preternatural  mobility 
may  occasionally  be  elicited,  when  the  region  is  not  deeply  covered  with  mus- 
cles, by  pressing  on  one  side  of  the  supposed  break  and  observing  that  a  part 
of,  and  not  the  entire,  rib  moves.  If  air  gathers  in  the  subcutaneous  tissue 
and  there  is  no  wound  of  the  surface,  it  is  proof  of  rib  fracture  with  lung 
damage.  In  such  a  case  the  lung  has  been  penetrated  by  a  fragment,  and 
air  has  been  forced  out  into  the  tissues.  This  condition  is  recognized  by  great 
and  growing  swelling,  which  crackles  when  touched.  Such  a  collection  of 
air  is  known  as  cellular  emphysema.  Bloody  expectoration  suggests  lung 
injury;  bloody  expectoration  and  cellular  emphysema,  without  an  external 
wound,  prove  injury  of  the  lung.  A  simple,  uncomplicated  case  of  frac- 
ture of  a  rib  or  ribs  in  a  young  person  gives  a  good  prognosis. 

The  complications  are:  additional  injury,  making  the  fracture  externally 
or  internally  compound;  laceration  of  the  pleura,  pericardium,  heart,  lung, 
diaphragm,  liver,  spleen,  or  colon;  rupture  of  an  intercostal  artery;  hemo- 
thorax; cellular  emphysema;  pulmonary  emphysema;  pneumothorax;  pyo- 
thorax;  traumatic  pleurisy;  pneumonia;  bronchitis;  congestion  or  edema  of 
the  lungs. 

Treatment. — In  an  uncomplicated  case  the  patient  is  not  kept  in  bed,  as 
breathing  is  easier  when  erect  than  when  recumbent.  Angular  displacement 
outward  is  corrected  by  direct  pressure.  Displacement  inward  is  soon  cor- 
rected, as  a  rule,  by  the  expansion  of  ordinary  respiratory  action;  but  if 
it  is  not  thus  corrected,  etherize,  the  deep  breathing  of  the  anesthetic  state 
almost  always  succeeding.  If  ether  fails,  and  dangerous  symptoms  come 
on,  incise  under  strict  antiseptic  precautions,  elevate,  and  drain,  or  some- 
times resect  a  portion  of  the  rib. 

After  correcting  any  existing  deformity  immobilize  the  injured  side. 
Direct  the  patient  to  raise  his  arms  above  his  head,  to  empty  his  chest  of  air 
by  a  forced  expiration,  and  to  keep  it  empty  until  a  piece  of  rubber  plaster 
(two  inches  wide)  is  forcibly  applied  seven  or  eight  inches  below  the  fracture 
and  from  the  spine  to  the  sternum.  The  patient  is  now  allowed  to  take 
a  breath  and  is  directed  to  empty  the  chest  again,  another  piece  of  plaster 
being  apphed,  covering  the  upper  two-thirds  of  the  width  of  the  first  strip. 
This  process  is  continued  until  the  side  is  strapped  well  above  and  well  below 
the  fracture  (PI.  6,  Fig.  13).  Over  the  plaster  light  turns  of  a  spiral  bandage 
of  muslin  are  carried,  or  a  figure-of-8  bandage  of  the  chest  is  applied,  the  turns 
crossing  over  the  .seat  of  injury.  About  once  a  week  the  plaster  is  removed 
and  fresh  pieces  applied  after  rubbing  the  chest  with  soap  liniment,  drying, 
and  anointing  excoriations  with  an  ointment  of  oxid  of  zinc.  The  dressing 
is  worn  for  three  or  four  weeks.  The  [)atient  avoids  cold,  damp,  and  draughts. 
The  diet  must  be  nutritious  but  non-stimulating,  and  any  cough  should 
be  treated  by  opiates  and  expectorants.  A  person  with  this  injury  who  has 
reached  the  age  of  sixty  must  take  stimulant  expectorants  (ammonii  carb., 
gr.  x,  in  infus.  .senega),  .^ss,  /.  i.  d.)  or  employ  a  steam-tent  several  times  a 
day.  The  oW  method  of  treatment,  in  which  the  chest  was  included  in  a 
forcibly  applied  broad  rib-roller,  is  not  to  be  used  except  as  a  temporary 
expedient;  it  compresses  the  entire  chest,  causes  pain  and  dyspnea,  and 
tends  to  loosen  and  slip. 

Fracture  of  the  ribs   complicated  with  visceral  injury  is  highly  dangerous, 


Fractures  of  the  Sternum  407 

and  requires  confinement  to  bed.  The  treatment  is  that  of  the  visceral 
injury.  If  there  be  bloody  expectoration,  apply  adhesive  strips  as  above 
indicated,  put  the  patient  to  bed  reclining  on  a  bed-rest,  keep  him  quiet, 
subdue  the  circulation,  and  employ  opium,  diaphoretics,  and  expectorants 
(a  good  mixture  consists  of  squill,  ipecac,  ammonium  acetate,  and  chloroform; 
opium  is  given  separately).  Inflammations  of  the  lung  or  the  pleura,  fortu- 
nately, are  apt  to  be  localized,  and  are  treated  as  are  ordinary  inflammations  of 
these  parts.  If  signs  of  pulmonary  injury  are  severe  from  the  start  or  become 
worse  under  medical  treatment,  incise,  resect  a  rib,  arrest  hemorrhage,  and 
drain  the  pleura.  In  laceration  of  an  intercostal  artery  incise  and  try  to 
ligate;  if  unable  to  ligate,  resect  a  rib  and  apply  a  ligature.  If  the  signs 
point  to  internal  bleeding,  resect  a  rib,  search  for  the  bleeding  point,  and 
hgate.  Emphysema  usually  soon  disappears;  but  if  it  does  not,  make  many 
small  incisions  in  the  cellular  tissue,  dress  antiseptically,  and  employ  pressure. 
When  there  arises  a  sudden  attack  of  dyspnea,  which  is  prone  to  happen 
in  these  cases,  and  in  which  the  face  becomes  blue,  the  heart  labors,  and 
suffocation  seems  imminent,  bleed  the  patient  almost  to  syncope. 

Fractures  of  the  costal  cartilages  are  not  common,  even  in  the  aged. 
Such  fractures  occur  either  through  the  cartilages  or  through  their  points  of 
junction  with  the  ribs.  These  injuries  generally  arise  from  direct  violence, 
the  cartilage  of  the  eighth  rib  being  most  prone  to  suffer.  Indirect  force 
(such  as  a  blow  upon  the  shoulder)  is  occasionally  the  cause,  but  when  it 
is  the  cause  some  other  injury  besides  the  fracture  of  the  cartilages  is  apt 
to  be  noticed.     Muscular  action  is  a  possible  cause. 

Symptoms. — Displacement  is  often  absent;  but  if  present,  it  is  forward  or 
backward  of  either  fragment,  and  is  due  chiefly  to  the  force  of  the  injury, 
but  partly,  it  may  be,  to  muscular  action.  When  displacement  is  absent, 
crepitus  will  not  often  be  found;  in  fact,  crepitus  is  usually  absent  in  these 
injuries.  Localized  pain,  swelling,  and  ecchymosis  are  noted.  Preternatural 
mobihty  may  or  may  not  be  detected.     Union  by  bone  is  to  be  expected. 

Treatment. — If  displacement  exists,  try  to  reduce  it.  If  the  fragment  is 
displaced  backward,  reduce  by  deep  inspirations;  if  the  fragment  is  displaced 
forward,  reduce  by  pulling  back  the  shoulders.  In  this  attempt  failure  is 
the  rule,  and  the  surgeon  may  then  adopt  Malgaigne's  expedient  of  applying 
a  truss  over  the  projection  for  a  day  or  two.  Dress  and  treat  the  case  as 
if  a  rib  were  broken,  removing  the  dressings  in  four  weeks. 

Fractures  of  the  Sternum. — The  sternum  may  be  broken,  along  with 
the  ribs  and  spine,  from  great  violence.  Fractures  of  the  sternum  alone 
are  infrequent,  because  the  bone  rests  on  a  spring-bed  of  ribs.  Fractures 
of  the  sternum  may  be  simple  or  compound,  complete  or  incomplete,  single 
or  multiple.  The  most  usual  injury  is  a  simple  transverse  fracture  at  or 
near  the  gladiomanubrial  junction,  at  which  point  dislocation  may  also 
occur.  Both  fracture  and  separation  of  the  ensiform  cartilage  are  very  rare. 
The  sternum  may  be  broken  along  with  the  ribs  or  clavicle. 

Causes. — These  are:  direct  force,  as  by  a  fall  of  an  embankment  or  of  a 
wall,  by  a  car-crush,  or  by  the  passing  of  a  cart-wheel  over  the  body;  indirect 
force,  as  by  a  fall  upon  the  head,  thus  driving  the  chin  against  the  chest;  by 
a  fall  upon  the  feet,  the  buttocks,  or  the  shoulder;  by  forced  flexion  or 
extension  of  the  body  over  an  edge  or  angle  (as  may  occur  during  labor- pains). 


4o8  Diseases  and  Injuries  of  Bones  and  Joints 

Symptoms. — In  fracture  of  the  sternum  displacement  is  not  always  present, 
but  when  it  does  occur  the  lower  fragment  is  apt  to  pass  forward;  displace- 
ment may,  however,  be  transverse  or  angular,  or  there  may  be  overriding. 
The  posterior  periosteum,  which  rarely  tears,  limits  displacement,  but  some 
deformity  can,  as  a  rule,  be  detected.  The  history  of  the  nature  of  the  acci- 
dent has  a  valuable  bearing  upon  the  question  of  diagnosis.  The  position 
assumed  by  the  patient  is  with  the  head  and  body  bent  forward,  as  attempts 
to  straighten  up  cause  much  suffering.  There  is  fixed  and  localized  pain, 
increased  by  deep  respiratory  action,  by  body-movements,  or  by  cough. 
Crepitus  is  sought  for  by  auscultation  and  by  placing  the  hand  over  the 
injury  and  directing  the  patient  to  make  quick  respirations.  Mobility  may 
become  manifest  on  external  pressure,  during  respiration,  or  while  attempts 
are  being  made  to  bring  the  body  erect.  Respiration  in  these  cases  is  usually 
much  interfered  with.  It  is  not  important  to  separate  diagnostically  diastasis 
from  fracture. 

Complications. — Other  fractures  generally  complicate  fracture  of  the 
sternum,  and  laceration  of  the  pleura  or  pericardium  and  hemorrhage  into 
the  anterior  mediastinum  may  exist.  Abscess  of  the  mediastinum  and  necrosis 
of  the  sternum  may  appear  as  late  consequences.  The  prognosis  is  good  in 
uncomphcated  cases. 

Treatment. — The  deformity  attending  fracture  of  the  sternum  is  to  be 
corrected,  if  possible,  by  external  pressure.  If  overriding  is  found,  effect 
reduction  by  bending  the  body  back  over  a  firm  pillow  and  ordering  the 
patient  to  respire  deeply;  if  this  method  fails,  give  ether  and  then  bend  the 
body  backward.  The  deformity,  after  reduction,  tends  to  recur,  but  the 
bones  unite  well  even  in  deformity,  and  no  great  harm  results.  The  frag- 
ments need  not  be  cut  down  on  or  be  hooked  up  unless  there  be  internal 
injury.  After  reducing  the  deformity,  cover  the  front  of  the  chest  with 
adhesive  strips  extending  laterally  from  one  axillary  line  to  the  other,  and 
covering  a  region  from  above  the  fracture  down  to  the  ensiform  cartilage. 
Place  over  this  covering  an  anterior  figure-of-eight  bandage  of  the  chest. 
In  some  cases,  where  deformity  recurs  after  reduction,  a  circular  bandage 
of  the  chest  is  apphed  and  the  shoulders  are  pulled  strongly  back  with  a 
posterior  figure-of-eight  bandage.  The  plaster  is  to  be  reapplied  once  a 
week.  Some  surgeons  treat  these  cases  by  means  of  a  large  compress  held 
by  adhesive  plaster  and  a  broad  tight  roller. 

The  patient  goes  promptly  to  bed,  and  reposes  erect,  or  semi-erect,  on 
a  bed-rest.  This  position  favors  easy  respiration  and  antagonizes  the  ten- 
dency to  displacement.  The  diet  should  be  light,  nutritious,  and  non-stimu- 
lating. Convalescence  is  established  in  four  weeks,  and  the  plaster  should  be 
permanently  removed  in  five  weeks.  When  the  ensiform  cartilage  is  so  bent 
in  as  to  cause  intense  pain  or  to  injure  the  stomach,  it  should  be  exposed 
by  incision  and  resected.  Edema  of  the  skin  and  fever,  if  they  appear,  in- 
dicate pus,  in  which  case  an  incisif)n  should  be  made  at  the  edge  of  the 
sternum  and  the  pus-cavity  should  be  irrigated  and  drained. 

Fractures  of  the  Pelvis. — In  some  of  the  indicated  fractures  serious 
injury  of  the  pelvic  contents  is  apt  to  be  found. 

Fractures  of  the  False  Pelvis. — Fractures  of  this  region  are  seldom 
dangerous  unless  comminuted.     There  may  be  fracture  of  the  iliac  crest 


Fractures  of  the  True  Pelvis 


409 


or  of  the  anterior  superior  spine,  or  the  Hne  of  fracture  may  traverse  the 
entire  length  of  the  fianged-out  ilium,  or  the  bone  may  be  comminuted  with 
the  association  of  grave  visceral  damage.  The  anterior  superior  and  posterior 
superior  spines  may  be  broken  off. 

Causes.^The  cause  of  fracture  of  the  false  pelvis  is  generallv  violent 
direct  force,  as  the  passage  of  a  wagon-wheel,  the  fall  of  a  wall,  the  kick  of 
a  horse  or  mule,  or  the  force  of  car-crushes.  Violent  contraction  of  the 
rectus  muscle  may  tear  off  the  anterior  inferior  spine  of  the  ilium. 

Symptoms. — In  fracture  of  the  false  pelvis  the  history  of  violent  force 
is  noted.  The  patient  leans  toward  the  injured  side.  Pain  exists,  which 
is  aggravated  by  movements  (particularly  by  bending  forward),  by  coughing, 
or  by  straining  to  empty  the  bowels  or  the  bladder.  Ecchymosis  and  swelling 
are  manifest.  Crepitus  and  preternatural  mobility  are  detected  by  moving 
the  iliac  crest.  Deformity  is  very  rarely  present.  Cases  uncomplicated  by 
visceral  injury  make  good  recoveries. 

Com  plications. — The  fracture  may  be,  but  rarely  is,  compound,  as  the 
parts  are  well  protected  with  muscles.  The  colon  may  be  injured  when 
comminution  has  taken  place. 

Treatment. — If  there  are  symptoms  of  injury  of  the  colon,  perform  lapar- 
otomy, search  for  the  injured  region,  and  suture  it.  In  treating  an  ordinary 
fracture  of  the  false  pelvis  put  the  patient  on  a  fracture-bed,  raise  the  shoul- 
ders, and  apply  a  canvas  binder  about  the  pelvis,  or  encase  the  pelvis  with 
broad  pieces  of  rubber  plaster,  or  employ  the  belt  or  girdle.  The  pressure 
of  the  binder,  girdle,  or  plaster  must  not  be  so  great  as  to  force  the  fragment 
of  ilium  inward.  Place  the  knees  over  two  pillows  so  as  to  seniiflex  the 
legs  and  thighs,  and  tie  the  knees  together.  To  restrain  thigh-movements  it 
may  be  necessary  to  encase  a  restless  patierit  with  splints  or  bind  him  to  sand- 
bags. If  the  pelvic  binder  displaces  the  fragments  or  causes  pain,  abandon 
it  and  trust  to  position.  If  the  fragment  cannot  be  retained  in  place,  wire 
it.  The  dressings  can  be  removed  in  six  weeks,  and  the  patient  is  allowed 
to  get  up  in  eight  weeks.  In  simple,  uncompHcated  fracture  of  the  false 
pelvis  the  prognosis  is  good.  In  compound  fractures  of  the  false  pelvis 
asepticize,  drain  and  dress,  put  on  a  binder,  and  direct  the  same  position 
to  be  maintained  as  for  simple  fractures. 

Fractures  of  the  True  Pelvis. — The  most  usual  seat  of  these  fractures 
is  through  the  obturator  foramen,  the  ascending  ischial  and  horizontal  pubic 
rami  being  broken.  A  fracture  may  occur  near  the  symphysis  pubis,  the 
symphysis  may  be  separated,  a  break  may  run  near  to  or  into  the  sacroiliac 
joint,  the  same  fracture  may  occur  on  each  side  of  the  body  of  the  pubis, 
and  there  may  be  multiple  fractures.  Fractures  of  the  acetabulum  and  of 
the  tuberosity  of  the  ischium  may  occur.  Before  the  seventeenth  year  the 
innominate  bone  may  be  broken  into  its  three  anatomical  segments.  Frac- 
tures of  the  true  pelvis  are  highly  dangerous  because  of  the  damage  which  is 
apt  to  be  inflicted  on  the  pelvic  contents.  There  may  be  rupture  of  the  blad- 
der or  membranous  urethra  and  injury  of  the  vagina,  the  rectum,  the  uterus, 
or  the  small  gut.  The  cause  of  pelvic  fracture  is  violent  force,  direct  or 
indirect.  Front  force  tends  to  produce  direct,  and  side  force  indirect  frac- 
ture.    The  acetabulum  may  be  broken  by  falls  upon  the  feet. 

Symptoms. — In  pelvic  fracture  there  is  a  history  of  violent  force.     There 


4IO  Diseases  and  Injuries  of  Bones  and  Joints 

are  great  shock,  ecchymosis  which  is  possibly  linear,  swelHng,  and  intense 
pain  increased  by  attempts  at  motion,  coughing,  and  straining.  There  is 
also  inability  to  sit  or  to  stand.  Mobility  becomes  obvious  on  grasping  an 
ilium  in  each  hand  and  moving  the  hands.  Crepitus  may  be  noticed  by 
this  maneuver  or  by  moving  an  ilium  with  one  hand,  a  finger  of  the  other 
hand  being  inserted  in  the  rectum  or  vagina.  In  making  movements  for 
diagnostic  purposes  be  very  gentle,  as  rough  manipulation  may  cause  injury 
by  sharp  fragments.  There  may  be  doubt  as  to  whether  crepitus  is  to  be 
referred  to  pelvic  fracture  or  to  fracture  of  the  neck  of  the  femur;  in  this 
case  follow  the  rule  of  John  Wood:  "The  surgeon  grasps  the  femur  with 
one  hand  and  places  the  other  firmly  upon  the  anterior  superior  iliac  spine 
or  crest  or  upon  the  pubes;  then,  on  moving  the  femur  and  abducting  it  freely, 
if  a  crepitus  be  detected,  it  will  be  felt  the  more  distinctly  by  that  hand  which 
rests  on  or  grasps  the  fractured  bone. " 

Rupture  of  the  bladder  is  made  manifest  by  pain  in  the  hypogastric 
region,  an  intense  desire  to  micturate,  an  inability  to  pass  urine  in  quantity 
although  a  few  drops  of  bloody  urine  may  be  voided,  great  shock,  sometimes 
dulness  on  percussion  in  the  loins,  and  evidences  of  extravasation  in  the 
prevesical  space.  The  condition  is  proved  to  exist  by  practising  the  maneu- 
vers suggested  under  Rupture  of  Bladder.  The  symptoms  of  ruptured 
urethra  are  set  forth  later.  Bleeding  from  vagina  or  rectum  points  to  lacera- 
tion of  the  part  by  a  fragment.  The  vagina  may  be  badly  lacerated  and  the 
bowels  may  emerge  from  the  laceration  (Maurice  H.  Richardson's  case). 
Intestinal  injury  is  apt  to  induce  septic  peritonitis.  Fracture  of  the  brim 
of  the  acetabulum  permits  dorsal  dislocation  of  the  femur  to  occur,  which 
dislocation  will  not  remain  reduced,  and  causes  shortening,  which  at  once  re- 
curs when  extension  is  abandoned — inversion  and  adduction,  although  the 
power  of  eversion  and  abduction  is  preserved  (Stokes).  There  is  crepitus, 
and  the  head  of  the  bone  goes  with  the  fragment  upward  and  backward 
(Stokes).  If  the  head  of  the  femur  be  driven  through  the  acetabulum  into 
the  pelvis,  the  injury  is  very  grave;  there  are  then  found  shortening,  adduc- 
tion, and  semiflexion  of  the  thigh,  absence  of  the  prominence  of  the  great 
trochanter,  and  more  capacity  for  movement  than  is  noted  in  dislocation. 
Fracture  of  the  ischium  rarely  occurs  alone. 

Treatment. — Examine  carefully  to  determine  if  the  bowel,  the  bladder,  the 
urethra,  or  the  vagina  is  injured.  If  such  an  injury  exists,  radical  operation 
is  of  course  demanded.  Always  use  a  catheter  to  see  if  the  urine  is  bloody. 
Bloody  urine  suggests,  but  does  not  prove,  the  existence  of  a  ruptured  bladder. 
It  may  be  due  to  simple  contusion  of  the  bladder  or  to  contusion  of  the  kidney. 
In  treating  a  pelvic  fracture  endeavor  to  restore  the  parts  to  a  normal  position, 
employing  external  manipulation  and  inserting  a  finger  in  the  rectum  or 
in  the  vagina.  If  reduction  is  difficult,  administer  ether.  The  pelvis  should 
be  encircled  with  a  canvas  binder  and  the  patient  should  be  placed  upon  a 
Bradff^rd  frame.  If  this  is  done  he  can  be  cleaned  readily  and  the  bed-pan 
can  be  easily  used.  If  movements  of  the  thighs  distort  the  pelvic  bones,  each 
thigh  should  be  bound  to  the  frame.  In  fracture  with  separation  of  the  pubic 
bones,  the  bones  should  be  wired  together.  If  urinary  extravasation  occurs, 
perform  perineal  section.  If  there  are  signs  of  bowel  injury  or  intraperitoneal 
rupture  of  the  bladder,  perform  laparotomy;  and  if  the  bladder  is  found  to 


Fractures  of  the  Clavicle  41  i 

be  torn,  apply  sutures.  All  visceral  injuries  are  treated  by  general  rules. 
Remove  the  dressings  in  six  weeks  and  allow  the  patient  to  get  about  in 
twelve  weeks.  In  fracture  of  the  acetabulum,  if  the  limb  is  shortened, 
give  ether  and  reduce  by  extension  and  counterextension.  Treat  these 
fractures  in  the  same  way  as  intracapsular  fractures  of  the  femur.  Frac- 
tures of  the  ischium  are  best  treated  by  the  application  of  a  pad  and 
adhesive  plaster,  and  rest  in  bed. 

Fractures  of  the  Sacrum. — This  bone  may  be  broken  by  direct  force, 
such  as  a  kick,  but  the  injury  is  rare.  The  sacral  plexus  is  usually  injured, 
and  if  it  is  paralysis  is  observed  in  the  territory  of  its  branches. 

Symptoms. — The  symptoms  of  fracture  of  the  sacrum  are  pain,  frequently 
incontinence  of  feces  and  retention  of  urine,  irregularity  of  the  sacral  spines, 
ecchymosis,  and  crepitus.  Crepitus  may  be  sought  for  with  one  hand  exter- 
nally and  a  finger  of  the  other  hand  in  the  rectum.  The  lower  fragment 
passes  forward  and  may  obstruct  or  may  tear  the  rectum.  Paralysis  may 
be  found  in  the  area  of  distribution  of  the  sacral  plexus. 

Treatment. — In  any  case  of  fracture  of  the  sacrum  if  there  are  evidences 
of  pressure  upon  nerves  by  displaced  bone,  incise  and  elevate  the  depressed 
bone.  If  the  rectum  is  lacerated  sutures  must  be  inserted.  In  many  cases 
of  fracture  of  the  sacrum  the  older  conservative  treatment  is  sufficient. 
The  conservative  treatment  is  as  follows:  Press  the  fragments  into  place 
with  a  hand  externally  and  a  finger  in  the  rectum.  Do  not  plug  the 
rectum.  Put  a  pad  over  the  upper  fragment,  hold  it  with  plaster  or  a  binder, 
place  the  patient  recumbent  on  a  fracture-bed,  and  insert  a  large  cushion 
underneath  the  pad.  Some  surgeons  give  opium  to  induce  constipation,  and 
allow  a  fecal  support  to  accumulate  in  the  rectum.  Use  a  clean  catheter 
regularly,  and  guard  against  bed-sores.  Union  occurs  in  about  four  weeks, 
when  the  dressing  can  be  removed.  The  patient  can  get  about  again  in 
six  weeks.  If  urinary  retention  persists  or  if  intractable  bed-sores  form  after 
eight  or  ten  w^eeks,  cut  down  on  the  seat  of  injury  and  elevate  or  remove 
the  portion  of  bone  causing  pressure. 

Fractures  of  the  Coccyx. — The  coccyx  may  be  broken  or  be  separated 
from  the  sacrum  by  a  fall,  a  blow,  a  kick,  or  the  straining  of  parturition. 
Its  mobility  is  so  great,  however,  that  it  does  not  often  break. 

Symptoms. — The  chief  symptom  of  fracture  of  the  coccyx  is  pain,  which 
is  much  aggravated  by  sitting,  walking,  or  straining  at  stool.  If  the  index 
finger  is  inserted  into  the  rectjum,  the  displaced  bone  is  felt;  if  the  thumb  of 
the  same  hand  is  also  placed  externally,  a  rocking  motion  will  develop  crepitus 
and  preternatural  mobility. 

Treatment. — In  treating  fracture  of  the  coccyx  reduce  by  external  pressure 
and  by  the  manipulations  of  a  finger  in  the  rectum  and  put  the  patient  to 
bed.  In  four  weeks  the  fracture  should  be  united.  If  union  does  not  take 
place,  defecation  and  all  movements  of  the  coccyx  will  cause  excruciating 
pain  by  pressure  on  the  last  sacral  nerve.  This  condition,  known  as  "coccy- 
godynia, "  demands  a  subcutaneous  division  of  the  nerve  or  of  the  muscles 
which  move  the  coccyx,  or  a  resection  of  the  bone. 

Fractures  of  the  Vertebra.     (See  page  648.) 

Fractures  of  the  Skull.     (See  page  608.) 

Fractures  of  the  Clavicle. — The  clavicle  is  more  often  fractured  than 
any  other  bone.     The  fracture  may  occur  at  any  age,  but  is  commonest 


412  Diseases  and  Injuries  of  Bones  and  Joints 

before  the  sixth  year  (Hulke  says  one-half  of  the  recorded  cases).  It  may 
be  simple,  multiple,  comminuted,  obhque,  transverse,  complete,  incomplete, 
or,  very  rarely,  compound.  Both  clavicles  may  be  broken.  Fractures  are 
most  apt  to  occur  just  external  to  the  middle,  at  the  point  where  the  inner 
or  large  curve  meets  the  outer  or  small  curve,  at  which  junction  the  bone 
is  at  its  smallest  diameter.  Fractures  of  the  acromial  end  are  more  frequent 
than  fractures  of  the  sternal  end,  and  less  frequent  than  fractures  of  the 
shaft.  The  causes  of  fracture  of  the  clavicle  are  direct  violence,  indirect 
violence,  and,  very  rarely,  the  contractions  of  "  the  deltoid  and  clavicular 
fibers  of  the  great  pectoral"  (Treves,  from  Polaillon). 

Fractures  of  the  shaft  are  usually  due  to  indirect  violence,  as  falls  upon 
the  shoulder  or  upon  the  outstretched  hand.  In  the  latter  accident,  which 
is  the  usual  mode  of  origin,  the  concussion  of  the  fall  travels  up  and  the 
body-weight  travels  down,  and  these  two  forces  compress  the  bone,  which 
snaps  at  its  weakest  point.  Fractures  from  indirect  force  are  oblique,  and 
in  children  are  of  the  green-stick  form.  Fractures  from  direct  force  are 
usually  transverse,  and  are  occasionally  comminuted.  Fractures  from  mus- 
cular action  have  been  recorded  (Rubini  the  tenor,  recorded  by  Melay). 

Symptoms. — In  fracture  of  the  shaft  of  the  clavicle  the  attitude  of  the 
patient  is  peculiar.  He  supports  the  elbow  or  wrist  of  the  injured  side  with 
the  hand  of  the  sound  side,  and  also  pulls  the  extremity  agaisnt  the  chest; 
the  head  is  turned  down  toward  the  shoulder  of  the  damaged  side,  as  if 
trying  to  listen  to  something  in  the  joint,  thus  relaxing  the  pull  of  the  sterno- 
cleidomastoid muscle  upon  the  inner  fragment.  The  shoulder  is  nearer  the 
sternum,  on  a  lower  level,  and  farther  front  than  that  of  the  sound  side. 
Loss  of  function  is  shown  by  inabihty  to  abduct  the  arm,  and  in  many 
cases  by  inability  to  place  the  hand  on  the  top  of  the  erect  head.  Consider- 
able pain  exists,  which  is  increased  by  motion,  by  pressure,  and  by  hanging 
down  the  extremity  without  support. 

The  deformity  above  noted  is  described  by  stating  that  the  shoulder 
goes  downward,  inward,  and  forward  (d.  i.  f.).  The  downward  deformity 
is  chiefly  due  to  the  weight  of  the  extremity,  which  pulls  down  the  unsupported 
outer  fragment,  and  is  contributed  to  by  the  action  of  the  pectoralis  minor 
muscle.  The  inward  deformity  is  chiefly  due  to  the  contraction  of  the  pec- 
toralis minor  and  subclavius  muscles  assisted  by  the  action  of  the  pectoralis 
major.  The  forward  deformity  is  due  to  rotation  of  the  outer  fragment, 
which  is  brought  about  by  the  serratus  magnus  muscle  carrying  the  scapula 
forward.  In  this  deformity,  the  inner  end  of  the  outer  fragment  is  below 
and  behind  the  outer  end  of  the  inner  fragment,  which  overrides  it.  The 
inner  fragment,  though  j)ulled  on  by  the  sternocleidomastoid  muscle  and  rela- 
tively higher  than  the  outer  fragment,  is  really  but  little,  if  at  all,  elevated, 
marked  elevation  being  prevented  by  the  attachment  of  the  rhomboid  liga- 
ment. .\fter  noting  the  deformity,  detect  with  the  finger  the  irregularity  of 
bony  contour.  Examine  for  preternatural  mobility  and  crepitus  by  raising 
and  throwing  back  the  shoulder.  In  looking  for  these  signs  in  children  it  is 
to  be  remembered  that  the  fracture  is  probably  incomplete.  The  prognosis 
is  good,  the  bone  uniting,  but  always  with  some  shortening  and  inequality. 

Complications. — Fractures  f)f  the  shaft  are  rarely  compound,  because  the 
sharp  end  of  the  outer  fragment  passes  backward  and  ljecau.se  of  the  free 


Fractures  of  the  Shaft  of  the   Clavicle 


413 


Fig.  17: 


-Fox's  apparatus  for  fractured  clav- 
icle. 


play  the  skin  makes  over  the  bone  (Pickering  Pick).  Both  clavicles  may 
be  broken.  One  or  more  ribs  may  be  fractured  at  the  same  time.  In  frac- 
tures from  direct  force  deeper  structures  may  be  injured  by  fragments.  Thus, 
injury  of  the  brachial  plexus  will  induce  paralysis.  There  are  11  recorded 
cases  of  simple  fracture  of  the  clavicle 
complicated  by  laceration  of  a  large 
vessel.  Eight  of  these  cases  died. 
The  vessel  ruptured  may  be  the  sub- 
clavian vein,  the  subclavian  artery, 
or  the  jugular  vein.  After  a  rupture 
a  huge  blood-clot  forms  (Gallois  and 
Piollet,  in  "Rev.  de  Chir.,"  July  and 
Aug.,  1901). 

Treatment. — In  treating  a  fracture 
of  the  shaft  of  the  clavicle  correct  the 
deformity  as  soon  as  possible  by  throw- 
ing the  shoulder  upward,  outward,  and 
backward.  If  the  patient  is  a  girl,  it 
is  desirable  to  minimize  the  deformity. 
Place  her  upon  her  back  upon  a  hard 
bed,  with  a  small  pillow  under  her  head, 
a  firm  and  narrow  cushion  between  the 

shoulders,  a  bag  of  shot  resting  over  the  seat  of  fracture,  and  the  forearm 
hing  on  the  front  of  the  chest,  the  arm  being  held  to  the  side  by  a  sand- 
bag. In  three  weeks  there  will  be  union,  practically  without  deformity. 
In  a  child  with  an  incomplete  fracture  a  handkerchief  sling  for  the  fore- 
arm, worn  three  weeks,  is  all  that  is  needed.  In  a  fracture  of  the  collar- 
bone of  an  adult  the  Velpeau  bandage  is  efficient.  Before  applying  it, 
place  lint  around  the  chest  and  cotton  over  the  elbow.     Change  the  bandage 

every  day  for  the  first  week,  and  after 
that  period  every  third  day.  Each  time 
it  is  changed  rub  the  skin  with  alcohol, 
ethereal  soap,  or  soap  liniment,  dry 
carefully,  and  examine  for  excoriations; 
if  any  are  found,  they  are  anointed 
with  zinc  ointment  before  the  dressing 
is  reapplied.  The  dressing  is  perma- 
nently removed  at  the  end  of  four 
weeks,  the  arm  being  carried  in  a  sling 
for  another  week.  The  classical  ap- 
paratus of  Desault  is  now  rareh'  used. 
The  posterior  figure-of-eight  bandage 
associated  with  the  second  roller  of 
Desault,  some  turns  being  made  from 
the  elbow  of  the  injured  side  to  the  shoulder  of  the  sound  side,  can  be 
used  in  cases  in  which  the  forward  deformity  is  apt  to  return.  The  appa- 
ratus of  Fox,  which  is  very  useful,  consists  of  a  pad  for  the  axilla,  a  sling 
for  the  forearm,  and  a  ring  for  the  opposite  shoulder,  to  which  ring  are  tied 
the  tapes  from  both  the  pad  and  the  sling  (Fig.  172). 


Fig.  173. — Sayre's  adhesive-plaster  dress- 
ing for  fracture  of  the  clavicle  (Stimson) :  A, 
First  piece  ;  B,  second  piece. 


414  Diseases  and  Injuries  of  Bones  and  Joints 

The  dressing  of  Moore,  of  Rochester,  is  valuable  in  an  emergency.  It 
consists  of  a  piece  of  cotton  cloth,  two  yards  long,  and  folded  like  a  cravat 
until  it  is  eight  inches  in  width  at  the  middle.  The  center  of  the  bandage 
rests  upon  the  elbow,  the  posterior  tail  is  carried  across  the  front  of  the  shoulder 
of  the  injured  side.  The  forearm  is  at  an  acute  angle  with  the  arm,  and 
the  other  end  of  the  bandage  is  carried  across  the  forearm,  across  the  back 
over  the  opposite  shoulder,  and  around  the  axilla,  where  the  extremities 
are  stitched  together.  The  forearm  is  suspended  in  a  bandage  shng  (S.  D. 
Gross).  The  four-tailed  bandage  is  preferred  by  Pick.  Sayre's  dressing  has 
many  advocates  (Fig.  173).  For  this  there  are  required  two  pieces  of  rubber 
plaster,  each  piece  being  three  inches  wide  and  sufficiently  long  to  go 
around  the  chest  one  and  a  half  times.  The  end  of  one  piece  encircles 
the  arm  of  the  injured  side  just  below  the  arm-pit;  the  plaster  strip  is 
pulled  across  the  back  to  the  other  side,  to  the  front  of  the  chest,  and 
returns  again  to  the  middle  of  the  back.  This  procedure  pulls  the 
elbow  back  and  throws  the  shoulder  out.  The  hand  of  the  injured  side 
is  placed  on  the  breast  of  the  opposite  side,  cotton  being  interposed,  and 
the  second  strip  of  plaster  runs  from  the  elbow  of  the  injured  side  and 
the  opposite  shoulder,  front,  around,  and  back,  pressing  the  elbow  forward, 
upward,  and  inward.  In  children,  if  it  is  found  difficult  to  immobihze  the 
parts,  the  most  satisfactory  result  is  obtained  by  the  appHcation  of  the 
Velpeau  bandage,  which  is  to  be  overlaid  by  a  thin  plaster-of-Paris  bandage. 
If  the  fragments  cannot  be  coaptated,  sterilize  the  parts,  administer  ether, 
incise,  clear  away  the  muscle  from  between  the  fragments,  saw  the  ends, 
bore  each  end  and  hold  them  in  contact  by  means  of  kangaroo-tendon  or 
silver  wire.  The  same  procedure  should  be  pursued  when  a  fracture  is 
compound  or  threatens  to  become  so,  or  if  signs  indicate  pressure  upon 
vessels  or  nerves.  If  a  large  vessel  has  been  injured,  the  operation  is  impera- 
tively necessary.  If  a  patient  suffering  under  a  fracture  which  threatens  to 
become  compound  refuses  the  aid  of  operation,  keep  him  in  bed  and  hold 
the  arm  in  abduction.  In  three  cases  in  the  Jefferson  Medical  College 
Hospital  the  author  wired  the  fragments  with  excellent  results. 

After  a  broken  collar-bone  has  united,  if  the  shoulder  is  found  to  be  stiiT, 
make  passive  movements  daily;  if  these  fail,  move  the  joint  forcibly,  first  giv- 
ing ether  or  nitrous  oxid. 

Fractures  of  the  acromial  end  of  the  clavicle  are  due  to  direct  force. 
If  the  fracture  is  between  the  two  coracoclavicular  ligaments,  deformity  is  very 
slight,  crepitus  is  elicited  by  manipulating  with  the  fingers,  and  pain  exists,  but 
loss  of  function  is  not  markedly  manifest  unless  it  is  due  to  pain.  These  frac- 
tures are  treated  by  interposing  cotton  between  the  arm  and  the  side,  binding 
the  arm  to  the  side  with  the  second  roller  of  Desault,  and  hanging  the  hand  in  a 
sling.  In  fractures  external  to  the  ligaments  crepitus  is  manifest  on  moving 
the  shoulder,  the  f)Utline  of  the  bone  is  irregular,  severe  pain  is  developed  by 
movement,  and  deformity  is  pronounced.  The  deformity  is  due  io  the  ser- 
ratus  magnus  muscle  rotating  the  scapula  forward,  the  inner  end  of  the  outer 
fragment  of  the  clavicle  often  coming  in  contact  with  the  anterior  surface  of  the 
outer  portion  of  the  inner  fragment.  Fracture  of  the  acromial  end  of  the 
clavicle  is  reduced  by  jjulling  both  of  the  shoulders  strf)ngly  backward,  and  it  is 
kept  reduced  by  the  use  of  a  posterior  figure-of-eight  bandage.     In  fracture 


Fractures  of  the  Acromion  415 

external  to  the  hgaments  the  displacement  frequently  cannot  be  corrected  by 
position  and  manipulation.  Such  cases  demand  incision  and  wiring.  In 
either  variety  of  fracture  the  dressings  are  worn  for  four  weeks. 

Fractures  of  the  sternal  end  of  the  clavicle  are  very  rare.  Thev  are 
caused  by  either  direct  or  indirect  force.  In  such  a  fracture  there  are  found 
crepitus,  projection  at  the  seat  of  fracture,  rigidity  of  the  sternocleidomastoid 
muscle,  and  shortening  of  the  clavicle.  The  inner  end  of  the  outer  fragment 
always  passes  forward,  and  often  also  downward  and  inward.  Reduce  these 
fractures  by  pulling  the  shoulders  back,  and  treat  them  by  means  of  the  poste- 
rior figure-of-eight  bandage  worn  for  four  weeks.     Wiring  may  be  necessary. 

Fractures  of  the  Scapula. — This  bone  is  not  often  broken,  as  it  rests  upon 
thick  muscles  and  elastic  ribs;  it  is  freely  movable,  and  it  has  attached  to  it  a 
bone  which  easily  breaks. 

Fractures  of  the  Body  of  the  Scapula. — These  are  due  to  direct  violence. 
The  symptoms  are  pain  (which  becomes  agonizing  on  attempting  to  rotate  the 
shoulder-blade),  ecchymosis,  and  swelling.  Crepitus  is  sought  for  by  placing 
the  hand  over  the  bone  and  making  movements  of  the  arm;  also  by  holding  the 
point  of  the  shoulder  and  lifting  up  the  lower  angle  of  the  bone.  The  latter 
plan  may  develop  mobility.  The  spine  of  the  scapula  is  uneven  only  when  it 
is  itself  fractured.  Examine  for  unevenness  of  the  vertebral  border  of  the 
shoulder-blade.  In  fractures  of  the  body  of  the  scapula  a  shoulder-cap  is  ap- 
plied, a  gutta-percha  sphnt  is  moulded  over  the  scapula,  the  arm  is  bound  to 
the  side,  and  the  hand  is  carried  in  a  shng.  The  apparatus  is  worn  for  four 
weeks. 

Fractures  of  the  spine  of  the  scapula  are  treated  as  are  fractures  of  the 
body  of  the  bone,  and  for  the  same  time. 

Fractures  of  the  Neck  of  the  Scapula. — Fracture  of  the  anatomical  neck 
has  not  been  proved  to  exist.  Fracture  of  the  surgical  neck  is  evinced  by  flat- 
tening of  the  shoulder,  prominence  of  the  acromion,  and  the  presence  of  a 
lump  in  the  axilla,  crepitus  being  developed  by  pressing  the  axillary  promi- 
nence upward  and  backward.  The  deformity  is  reduced  with  ease,  but  it  at 
once  recurs.  The  condition  is  treated  by  placing  a  pad  in  the  axilla,  a 
shoulder-cap  on  the  shoulder,  applying  the  second  roller  of  Desault,  and  sup- 
porting the  forearm  and  elbow  in  a  sling.  A  \>lpeau  dressing  can  be  used, 
associated  with  the  application  of  a  folded  towel  in  the  axilla.  The  dressing 
is  to  be  worn  for  five  weeks. 

Fractures  of  the  glenoid  cavity  are  not  \ery  unusual,  and  ma\-  occur 
with  or  without  dislocation.  Fracture  of  this  region  arises  from  direct  force 
applied  to  the  shoulder.  The  existence  of  this  fracture  is  determined  by  ex- 
cluding fractures  of  other  bones  and  by  detecting  crepitus  when  the  arm  is  at  a 
right  angle  to  the  body  and  the  humerus  is  pushed  against  the  glenoid  cavity, 
the  crepitus  not  being  found  when  the  arm  hangs  by  the  side. 

Treatment  is  by  the  second  roller  of  Desault  and  a  forearm  sling  worn 
for  four  weeks;  careful  passive  movements  limit  ankylosis.  If  ankylosis 
occurs,  adhesions  must  be  broken  up  while  the  patient  is  under  ether  or 
nitrous  oxid. 

Fractures  of  the  acromion  process  are  often  met  with  as  the  result 
of  direct  violence.  The  existence  of  fracture  of  the  acromion  is  indicated 
by  pain,  by  inabihty  to  abduct  the  arm,  by  flattening  of  the  shoulder,  by 


4i6  Diseases  and  Injuries  of  Bones  and  Joints 

sudden  lowering  of  the  point  of  the  shoulder,  by  mobility,  and  by  crepitus. 
To  treat  a  case  of  this  kind,  put  a  large  pad  in  the  axilla  with  the  base  down, 
bind  the  arm  over  the  pad  with  the  second  roller  of  Desault,  lifting  the  elbow 
with  turns  of  the  roller  carried  over  it  and  the  opposite  shoulder,  thus  splinting 
the  bone  in  place  by  the  head  of  the  humerus  pushing  against  the  coraco- 
acromial  ligaments.     The  dressing  is  to  be  worn  for  four  weeks. 

Fractures  of  the  coracoid  process  rarely  happen  alone,  and  may  arise 
from  direct  force  or  from  muscular  action.  But  little  displacement  is  found. 
Crepitus  and  mobility  are  usually  detected.  Inability  to  shrug  the  shoulder 
inward  was  pointed  out  as  a  symptom  by  Byers.  Such  a  case  is  well  treated 
by  a  Velpeau  bandage,  which  is  to  be  worn  for  four  weeks. 

Fractures  of  the  humerus  are  divided  into  (i)  fractures  of  the  upper 
extremity;  (2)  fractures  of  the  shaft;  and  (3)  fractures  of  the  lower  extremity. 
In  examining  any  fracture  of  the  humerus,  feel  at  once  for  the  pulse,  so  as 
to  ascertain  if  the  artery  has  been  torn;  in  any  fracture  near  the  head  of 
the  humerus  be  certain  that  dislocation  does  not  exist. 

Examination  of  the  Shoulder. — In  some  cases  ether  must  be  administered. 
Compare  the  injured  shoulder  with  the  sound  shoulder,  the  patient,  if  not 
anesthetized,  being  seated  in  a  chair  or  stool.  The  direction  of  the  axis 
of  the  arm  is  noted.  The  surgeon  grasps  the  fle.xed  elbow  with  one  hand 
and  the  shoulder  with  the  other;  he  thus  can  move  the  extremity  and  palpate 
the  joint  and  adjacent  points.  The  shoulder  is  moved  gently  in  every  direc- 
tion, and  the  surgeon  notes  if  the  head  of  the  bone  moves  with  the  shaft. 
Examination  shows  if  the  head  of  the  bone  is  in  place  or  if  the  glenoid  cavity 
is  vacant — if  the  head  of  the  bone  is  in  an  abnormal  situation,  if  it  is  altered 
in  contour,  if  there  is  crepitus  or  preternatural  mobility,  and  if  any  movement 
is  impaired.  The  acromion  process,  outer  end  of  the  clavicle,  coracoid  process 
of  the  scapula,  and  neck  of  the  scapula  are  also  investigated.  The  length 
of  the  arm  is  obtained  by  measuring  from  the  apex  of  the  acromion  process 
of  the  scapula  to  the  apex  of  the  external  condyle  of  the  humerus,  and  it  is 
compared  with  the  length  of  the  sound  extremity. 

I.  Fractures  of  the  upper  extremity  of  the  humerus  include  (a)  frac- 
tures of  the  anatomical  neck;  {b)  fractures  of  the  surgical  neck;  {c)  fractures 
of  the  head,  oblique  and  longitudinal;  and  {d)  separation  of  the  upper 
epiphysis. 

Fractures  of  the  Anatomical  Neck  of  the  Humerus. — The  anatomical 
neck  is  the  constricted  circumference  of  the  articular  surface,  and  fractures 
of  it,  though  rare,  do  occur,  especially  in  the  aged.  The  Hne  of  fracture  in 
some  cases  follows  the  insertion  of  the  capsule,  in  others  it  is  entirely  within 
the  capsule,  but  in  most  it  is  without  the  capsule  above  and  within  the  capsule 
below;  hence  the  term  "intracapsular"  is  rarely  correct  as  a  designation. 
Such  a  fracture  may  be  impacted.  The  cause  is  direct  violence  or  a  fall 
or  a  blow  upon  the  elbow  when  the  arm  is  abducted.  Polloson,  of  Lyons,* 
has  reported  a  case  due  to  muscular  action.  The  patient  died  in  eclampsia, 
and  at  the  necropsy  it  was  found  that  both  humeral  heads  were  fractured  and 
impacted.  The  fractures  must  have  been  produced  by  the  muscles  throwing 
the  heads  of  the  bones  violently  against  the  glenoid  cavities,  probably  by 
adduction. 

*Rev.  de  Chir.,  vol.  viii,  1888. 


splints; 


Plate  6. 


I.  Fracture-box.  2.  Double  Inclined  Plane  Fracture-box.  3.  Jaw-cup  (unfolded).  4.  Jaw-cup 
(folded).  5.  Anterior  Angular  Splint.  6.  Internal  Angular  Splint.  7.  Bond  Splint.  8.  Shoulder-cap. 
9.  Dupuytreu  Splint  in  Pott's  Fracture.  10.  Agnew  Splint  for  Fracture  of  llie  Metacarpus.  11.  Agnew 
Splint  for  Fracture  of  the  Patella.  12.  Agnew  Splint  applied.  13.  Strapping  the  Chest  in  Fractured 
Kibs.  14.  Extension  Apparatus  in  Fracture  of  the  Femur.  15,  16.  Adhesive  Strips  for  Extension 
Apparatus. 


Fractures  of  the  Anatomical  Neck  of  the  Humerus 


417 


Symptoms. — The  symptoms  in  fracture  of  the  anatomical  neck  are  pain, 
swelling,  ecchymosis,  slight  irregularity  of  the  shoulder  (which  irregularity 
is  soon  hidden  by  tumefaction),  and  inability  to  actively  abduct  the  arm. 
Deformity,  as  a  rule,  is  slight  or  is  absent,  because  the  capsule  is  rarely 
entirely  torn  from  the  lower  fragment.  If  deformity  exists,  it  is  due  to  the 
muscles  inserted  on  the  bicipital  groove  and  to  the  coracobrachialis,  which 
pull  the  lower  fragment  inward  and  forward.  Treves  says  that  a  tear  of 
the  retlected  fibers  of  the  capsule  leads  to  subsequent  necrosis,  because 
this  joint  has  no  ligamentum  teres.  In  unimpacted  cases  there  is  crepitus, 
and  mobility  of  the  shaft  can  be  detected  near  the  head  of  the  bone.  In 
some  cases  impaction  occurs,  the  upper  fragment  impacting  into  the  lower. 
In  this  condition  there  are  very  slight  shortening  and  trivial  shoulder-flattening, 


Fig.  174. — Fracture  at  upper  end  of  the 
humerus.  Note  hand,  forearm,  and  elbow  ban- 
daged ;  axillary  pad  and  strap,  plaster-of-Paris 
shoulder-cap,  sling  (Scudder). 


F'g-  175- — Fracture  at  upper  end  of  the 
humerus.  Arm  and  elbow  bandaged.  Axillary- 
pad  and  shoulder-cap  in  position.  Application 
of  circular  bandage  to  trunk  and  shoulder. 
Slitig  not  shown  (Scudder). 


no  crepitus  unless  the  tuberosity  is  broken  off,  no  mobilitv,  and,  as  Erichsen 
says,  the  head  of  the  bone,  while  it  can  be  felt  through  the  a.xilla,  is  not  in 
the  axis  of  ihe  limb. 

The  prognosis  of  fracture  of  the  anatomical  neck  is  usually  good  for  bony 
union  (Hamilton,  Pick,  and  R.  W.  Smith),  but  a  stiff"  joint  is  apt  to   result. 

Treatment. — Feel  the  pulse  to  be  sure  the  artery  is  untorn.  In  most 
ca.ses  an  anesthetic  should  be  given  in  order  to  e.xamine  with  ease  and  dress 
with  satisfaction.  Sometimes  the  fragments  are  readily  coaptated;  occasion- 
ally they  are  not.  In  a  case  reported  by  Carl  Beck  the  a.xes  of  the  fragments 
were  at  right  angles  and  they  could  only  be  kept  in  contact  by  holding  the 
arm  at  a  right  angle  to  the  body  ("New  York  Med.  Jour.,"  April  5,  1902). 
Some  surgeons  treat  this  fracture  by  simply  hanging  the  wrist  in  a  sling 
27 


4i8 


Diseases  and  Injuries  of  Bones  and  Joints 


and  suspending  a  bag  of  shot  from  the  elbow  to  make  extension.  The  usual 
plan  of  treatment  is  as  follows:  flex  the  arm  to  a  right  angle  with  the  body, 
and  carry  up  from  the  base  of  the  fingers  to  above  the  elbow  the  turns  of 
a  spiral  reversed  bandage  made  of  flannel.  Interpose  lint  between  the  arm 
and  the  side,  and  place  a  V-shaped  pad  with  the  apex  upward  in  the  axilla, 
tving  the  tapes  over  the  opposite  shoulder.  A  shoulder-cap  made  of  paste- 
board (PL  6,  Fig.  8)  or  plaster-of-Paris  (Fig.  174),  moulded  to  fit  and  well 
lined  with  cotton,  is  applied.  The  plaster-of-Paris  cap  is  the  most  satisfactory. 
It  is  applied  "  so  as  to  cover  the  whole  shoulder,  the  anterior  and  posterior  as- 
pects of  the  chest  and  the  outer  side  of  the  upper  arm  down  to  the  external  con- 
dyle of  the  humerus"  (Scudder,  on  "The  Treatment  of  Fractures")  (Fig. 
174).  The  arm  with  the  shoulder-cap  is  fixed  to  the  side  by  the  second  roller 
of  Desault,  and  the  wrist  is  hung  in  a  sling  (Fig.  175).  The  edges  of  the 
bandage  should  be  stitched  together.  This  apparatus  is  changed  daily  for 
the  first  few  days,  the  body  and  arm  being  rubbed  at  each  change  with  alco- 
hol, soap  liniment  or  ethereal  soap.  After  this  period  a  change  every  third 
or  fourth  day  is  often  enough.  Massage  is  begun  at  the  end  of  one  week, 
but  rotation  and  motion  of  the  joint  are  not  employed  until  after  three 
weeks.  The  dressings  are  removed  at  the  end  of  four  weeks,  the  forearm 
being  carried  in  a  sling  for  two  weeks  more.  In  impacted  fracture  do  not 
pull  apart  the  impaction,  do  not  use  a  pad,  but  apply  a  cap  to  the  shoulder 
and  fix  the  arm  to  the  side  for  five  weeks.  The  fracture  unites  with  deformity. 
Fractures  of  the  Surgical  Neck  of  the  Humerus. — The  surgical  neck 
is  the  constricted  portion  of  bone  between  the  tuberosities  and  the  upper 

line  of  the  insertion  of  the  muscles  on  the 
bicipital  groove.  Fractures  in  this  region  are 
usually  transverse,  but  they  may  be  oblique. 
The  causes  are:  direct  force  almost  always; 
indirect  force  occasionally;  and  muscular  ac- 
tion in  rare  instances. 

Symptoms. — The  symptoms  in  fracture  of 
the  surgical  neck  are:  pain  running  into  the 
fingers  from  pressure  upon  the  brachial  plexus; 
crepitus  and  mobility  on  extension;  and  flat- 
tening, which  differs  from  the  flattening  of  dis- 
location in  that  it  occurs  farther  below  the 
acromion  and  that  this  process  is  not  so 
prominent.  Shortening  to  the  extent  of  an  inch 
is  noted.  The  head  of  the  bone  can  be  felt 
in  the  glenoifJ  cavity,  but  it  does  not  move  on 
rotating  the  arm.  The  upper  end  of  the  lower  fragment  is  felt  and  moves  on  ro- 
tating the  arm.  The  displacement  is  pronounced.  The  lower  fragment  is  pulled 
upward  by  the  deltoid,  biceps,  coracobrachialis,  and  triceps;  inward  by  the 
muscles  of  the  bicipital  groove;  and  forward  by  the  great  pectoral;  thus,  the 
upper  end  of  the  lower  fragment  y)rojects  into  the  axilla,  and  the  elbow  lies 
from  the  side  and  backward.  Pean  holds  that  the  violence  drives  the  lower 
fragment  forward.  The  upper  fragment  is  abducted  and  rotated  outward, 
which  position  is  due,  it  is  generally  taught,  to  the  action  of  the  supraspinatus, 
infraspinatus,  and  teres  minor  muscles.     In  some  cases  displacement  is  for- 


Fig.  176. — Internal  angular  splint 
and  shoulder-cap  in  fracture  of  the 
surgical  neck  of  the  humerus. 


Fractures  of  the  Head  of  the  Humerus 


419 


ward,  and  in  other  cases  it  is  not  obvious.  The  lower  fragment  may  impact 
into  the  upper,  in  which  case  the  symptoms  are  obscure  and  the  diagnosis 
is  made  by  exchision.  If  the  impaction  is  solid  and  complete,  there  are 
the  history  of  direct  force,  the  impaired  movements,  the  slight  deformity, 
and  the  absence  of  crepitus.  In  all 
fractures  of  the  upper  end  of  the  hu- 
merus the  distinction  can  be  made 
from  dislocation  by  feehng  the  head 
of  the  bone  under  the  acromion  and 
by  noting  that  it  does  not  move  on 
rotating  the  arm. 

The  prognosis  of  fracture  of  the 
surgical  neck  of  the  bone  is  good. 

Treatment. — Some  surgeons  treat 
a  fracture  of  the  surgical  neck  in 
e.xactlv  the  same  manner  as  a  frac- 
ture of  the  anatomical  neck.  We 
prefer  the  following  plan :  In  many 
cases  give  ether  in  order  to  examine 
and  dress.  Feel  the  pulse  to  see 
that  the  artery  has  not  been  dam- 
aged. Reduce  by  traction  and  ma- 
nipulation; if  there  is  an  impaction, 
pull  it  apart.  Take  an  internal 
angular  splint  (PL  6,  Fig.  6)  and 
pad  it  well,  putting  on  extra  padding 
at  the  points  that  are  to  rest  against  the  palm,  the  inner  condyle,  and 
the  axillary  folds.  Lay  the  arm  and  pronated  forearm  upon  the  splint. 
Apply  a  padded  shoulder-cap.  Fix  the  splint  and  cap  in  place  with  a  spiral 
reversed  bandage  terminating  as  a  spica  of  the  shoulder,  and  hang  the  hand 
or  forearm  in  a  sling  (Fig.  176).  The  dressing  is  to  be  worn  for  four  weeks, 
and  the  rules  to  be  followed  in  changing  it  are  the  same  as  in  fracture  of 
the  anatomical  neck.  Massage  is  used  after  one  week  and  passive  motion 
after  four  weeks  to  amend  stiffness.  In  rare  cases — those  with  strong  ante- 
rior projection  of  the  lower  end  of  the  upper  fragment — apply  an  anterior 
angular  spHnt.  In  some  cases  where  the  deformity  strongly  tends  to  recur 
support  by  a  plaster-of-Paris  trough  on  the  back  and  sides  of  the  arm  and 
shoulder  (Fig.  177),  or  maintain  extension  by  weights  and  pulleys,  the  patient 
being  ke]it  in  bed  (Stimson). 

Longitudinal  and  Oblique  Fractures  of  the  Head  of  the  Humerus. — 
By  this  term  may  be  designated  separation  of  the  great  tuberosity,  or  separa- 
tion of  a  portion  of  the  articular  surface,  together  with  the  great  tuberosity, 
from  the  shaft  and  lesser  tuberosity  (Pickering  Pick,  Guthrie,  and  Ogston). 
The  cause  is  direct  violence  to  the  front  of  the  shoulder. 

Symptoms. — The  symptoms  in  longitudinal  and  oblique  fracture  of  the 
head  are  broadening  and  flattening  of  the  shoulder  with  projection  of  the 
acromion.  The  upper  fragment  passes  upward  and  outward,  and  the  lower 
fragment  passes  upward  and  inward  to  rest  on  the  margin  of  the  glenoid 
cavity  below  the  coracoid  process.     The  elbow  is  drawn  from  the  side,  there 


Fig.  177. — Apparatus  for  fracture  of  the  humerus 
at  any  point  above  the  cond\les. 


420  Diseases  and  Injuries  of  Bones  and  Joints 

is  some  shortening,  and  the  patient  cannot  abduct  his  arm.  If  the  surgeon 
grasps  the  patient's  elbow  and  holds  it  to  the  side  and  rotates  the  arm  while 
with  his  other  hand  he  grasps  the  upper  fragment,  crepitus  is  very  positive. 
Examination  develops  wide  separation  of  the  fragments.  The  deformity 
cannot  be  entirely  corrected,  because  the  biceps  tendon  usually  gets  between 
the  fragments  (Ogston),  but  a  useful  limb  can  usually  be  obtained. 

Treatment. — -The  plan  which  gives  the  best  result  in  treating  longitudinal 
and  obhque  fracture  of  the  head  of  the  bone  is  to  place  the  patient  on  his 
back  upon  a  hard  bed  with  a  small,  firm  pillow  under  his  head,  abduct  the 
arm  above  the  head,  rotate  it  outward  so  that  the  back  of  the  hand  rests 
on  the  bed,  and  hold  it  in  place  by  sand-bags.  This  position  should  be 
maintained  for  three  weeks,  at  the  end  of  which  period  the  fracture  can 
be  treated  for  three  weeks  more  as  is  a  fracture  of  the  anatomical  neck.  If 
the  patient  refuses  to  go  to  bed,  treat  the  injury  as  a  fracture  of  the  ana- 
tomical neck,  padding  well  over  the  tuberosities.  The  dressings  should  be 
worn  for  five  weeks,  passive  motion  being  made  after  four  weeks.  In  the 
above  injury  feel  at  once  for  the  pulse,  to  see  if  the  artery  has  been  torn. 

Separation  of  the  Upper  Epiphysis  of  the  Humerus. — The  epiphysis 
is  united  during  the  twentieth  year.  Separation  is  a  rare  accident  and  is 
produced  by  direct  force. 

Symptoms. — The  chief  symptom  in  separation  of  the  upper  epiphysis  is 
projection  of  the  upper  end  of  the  lower  fragment  inward,  forward,  and 
upward  beneath  the  coracoid,  and  consequently  a  projection  of  the  elbow 
backward  and  from  the  side.  If  the  lower  fragment  passes  forward  and 
not  inward,  the  elbow  simply  passes  back.  The  upper  end  of  the  lower 
fragment  is  smooth  and  convex.  Rotation  of  the  shaft  develops  soft  crepitus 
when  the  fragments  are  in  contact. 

The  prognosis  is  good  for  bony  union,  though  the  future  growth  of  the 
limb  may  be  impaired. 

Treatment. — The  treatment  for  separation  of  the  upper  epiphysis  is  a 
pad  in  the  axilla,  a  shoulder-cap,  binding  the  arm  to  the  side,  and  hanging 
the  hand  in  a  sling.  Wear  the  dressing  for  four  weeks,  and  begin  passive 
motion  as  directed  when  dealing  with  fracture  of  the  upper  end  of  the  humerus. 

2.  Fractures  of  the  Shaft  of  the  Humerus. — Fracture  of  the  shaft 
of  the  humerus  is  a  very  common  accident.  The  cause  is  usually  direct 
violence,  such  as  a  blow.  The  fracture  may  arise  from  indirect  violence, 
such  as  a  fall  upon  the  elbow.  Muscular  action  is  not  rarely  also  a  cause, 
as  in  throwing  a  ball,  in  catching  a  tree-limb  while  falling,  or  in  turning 
another's  wrist  as  a  test  of  strength  (Treves). 

The  symptoms  of  fracture  of  the  shaft  of  the  humerus  are  pain,  swelling, 
ecchymosis,  inability  to  move  the  arm,  mobility,  and  distinct  crepitus.  Short- 
ening to  the  extent  of  three-fourths  of  an  inch  occurs.  The  displacement 
varies  with  the  .situation  of  the  fracture  and  the  direction  of  the  force.  If 
the  fracture  is  above  the  insertion  of  the  deltoid,  the  lower  fragment  is  pulled 
up  by  the  triceps,  biceps,  and  deltoid,  and  pulled  out  by  the  deltoid,  and 
the  upper  fragment  is  pulled  inward  by  the  arm-pit  muscle.  In  fracture 
below  the  deltoid  this  muscle  is  apt  to  pull  the  lower  end  of  the  upper  frag- 
ment outward,  while  the  lower  fragment  passes  inward  and  upward  because 
of  the  action  of  the  biceps  and  triceps.     Injury  of  the  musculospiral  nerve 


Fractures  of  the  Shaft  of  the  Humerus 


421 


sometimes  occurs.     The  nerve  may  be  contused,  producing  pain  at  the  seat 
of  bruising,  and  tinghng  and  numbness  in  the  region  suppHed  by  the  nerve. 


Fig.  178. — Fracture  of  the  shaft  of  the  humerus.     Note  bandage  to  hand,  forearm,  and  elbow  ;  axillary 
pad  and  strap  ;  coaptation  splints  and  sling.     Bandage  does  not  cover  fracture  (Scudder). 


Fig.  179, — Fracture  of  the  shaft  of  the  humerus.    Note  bandage  to  hand,  forearm,  and  elbow  ;  adhesive- 
plaster  swathe  holding  arm  upon  axillary  pad  and  covering  coaptation  splints.     Sling  (Scudder). 


In  most  cases  the  symptoms  soon  pass  away,  but  sometimes  neuritis  ensues. 
A  severe  contusion  produces  not  only  pain,  but  paraly.sis  of  the  muscles 


422  Diseases  and  Injuries  of  Bones  and  Joints 

supplied  by  the  nerve,  and  surface  anesthesia.  In  most  cases  this  condition 
is  recovered  from  in  a  few  weeks,  but  sometimes  it  lasts  a  long  while  or  even 
permanently.  In  musculospiral  paralysis  the  patient  is  unable  to  extend 
the  wrist  and  lingers  or  to  supinate  the  forearm.  There  is  ''  complete  loss 
or  impaired  sensation  in  the  lower  half  of  the  outer  and  anterior  aspect  of 
the  arm  and  in  the  middle  of  the  back  of  the  forearm  as  far  as  the  wrist" 
(Scudder,  in  "The  Treatment  of  Fractures").  The  nerve  may  be  divided 
by  a  sharp  fragment,  paralysis  of  motion  and  anesthesia  resulting  at  once. 
In  some  cases  the  nerve  is  caught  in  and  compressed  by  callus,  scar-tissue, 
or  fragments,  motor  and  sensory  disturbances  resulting. 

The  prognosis  is  good,  but  the  fact  should  always  be  remembered  that 
ununited  fractures  are  commoner  in  the  humerus  than  in  any  other  bone. 
Treves  believes  this  to  be  due  to  entanglement  of  muscle  between  the  frag- 
ments, lack  of  fixation  of  the  shoulder-joint,  and  imperfect  elbow-support. 
Hamilton  believes  that  it  is  due  to  the  facts  that  the  elbow  soon  becomes 

fixed  at  a  right  angle,  and  that  any  movement 
of  the  forearm  moves  the  seat  of  fracture,  and 
not  the  elbow. 

Treatment. — It  is  rarely  necessary  to  anes- 
thetize unless  the  patient  be  a  nervous  woman 
or  an  excitable  child.  Feel  the  pulse,  to  be 
certain  the  artery  has  not  been  lacerated. 
Reduce  the  fracture  by  extension,  counter- 
extension,  and  manipulation.  Apply  an  in- 
ternal angular  splint  without  the  shoulder-cap 
(Fig.  i8o).  If  this  spHnt  does  not  maintain  co- 
aptation of  the  fragments,  associate  with  it  three 
4^^^/^.- 1,//  short  humeral  splints  instead  of  the  shoulder- 
Fig.  i8o.-internai  angular  splint  in  Cap  used  in  fractures  near  the  shoulder-joint, 
fracture  of  the  shaft  of  the  humerus.      Splints  are  to  be  worn  for  five  or  six  weeks,  and 

after  the  removal  of  the  splints  the  wrist  is  hung 
in  a  sling.  The  shng  is  dispensed  with  eight  weeks  after  the  infliction  of  the 
injury.  Passive  movements  are  not  to  be  made  until  the  fracture  is  well 
united  (after  five  or  six  weeks),  for,  if  made  too  soon,  they  predispose  to 
non-union,  and,  as  no  joint  is  involved,  genuine  ankylosis  will  not  occur. 
Many  surgeons  treat  these  fractures  by  applying  plaster-of-Paris  to  the  fore- 
arm and  the  arm  (the  elbow  being  flexed  to  a  right  angle),  binding  the  arm 
to  the  .side  and  hanging  the  wrist  in  a  sling.  Others  apply  a  trough  to  the 
arm  and  forearm  (Fig.  177).  Scudder  prefers  to  bandage  the  hand,  fore- 
arm, and  elbow,  and  apply  an  axillary  pad,  coaptation  splints,  a  swathe  of 
adhesive  plaster  holding  arm  to  the  side,  and  a  sling  (Figs.  178,  179).  In 
any  case  in  which  it  is  impossible  to  obtain  and  maintain  correct  apposition 
of  the  fragments,  cut  down  upon  them,  and  apply  sutures.  If  the  nerve  is 
divided,  an  incision  must  be  made,  and  the  nerve  sutured  and  the  bone 
wired.  If  the  nerve  is  caught  in  the  callus,  after  repair  has  taken  place  the 
nerve  must  be  liberated  by  chiseling  the  callus  away.  Neuritis  is  treated  by 
blisters  over  the  nerve,  the  use  of  the  descending  galvanic  current,  and  the 
administration  of  salicylate  of  ammonium  and  the  bromids. 


Fractures  of  the  External  Condyle  of  the  Humerus  423 

3.  Fractures  of  the  Lower  Extremity  of  the  Humerus. — These  frac- 
tures are  spoken  of  as  fractures  in,  or  in  the  neighborhood  of,  the  elbow- 
joint,  and  they  include  (a)  fractures  of  the  external  condyle;  (b)  fractures  of 
the  internal  condyle;  (r)  fractures  of  the  internal  epicondyle;  (d)  fractures 
at  the  base  of  the  condyles;  (e)  T-  or  Y-shaped  fractures;  (/)  epiphyseal  sepa- 
ration; and  (g)  fractures  of  the  capitellum  and  trochlea.  There  may  be  more 
than  one  fracture,  or  there  may  be  also  a  dislocation  of  the  humerus,  of  the 
ulna,  or  of  both  bones.  Rarely  the  fracture  is  compound.  These  fractures 
are  frequent  injuries  in  childhood,  and  are  not  uncommon  in  adults. 

Method  oj  Examination. — A  fracture  of  the  elbow  is  rapidly  followed  by 
great  swelling,  and  the  diagnosis  is  often  very  difficult.  In  most  cases,  when 
possible,  the  .r-rays  should  be  used  in  arriving  at  a  diagnosis.  In  every  case 
in  which  the  .v-rays  are  not  used,  and  in  most  cases  in  which  they  are,  the  sur- 
geon examines  the  parts  carefully  while  the  patient  is  under  ether.  If  swelling 
is  very  great,  it  is  necessary  to  abate  it  in  order  to  reach  any  conclusion  as  to  the 
condition.  We  can  bandage  the  arm,  rest  it  semiflexed  on  a  pillow,  and  apply 
evaporating  lotions  or  even  an  ice-bag  for  a  day  or  two,  or,  what  is  better,  tem- 
porarily diminish  the  swelling  by  Gerster's  plan,  which  is  as  follows:  Apply  an 
Esmarch  bandage  from  the  hand  to  well  above  the  seat  of  fracture;  this  will 
drive  away  extra-articular  swelling  and  permit  of  thorough  examination.  It 
is  a  great  advantage  to  have  the  patient  anesthetized,  for  then  not  only  can 
we  make  an  accurate  diagnosis,  but  we  can  reduce  the  fracture  satisfactorily 
and  apply  a  careful  first  dressing. 

Compare  the  injured  with  the  sound  elbow.  Note  swelling  and  local 
ecchymosis.  Feel  the  radial  pulse.  Note  the  "  carr3-ing  angle  ''  (Fig. 
182J.  Measure  each  arm  from  the  tip  of  the  acromion  process  of 
the  scapula  to  the  tip  of  the  external  condyle  of  the  humerus.  Feel  each 
prominent  body-point  and  note  if  it  is  mobile  (condyles,  olecranon,  head 
of  ulna).  Feel  the  shaft  just  above  the  condyles.  Mark  with  ink  on  each 
elbow  the  tip  of  the  external  condyle,  the  tip  of  the  internal  condyle,  and 
the  tip  of  the  olecranon,  and  observe  the  relation  between  these  points  of 
each  elbow  in  flexion  and  in  extension.  In  an  uninjured  elbow  a  straight 
line  transverse  to  the  long  axis  of  the  limb  with  the  joint  in  extension  will 
pass  through  the  condyles  and  leave  the  tip  of  the  olecranon  just  a  shade 
above  it.  "  When  the  elbow  is  at  a  right  angle,  these  three  points  will  be 
found  in  the  same  plane  with  the  back  of  the  upper  arm"  (Scudder,  in  "The 
Treatment  of  Fractures").  Rotate  the  radius  while  a  thumb  is  held  against 
the  head  of  the  bone.  Make  flexion  and  extension  of  the  elbow  and  determine 
if  there  is  any  lateral  motion.  Test  for  mobility  just  above  the  condyles. 
The  above  maneuvers  will  determine  the  presence  or  absence  of  crepitus, 
preternatural  mobihty,  deformity,  etc. 

Fractures  of  the  External  Condyle  of  the  Humerus. — A  fracture  i)f 
the  external  condyle  runs  into  the  joint  and  the  capitellum  is  usualh'  broken 
oft".  Such  an  injury  occurs  oftenest  in  children,  being  due  to  falling  on 
the  hand;  but  it  may  occur  from  direct  force,  and  may  happen  to  adults. 

Symptoms. — The  symptoms  of  fracture  of  the  external  condyle  are  severe 
pain,  great  swelling,  and  crepitus  (found  on  pressing  or  moving  the  condyle 
and  on  rotating  the  radius).     Mobility  may  also  be  discovered.     A  projection 


424 


Diseases  and  Injuries  of  Bones  and  Joints 


is  felt  on  the  outer  and  posterior  surface  of  the  elbow.  The  forearm  is  semi- 
flexed and  supinated.     The  patient  cannot  use  the  joint. 

Fractures  of  the  Inner  Epicondyle  of  the  Humerus. — The  inner 
epicondyle  is  an  epiphysis  which  unites  during  the  seventeenth  year.  It  not 
infrequently  breaks  from  muscular  action  or  from  direct  violence,  and  the 
fracture  does  not  involve  the  joint.  Crepitus  and  mobility  can  be  detected. 
Displacement  is  slight.     The  outer  epicondyle  is  never  fractured  alone. 

Fractures  of  the  Internal  Condyle  of  the  Humerus. — The  hne  of 
fracture  after  a  break  of  the  internal  condyle  runs  into  the  joint,  to  the  troch- 
lear surface  of  the  humerus.     The  cause  is  always  direct  violence. 

Symptoms. — In  fracture  of  the  internal  condyle  the  fragment,  accompanied 
by  the  ulna,  goes  upward  and  backward,  and  when  the  forearm  is  extended 


Fig.  i8i,— Loss  of  carrying  function  after  fracture  of  inner  condyle  of  tlie  liumerus. 


the  ulna  j)r()jects  posteriorly,  the  lower  end  of  the  humerus  being  felt  in 
front.  The  fragment  forms  a  projection  back  of  the  elbow.  Crepitus  and 
preternatural  mobility  can  be  found  if  swelling  is  not  too  great.  Crepitus 
is  detected  by  flexing  and  extending  the  forearm.  The  space  between  the 
condyles  is  broader  than  normal,  and  the  forearm  takes  a  bend  toward  the 
ulnar  side,  the  "carrying  function"  of  the  forearm  being  lost  (Fig.  i8i). 
When  a  person  carries  a  heavy  object,  such  as  a  backet,  he  instinctively  rests 
the  inner  condyle  upon  the  pelvis,  and  the  normal  deviation  of  the  forearm  out- 
ward keeps  the  bucket  from  striking  the  leg.  This  deviation  outward  when 
the  inner  condyle  rests  against  the  ilium  gives  us  the  carrying  function.  In 
fracture  of  the  inner  condyle  the  broken  condyle  ascends  and  the  "carrying 
function"  is  lost  (Fig.  1S2). 


T-Fractures  of  the  Humerus 


425 


Fractures  at  the  Base  of  the  Condyles  of  the  Humerus. — A  fracture  in 
this  region  is  just  above  the  olecranon  and  is  on  a  higher  level  behind  than  in 
front.     The  cause  is  direct  force  acting  upon  the  olecranon. 

The  symptoms  are  loss  of  function  and  pain  from  injury  of  the  median  or 
ulnar  nerve.  Crepitus  and  mobility  are  readily  found.  The  lower  fragment  is 
drawn  backward  and  upward  by  the  action  of  the  triceps,  biceps,  and  brachialis 
anticus  muscles.  The  lower  end  of  the  upper  fragment  projects  in  front  of 
the  joint.  This  lesion  ma>  be  mistaken  for  dislocation  of  the  bones  of  the 
forearm  backward.  In  fracture  the  limb  is  mobile;  in  dislocation  it  is  rigid. 
In  fracture  the  deformity  is  easily  reduced  and  strongly  tends  to  recur;  in 


Fig.  182.— Diagram  to  exhibit  the  "  carrying  function  "  of  the  forearm,  and  the  loss  of  this  func- 
tion in  fracture  of  the  inner  condyle  of  the  humerus  :  a  and  b  show  the  normal  relation  of  the  parts 
when  carrying;  c  show-s  the  alteration  of  axis  of  the  forearm  when  the  inner  condyle  is  fractured, 
what  is  known  as  gunstock  deformity  resulting  (after  Allis). 


dislocation  the  deformity  is  reduced  with  dii^culty  and  does  not  tend  to  recur. 
In  dislocation  there  is  shortening  of  the  forearm,  but  not  of  the  arm;  in  fracture 
there  is  shortening  of  the  arm  but  not  of  the  forearm.  In  dislocation  there 
is  a  smooth,  large  projection  below  the  crease  in  front  of  the  elbow;  in  fracture 
there  is  a  sharp  projection  above  the  crease.  In  fracture  there  is  crepitus; 
in  dislocation  there  is  no  crepitus. 

The  diagnosis  can  usually  be  settled  by  the  Rontgen  rays. 

T-fractures  of  the  Humerus.— .\  T-fracture  consists  of  a  transverse 
fracture  above  the  condyles  ])lus  a  vertical  fracture  between  them.  The  cause 
is  violent  direct  force  applied  posteriorly. 


426 


Diseases  and  Injuries  of  Bones  and  Joints 


Symptoms. — The  symptoms  are  increase  in  breadth  of  the  joint  (Fig. 
183),  preternatural  mobility,  crepitus,  pain  and  sweUing,  mounting  up  of  the 
inner  condyle  back  of  the  elbow  on  the  inner  side,  and  of  the  outer  condyle 
back  of  the  elbow  on  the  outer  side.  The  forearm  is  semiflexed  and  supin- 
ated,  and  the  carrying  function  is  lost. 

Prognosis  of  Fractures  in  or  near  the  Elbow-joint. — In  many  fractures 
it  is  dithcult  or  impossible  to  obtain  reduction,  and  in  some  it  is  impossible  to 
maintain  reduction.  Stimson  is  undoubtedly  right  when  he  says  that  "in 
intercondyloid  fracture  with  marked  separation  there  is  no  practicable  means 
merely  to  maintain  reduction."*  The  prognosis  for  complete  restoration  of 
fvmction  is  bad,  and  in  most  of  these  fractures  some  deformity  and  considerable 
stiffness  are  inevitable.  Ankylosis  partial  or  complete  is  a  not  unusual  se- 
quence. Ankylosis  may  result  from  prolonged  immobilization,  the  muscles  con- 
tracting and  becoming  fibrous,  the  fascia  and  ligaments  about  the  joint  short- 
ening, the  capsule  shrinking  and  thickening,  some  of  the  cartilages  becoming 


Fig.  183. — Deformity  following:  fracture  of  the  humerus  between  the  condj-les. 


fibrous,  and  the  joint  being  partly  obliterated.  It  may  result  from  extravasa- 
tion of  blood  into  the  joint  and  tendon-sheaths  with  subsequent  formation  of 
fibrous  tissue.  It  may  arise  from  organization  of  inflammatory  exudate  within 
and  about  the  joint  and  in  the  sheaths  of  muscles  and  tendons.  It  may  arise 
from  the  formation  of  an  excess  of  callus.  Bruns  claims  that  in  fracture  in  the 
joint  excess  of  callus  rarely  forms,  and  that  masses  of  callus  form  chiefly  in  the 
line  of  fracture  near  but  not  in  a  joint. f  Excessive  callus-formation  is  sure  to 
take  place  if  reriuction  is  not  thoroughly  accomplished  or  if  the  fragments  are 
not  well  immobilized  but  move  upon  each  other.  A  mass  of  callus  in  or  about 
a  joint  limits  or  prevents  motion. 

*  Transactions  American  Surgical  Association,  vol.  ix. 
•{"Max  Oberst,  in  Volkmann's  "  Sammlung  Vortrage." 


Fractures  in  or  near  the  Elbow-joint 


427 


Treatment  of  Fractures  in  or  near  the  Elbow-joint. — Thoroughl\-  set 
the  fracture  while  the  patient  is  under  ether.  It  is  advisable,  when  it  can  be 
done  conveniently,  to  use  the  .r-rays  to  confirm  the  diagnosis  and  to  use  them 
again  after  dressings  have  been  applied,  to  be  sure  that  the  bones  remain  in 
good  position.  If  swelling  is  very  great,  it  may  be  necessary  to  delay  setting  for 
two  or  even  three  days,  the  arm  being  bandaged  and  laid  upon  a  pillow  or 
lightly  supported  on  an  anterior  angular  splint  during  the  waiting  period. 

In  all  cases  except  transverse  fracture  above  the  condyles  reduction  is  best 
effected  by  drawing  upon  the  forearm,  supinating  it,  extending  it,  and  then 
bending  it  slowly  into  a  position  of  acute  flexion,  the  degree  of  flexion  being  in 
inverse  ratio  to  the  amount  of  swelling. 

In  transverse  fracture  above  the  condyles  reduction  is  effected  by  drawing 
the  forearm  and  the  lower  fragment  downward  and  forward  and  at  the  same 
time  pushing  the  upper  fragment  back. 

Some  surgeons  advocate  dressing  the  fracture  on  an  anterior  angular  splint, 
the  forearm  being  fully  supinated.  The  advantage  claimed  for  this  splint  is 
that  if  ankylosis  occurs  the  joint  is  in  a 
position  to  be  useful,  which  it  is  not  if 
ankylosed  in  extension.  Some  deform- 
ity is  usually  apparent  after  treating  a 
case  with  this  splint;  the  deformity  fol- 
lowing fracture  of  the  inner  condyle  is 
not  corrected  by  it,  but  if  the  sphnt  is 
carefully  applied  the  result  is  usually  a 
useful  extremity  in  all  cases  except 
fracture  of  the  inner  condyle.  In  trans- 
verse fracture  of  the  shaft  of  the  hu- 
merus above  the  condyles  the  anterior 
angular  sphnt  is  the  best  method  of 
treatment,  as  it  prevents  displacement. 
The  splint  must  not  be  applied  when 

there  is  great  swelling,  and  swelling  must  be  removed  by  resting  the  ex- 
tremity on  a  pillow,  the  elbow  being  semiflexed,  applying  evaporating 
lotions  or  even  an  ice-bag,  employing  massage,  and  gently  compressing 
by  bandaging.  In  some  cases  the  joint  should  be  aspirated.  In  order  to 
apply  this  dressing,  take  a  right-angled  splint  and  pad  its  outer  surface,  being 
careful  to  place  thick,  soft  pads  over  the  convexity  which  will  press  in  front  of 
the  elbow  and  over  each  end  of  the  sphnt.  Fasten  the  upper  end  to  the  arm, 
then  make  extension  of  the  forearm,  and  if  the  fracture  is  found  to  be  well  re- 
duced, fasten  the  hand  and  forearm  to  the  splint  (Fig.  184).  If  the  hand  and 
forearm  are  first  fixed  to  the  sphnt,  there  will  be  no  extension  from  the  elbow 
and  deformity  will  result.  If  posterior  projection  exists,  a  pasteboard  cup  is 
moulded  over  the  elbow.  The  extremity  is  hung  in  a  triangular  sling.  At 
night  the  extremity  is  kept  in  the  sling  or  laid  on  a  pillow.  Every  third  or 
fourth  day,  while  the  extremity  is  carefully  steadied,  the  splint  is  removed,  the 
arm  and  forearm  well  rubbed  with  alcohol,  massaged,  and  the  splint  reapplied. 
The  splint  is  worn  between  five  and  six  weeks.  At  the  end  of  the  third  week, 
after  removing  the  dressings,  slightly  flex,  slightly  extend,  and  slightly  pronate 
the  forearm,  and  reapply  the  splint.     At  the,  end  of  the  fourth  week   repeat 


184. — Anterior  angular  splint  for  frac- 
tures in  or  near  the  elbow-joint. 


428 


Diseases  and  Injuries  of  Rones  and  Joints 


this  maneuver,  making  movements  of  greater  range.  In  the  middle  of  the 
fifth  week  and  at  the  end  of  the  fifth  week  do  it  again,  and  flex  and  extend 
as  much  as  possible.  Very  early  and  very  frequent  passive  motion  is  objec- 
tionable, as  it  leads  to  overproduction  of  callus  and  ankylosis,  but  passive 
motion  as  above  described  is  imperatively  necessary.  Many  surgeons  at  the 
end  of  the  second  week  apply  a  Stromeyer  splint,  which  permits  the  patient 
and  the  surgeon  to  make  some  motion  by  means  of  the  screw  without  re- 
moving the  dressings.  In  very  stout  people  an  anterior  angular  splint  will  not 
stay  in  place.  In  such  a  case  the  forearm  may  be  placed  at  a  right  angle  to  the 
arm  and  plaster-of-Paris  be  used.  After  the  dressings  are  removed  employ 
passive  motion,  massage,  hot  and  cold  douches,  inunctions  of  ichthyol  or  mer- 
curial ointment,  iodin  locally,  corrosive  subHmate  and  iodid  of  potassium  in- 
ternally, and  direct  the  patient  to  systematically  use  the  arm.  If  in  any  case 
after  four  weeks  non-union  exists,  put  up  the  arm  in  a  plaster  splint  for  three 

or  four  weeks  more.  Some  surgeons  use  a 
posterior  right-angled  trough  instead  of  an  an- 
terior angular  splint  (Fig.  177). 

Allis  warmly  advocates  treatment  in  exten- 
sion. He  holds  that  the  extended  position  secures 
the  best  circulation,  and  if  either  condyle  is  un- 
broken secures  the  benefit  derivable  from  a 
natural  splint.  Furthermore,  in  fractures  of 
the  inner  condyle,  it  restores  the  carrying  func- 
tion, which  the  flexed  position  does  not  do.  For 
one  week  after  the  accident  the  patient  stays 
in  bed,  with  his  arm  extended  upon  a  pillow. 
After  sweUing  subsides  the  limb  is  wrapped 
firmly  in  a  spiral  flannel  bandage  and  plaster 
is  rubbed  in  or  the  bandage  is  covered  with 
adhesive  plaster. 

Some  surgeons  extend  the  hmb  and  apply  an 
ordinary  plaster  bandage,  and  in  about  three 
weeks  substitute  an  anterior  angular  splint. 
The  trouble  with  treatment  in  extension  is  that 
if  ankylosis  ensues  the  limb  is  nearly  useless.  Furthermore,  treatment  by 
extension  requires  confinement  to  bed. 

Jones,  of  Liverpool,  thinks  that  splints  and  bandages  are  largely  responsi- 
ble for  the  stiff"ness  which  so  commonly  ensues  upon  an  elbow  injury.  He  ad- 
vocates treatment  by  acute  flexion  in  all  elbow  injuries  except  fracture  of  the 
olecranon.  It  has  been  demonstrated  that  the  position  of  acute  flexion  forces 
the  fragments  into  place  and  holds  them  firmly  between  the  coronoid  process  of 
the  ulna,  the  trochlear  surface  of  the  ulna,  the  fascia,  and  the  triceps  tendon. 
The  surgeon  must  be  certain  that  the  radial  pulse  is  perceptible  ajter  the 
el?^ow  has  been  flexed.  Flexion  is  maintained  by  fastening  a  bandage  around 
the  wrist  and  neck.  The  bandage  around  the  neck  passes  through  a  rubber 
tube,  which  serves  to  protect  the  neck.  The  ball  of  the  thumb  should  rest 
against  the  neck.  The  bandage  is  fastened  to  a  leather  band  around  the 
wrist.  The  most  convenient  dressing  to  maintain  Jones's  position  was  de- 
vised by  Frazier;  it  is  shown  in. Fig.  185. 


Fig.  185. — Frazier's  modifica 
tion  of  Jones's  dressing  for  in 
juries  of  the  elbow-joint. 


Fractures  of  the  Coronoid  Process  of  the  Uhia  429 

After  the  dressing  has  been  apphed  certain  precautions  are  to  be  observed. 
For  the  first  week  or  ten  days  look  at  the  arm  daily.  If  the  swelHng  grows 
worse,  diminish  the  degree  of  flexion,  and  do  the  same  if  there  is  severe  pain. 
If  the  radial  pulse  disappears,  diminish  the  flexion  until  free  circulation  is 
obtained.  This  position  is  maintained  from  three  to  six  weeks.*  Passive 
motion  and  massage  are  applied  as  if  an  anterior  splint  were  being  used. 
The  author  has  treated  a  number  of  cases  by  Jones's  method,  and  now  prefers 
it  to  any  other  plan  in  all  fractures  of  the  elbow  except  fracture  of  the  ole- 
cranon and  transverse  fracture  above  the  condyles.  The  former  injury  must 
be  dressed  in  extension  and  the  latter  requires  an  anterior  angular  splint. 

If  it  is  found  impossible  to  reduce  the  fragments  or  to  maintain  reduction 
we  should  follow  the  advice  of  John  B.  Roberts,  make  an  incision  and  nail  the 
fragments  in  place.     A  comminuted  fracture  requires  operation. 

In  young  children  the  anterior  angular  splint  must  not  be  used.  It  will 
become  loosened,  and  motion  will  inevitably  take  place  at  the  seat  of  fracture. 
Such  cases  can  be  treated  satisfactorily  in  Jones's  position  with  Frazier's  sling, 
or  we  can  treat  them  in  extension.  Bertomier's  plan  is  very  useful  in  young 
children.!  The  extremity  is  dressed  without  pressure  in  e.xtension  and  supi- 
nation. This  can  be  effected  by  flannel  bandages.  In  from  four  to  eight  days 
a  silicate  of  sodium  bandage  is  applied  in  order  to  prevent  pronation.  About 
the  sixteenth  day  the  bandage  is  cut  so  as  to  form  two  troughs.  From  this 
period  every  third  day  the  splints  are  removed  and  gentle  passive  motion  is 
made.     The  splints  are  removed  permanently  at  the  end  of  four  weeks. 

If  false  ankylosis  follows  fracture  of  the  elbow,  the  adhesions  should  be 
broken  up  under  ether,  and  for  some  time  the  hot-air  apparatus  should  be 
used  daily  and  massage,  passive  motion,  and  the  hot  and  cold  douche  should 
be  employed.  In  true  ankylosis  an  operation  should  be  performed  and  the 
interlocking  callus  or  the  interposed  tissue  or  fragment  removed,  if  a  skia- 
graph shows  that  operation  promises  success.  If  gunstock  deformity  results 
and  produces  marked  disablement,  it  should  be  operated  upon.  An  osteot- 
omy is  performed  on  the  inner  condyle.  The  arm  is  set  in  the  extended  posi- 
tion, plaster-of-Paris  apphed,  and  is  not  removed  for  six  w'eeks.J 

Separation  of  the  lower  epiphysis  of  the  humerus  is  a  not  unusual 
accident.  The  inferior  extremity  of  the  humerus  may  be  separated,  or  the 
condyles  may  be  separated  from  each  other  and  from  the  shaft  of  the  bone. 

Symptoms. — The  symptoms  are  prominence  in  front  of  the  joint,  caused 
by  the  lower  end  of  the  shaft  of  the  humerus;  projection  backward  of  the 
olecranon;  the  forearm  rests  midway  between  pronation  and  supination. 
Epiphyseal  separation  may  retard  growth  and  produce  deformity. 

Treatment. — Jones's  position  or  an  anterior  splint  as  above  directed. 

Fractures  of  the  ulna  comprise  the  following  varieties:  (i)  fracture  of 
the  coronoid  process;  (2)  fracture  of  the  olecranon  process;  (3)  fracture  of 
the  shaft;  and  (4)  fracture  of  the  styloid  process. 

Fractures  of  the  coronoid  process  of  the  ulna  are  rarely  observed, 
and  practically  occur  only  as  a  complication  of  backward  dislocation  of  the 
ulna  or  in  association  with  other  fractures. 

*  Provincial  Medical  Jovir..  Dec,  1894.  and  Jan.,  1895. 

t  Revue  de  Chir.,  vol.  viii,  1888. 

j  G.  G.  Davis,  Phila.  Med.  Jour,  May  13,  1S99. 


430  Diseases  and  Injuries  of  Bones  and  Joints 

Symptoms. — When  fracture  of  the  coronoid  process  is  associated  with  a 
dislocation,  crepitus  is  appreciated  on  reduction,  and  it  is  found  that  the  de- 
formity of  the  dislocation  promptly  returns  on  cessation  of  extension.  The 
upper  fragment  may  be  pulled  upward  by  the  brachialis  anticus  muscle,  and 
there  exists  an  inability  to  flex  the  forearm  completely.  The  position  is  one 
of  extension  with  posterior  projection  of  the  olecranon.  The  broken  piece 
is  felt  in  front  of  the  joint. 

Treatment. — The  treatment  is  by  an  anterior  splint  the  angle  of  which 
is  less  than  a  right  angle.  Jones's  position  may  be  used  in  treating  such  a 
case.     A  stiff  joint  may  follow. 

Fractures  of  the  olecranon  process  of  the  ulna  occur  not  uncommonly 
in  adults.  Hulke  states  that  such  a  fracture  never  occurs  before  the  age  of 
fifteen,  but  the  writer  has  seen  in  the  Jefferson  Medical  College  Hospital  a 
girl  aged  fourteen  with  a  fractured  olecranon.  The  cause  is  direct  violence 
or  muscular  action.  Only  a  small  fragment  may  be  torn  away,  or  the  entire 
olecranon  may  be  broken  off,  and  the  break  may  be  comminuted  or  may  even 
be  compound. 

Symptoms. — The  symptoms  of  fracture  of  the  olecranon  are:  swelling; 
partial  flexion  of  the  forearm;  separation  of  the  fragments,  the  upper  piece 
being  pulled  up  from  half  an  inch  to  two  inches  by  the  triceps;  the  space 
between  the  fragments  is  increased  by  flexion  at  the  elbow,  and  lessened  by 
extension  at  the  elbow;  and  there  is  inability  to  extend  the  arm.  Bulging  of 
the  triceps  above  the  fragments  and  crepitus  on  approximating  the  fragments 
are  observed.  In  some  few  cases  there  is  no  separation,  the  periosteum  being 
untorn  or  the  fascial  expansions  from  the  triceps  holding  the  fragments  in  ap- 
position. In  such  cases  crepitus  can  be  elicited  by  rocking  the  upper  frag- 
ment from  side  to  side. 

The  prognosis  is  fair,  fibrous  union  being  the  rule.  Some  joint-stiffness 
usually  occurs,  and  much  ankylosis  may  be  unavoidable. 

Treatment. — Fracture  of  the  olecranon  is  treated  with  a  well-padded  ante- 
rior splint  almost,  but  not  quite,  straight.  A  perfectly  straight  splint  is  uncom- 
fortable, and  by  opening  a  retiring  angle  between  the  fragments  and  into  the 
joint,  favors  non-union  and  ankylosis.  The  splint  should  reach  from  a  level 
with  the  axillary  margin  to  below  thN-fingers.  If  the  upper  fragment  does  not 
come  in  contact  with  the  lower,  pull  it  down  by  adhesive  plaster  and  fasten  the 
strips  to  the  splint.  The  author  in  one  case  employed  a  glove  to  which  strings 
from  the  adhesive  plaster  were  attached.  After  applying  the  splint  keep  the 
patient  in  bed  for  three  weeks.  The  danger  of  ankylosis  in  this  fracture  is  very 
great,  and,  in  case  it  occurs  in  the  position  of  extension,  an  almost  useless  arm 
results.  Follow  the  rule  of  T.  Pickering  Pick,  and  at  the  end  of  three  weeks 
anesthetize  the  patient,  press  the  thumb  firmly  down  upon  the  top  of  the  ole- 
cranon, put  the  forearm  at  a  right  angle,  and  apply  an  anterior  angular  splint 
and  direct  it  to  be  worn  for  two  weeks.  When  the  anterior  sphnt  has  been 
applied,  passive  motion  should  be  made  every  other  day,  or  every  third  day, 
and  massage  should  be  used  at  the  same  time.  When  the  splint  is  removed, 
try  to  increase  the  range  of  motion  as  previously  directed.  If  it  is  found  im- 
po.s.sible  to  secure  apposition  of  the  fragments  after  fracture  of  the  olecranon, 
incise  and  apply  wires.  A  compound  fracture  and  a  comminuted  fracture 
require  operation.     Non-union  requires  wiring  of  the  fragments. 


Fractures  of  the  Shaft  of  the  Ulna 


431 


Fractures  of  the  shaft  of  the  ulna  alone  are  most  usual  near  the  middle 
of  the  bone,  are  always  due  to  direct  violence,  and  are  not  infrequently  com- 
pound.    An  injury  which  breaks  the  ulna  is  very  apt  to  break  the  radius  also. 

Symptoms. — By  running  the  finger  along  the  inner  surface  of  the  bone  there 
are  detected  inequality  and  depression;  crepitus  and  mobility  are  easily  devel- 
oped ;  there  are  pain  and  the  evidence  of  direct  violence.  The  long  a.xis  of  the 
hand  is  not  on  a  line  with  the  long  axis  of  the  forearm,  but  is  internal  to  it.     If 


Fig.  1S6.— Fracture  of  the  sliaft   of  the  ulna  (case  in  the  Pennsylvania   Hospital ;    skiagraphed  by 

Dr.  Gaston  Torrance). 


deformity  exists,  it  is  due  to  the  lower  fragment  pa.ssing  into  the  interosseous 
space  because  of  the  action  of  the  pronator  quadratus  muscle;  the  upper  frag- 
ment, acted  on  by  the  brachialis  anticus,  passes  a  little  forward  (Fig.  186). 
The  forearm  at  and  below  the  seat  of  fracture  is  narrower  and  thicker  than 
normal. 

Treatment. — In  treating  fracture  of  the  shaft  of  the  ulna  place  the  forearm 
midway  between   pronation  and   supination,  so  as   to   bring   the   fragments 


432 


Diseases  and  Injuries  of  Rones  and  Joints 


1S7. — Two   straight   splints  in   fracture   of 
both  bones  of  the  forearm. 


together  and  to  obtain  the  widest  possible  interosseous  space,  and  thus  limit 
the  danger  of  union  taking  place  between  the  radius  and  ulna.     The  position 

midway  between  pronation  and  supi- 
nation is  obtained  by  flexing  the  fore- 
arm to  a  right  angle  with  the  arm  and 
pointing  the  thumb  to  the  nose.  Take 
two  well-padded  straight  splints,  one 
long  enough  to  reach  from  the  inner 
condyle  to  below  the  fingers,  the  other 
from  the  outer  condyle  to  below  the 
wrist ;  place  a  long  pad  of  lint  over 
the  interosseous  space  on  the  flexor 
side  of  the  limb,  and  another  on  the 
extensor  side;  apply  the  splints  and 
hang  the  forearm  in  a  triangular  sling 
(Fig.  187).  Passive  motion  is  to  be  made  in  the  third  week,  and  the  splints 
are  to  be  worn  for  four  weeks.  Fractures  of  the  ulna  can  be  treated  very  effi- 
ciently with  plaster-of-Paris. 

Fractures  of  the  styloid  process  of  the  ulna  are  due  to  direct  force. 
The  displacement  is  obvious. 

Treatment. — In  treating  fracture  of  the  styloid  process  push  the  fragment 
back  into  place  and  use  a  Bond  splint  with  a  compress  for  four  weeks,  or  a 
plaster-of-Paris  dressing. 

Fractures  of  the  radius  include  the  following  varieties:  {a)  fractures  of 
its  head;  {b)  fractures  of  its  neck;  (r)  fractures  of  its  shaft;  and  {d)  fractures  of 
its  lower  extremity. 

Fracture  of  the  head  of  the  radius  very  rarely  occurs  alone,  but  it  may 
complicate  backward  dislocation  of  the  radius. 

Symptoms. — The  symptoms  of  fracture  of  the  head  of  the  radius  are  crepitus 
on  passive  pronation  and  supination,  and  loss  of  voluntary  pronation  and  supi- 
nation. 

Treatment. — The  treatment  of  a  fracture  of  the  head  of  the  radius  is  the 
same  as  for  a  fracture  in  or  near  the  elbow-joint,  namely,  an  anterior  angular 
splint,  or  placing  the  extremity  in  Jones's  position. 

Fracture  of  the  neck  of  the  radius  very  rarely  occurs  alone. 
Symptoms. — In  this  fracture  the  forearm  is  pronated  and  the  patient  is 
found  to  have  lost  the  power  of  voluntary  pronation  and  supination.  Under 
forced  pronation  and  supination  it  will  be  noted  that  the  head  of  the  radius  does 
not  move  and  crepitus  is  felt.  The  lower  fragment,  being  pulled  upward  and 
forward  by  the  biceps,  can  be  felt  in  front  of  the  elbow-joint. 

Treatment.^The  treatment  for  fracture  of  the  neck  of  the  radius  is  the 
same  as  for  fracture  of  the  elbow-joint — namely,  an  anterior  angular  splint  or 
Jones's  position. 

Fracture  of  the  shaft  of  the  radius  is  far  commoner  than  fracture  of  the 
shaft  of  the  ulna.  It  may  occur  above  or  Ijelow  the  insertion  of  the  pronator 
radii  teres  muscle.  It  may  arise  from  either  direct  or  indirect  force.  Fracture 
of  the  shaft  of  the  ulna  may  coexist  as  a  result  of  the  same  accident. 

Fracture  of  the  Shaft  of  the  Radius  above  the  Insertion  of  the 
Pronator  Radii  Teres  Muscle. — Symptoms. — The  upper  fragment  is  drawn 


Fracture  of  the  Shafts  of  both  Rones  of  the  Forearm         433 

forward  by  the  biceps  and  is  fully  supinated  by  the  supinator  brevis.  The 
lower  fragment  is  fully  pronated  by  the  pronator  quadratus  and  pronator  radii 
teres,  and  its  upper  end  is  pulled  into  the  interosseous  space.  There  are  crepi- 
tus, mobihty,  pain,  narrowing  and  thickening  of  the  forearm  below  the  seat  of 
fracture,  and  loss  of  the  power  of  pronation  and  supination.  The  head  of  the 
bone  is  motionless  during  passive  pronation  and  supination.  The  hand  is 
prone. 

Treatment. — In  treating  this  fracture  do  not  put  the  forearm  midwav  be- 
tween pronation  and  supination,  as  this  position  will  not  bring  the  fragments 
into  contact,  the  upper  fragment  remaining  flexed  and  supinated.  To  bring 
the  lower  fragment  in  contact  with  the  upper,  flex  and  fully  supinate  the  fore- 
arm. Apply  an  anterior  angular  splint  to  the  extremity  for  four  weeks,  and 
make  passive  motion  in  the  third  week. 

Fracture  of  the  Shaft  of  the  Radius  below  the  Insertion  of  the 
Pronator  Radii  Teres  Muscle. — In  this  variety  of  fracture  the  upper  frag- 
ment is  acted  on  by  the  biceps,  the  supinator  brevis,  and  the  pronator  radii 
teres,  and  it  remains  about  midway  between  pronation  and  supination,  pass- 
ing forward  and  also  into  the  interosseous  space.  The  lower  fragment  is  acted 
on  by  the  supinator  longus  and  the  pronator  quadratus,  the  latter  being  the 
more  powerful  of  the  two,  hence  the  lower  fragment  is  moderatelv  pronated, 
its  upper  extremity  being  drawn  into  the  interosseous  space.  Other  svmp- 
toms  are  identical  with  those  of  fracture  above  the  insertion  of  the  pronator 
radii  teres. 

Treatment. — In  treating  fracture  below  the  pronator  radii  teres  the  forearm 
is  flexed  and  is  placed  midway  between  pronation  and  supination;  two  inter- 
osseous pads  and  two  straight  splints  are  applied  as  for  fracture  of  the  ulna 
(Fig.  187).  The  splints  are  worn  for  four  weeks,  and  passive  motion  is  made 
in  the  third  week.     Plaster-of-Paris  is  a  most  satisfactory  dressing. 

Fracture  of  the  shafts  of  both  bones  of  the  forearm  is  not  frequently 
seen.     It  is  caused  by  either  direct  or  indirect  force. 

Symptoms. — After  fracture  of  both  bones  of  the  forearm  the  hand  is  pro- 
nated and  the  two  lower  fragments  come  together  and  are  drawn  upward  and 
backward  or  upward  and  forward  by  the  combined  force  of  flexor  and  extensor 
muscles,  shortening  being  manifest  and  the  projection  of  the  lower  fragments 
being  detected  on  either  the  dorsal  or  the  fle.xor  surface  of  the  forearm.  The 
upper  fragment  of  the  ulna  is  somewhat  flexed  by  the  brachialis  anticus;  the 
upper  fragment  of  the  radius  is  fle.xed  by  the  biceps  and  is  pronated  and  drawn 
toward  the  ulna  by  the  pronator  radii  teres.  The  forearm  is  narrower  than  it 
should  be  (the  ends  of  the  fragments  having  passed  into  the  interosseous  space) 
and  is  thicker  than  normal  from  front  to  back  (the  contents  of  the  interosseous 
space  having  been  forced  out).  Crepitus,  mobility,  pain,  and  inequality  exist, 
the  power  of  rotation  is  lost,  and  on  passive  rotation  the  head  of  the  radius  does 
not  move.     The  forearm  is  prone  and  semiflexed. 

Treatment. — The  treatment  consists  in  the  application  of  two  straight  splints 
and  two  interosseous  pads,  the  forearm  being  fle.xed  to  a  right  angle  and  placed 
midway  between  pronation  and  supination  (Fig.  187).  The  splints  are  worn 
for  four  weeks,  and  passive  motion  is  made  in  the  third  week.  Instead  of 
these  splints,  a  plaster-of-Paris  dressing  can  be  used. 

Fractures  of  the  Lower  Extremity  of  the  Radius. — Col/es's  'fracture  is  a 
28 


434 


Diseases  and  Injuries  of  Bones  and  Joints 


Fig.  i8S.— Effect  upon  Ihe  lower  end 
of  the  radius  of  the  cross-breaking  strain 
produced  by  extreme  backward  flexion 
of  the  hand  (Pilcher). 


transverse  or  nearly  transverse  fracture  of  the  lower  end  of  the  radius,  between 
the  limits  of  one-quarter  of  an  inch  and  one  and  a  half  inches  above  the  wrist- 
joint,  the  lower  fragment  sometimes  mounting  upon  the  dorsum  of  the  upper 

fragment.  An  oblique  fracture  beginning 
within  half  an  inch  of  the  joint  and  passing 
into  the  joint  is  known  as  Barton's  jracture. 
Colles's  fracture  was  first  recognized  as  a 
fracture  by  Colles,  of  Dublin,  in  1814. 
Before  his  time  the  injury  was  called  back- 
ward dislocation  of  the  wrist.  It  is  a  very 
common  injury,  is  met  with  most  frequently 
in  those  beyond  the  age  of  forty,  and  oftener 
in  women  than  in  men.  It  is  due  to  trans- 
mitted force  (a  fall  upon  the  palm  of  the 
pronated  hand).  Some  think  that  the  force 
is  received  by  the  ball  of  the  thumb  and 
passes  to  the  carpal  bones  and  the  edge  of 
the  radius;  a  fracture  beginning  posteriorly 
rather  than  anteriorly  and  the  force  driv- 
ing the  lower  fragment  upon  the  dorsal 
surface  of  the  radius,  the  carpus  and  lower 
fragment  moving  upward  and  outward. 
It  is  much  more  likely  that  this  fracture  is  due  to  cross-strain  on  the  bone. 
There  is  sudden  traction  upon  the  anterior  ligaments,  which  drag  upon  the 
bone  and  break  it  at  a  point  where  the  cancellous  end  of  the  radius  joins 
the  compact  shaft  (Fig. 
188).  The  fragments  are 
not  unusually  impacted. 
In  the  author's  experience 
dislocation  of  the  lower 
end  of  the  ulna  is  a  not  un- 
usual complication,  which 
arises  from  a  fracture  of 
the  ulnar  styloid  or  tearing 
off  of  the  internal  lateral 
ligament  of  the  wrist. 

Symptoms. — In  Colles's 
fracture  the  hand  is  ab- 
ducted (drawn  to  the  radial 
side  of  the  forearm)  and 
pronated,  the  head  of  the 
ulna  is  prominent,  the  sty- 
loid process  of  the  radius  is 

raised,  and  the  lower  fragment  may  mount  on  the  back  of  the  lower 
end  of  the  upper  fragment,  causing  a  dorsal  j^rojcction,  termed  by 
Liston  the  "silver-fork  deformity"  (Figs.  189  and  190).  The  lower  end 
of  the  upper  fragment  can  be  felt  beneath  the  flexor  tendons  above  the 
wrist.  The  position  in  fleformity  is  produced  by  the  force.  Some  con- 
sider it  is  maintained  jjy  the  action  of  the  supinator  longus  and  the  flexor  and 


Figs.  189,- 190 — Deformity  at  the  wrist  consequent  upon 
displacement  backward  of  the  lower  fragment  of  the  radius 
after  fracture  at  its  lower  cxlrcmily  (Levis). 


Fractures  of  the  Lower  Extrcmit\'  of  the  Radius 


435 


extensor  muscles,  but  particularly  by  the  extensors  of  the  thumb.  Pilcher 
has  demonstrated  the  fact  that  in  this  fracture  a  portion  of  the  dorsal  perios- 
teum is  untorn,  and  this  untorn  portion  acts  as  a  binding  band  to  hold  the 
fragments  in  deformity.  Pronation  and  supination  are  lost.  In  this  fracture 
the  hand  can  be  greatly  hyperextended  (Maisonneuve's  symptom).  Crepitus, 
which  is  best  obtained  by  alternate  hyperextension  and  flexion,  can  be  secured 
unless  swelling  is  great  or  impaction  exists.  Crepitus  on  side  movements  is 
rarely  obtainable.  Impaction  may  greatly  modify  the  deformity,  though  dis- 
placement generally  exists  to  some  extent,  and  the  fragments  do  not  ride 
easily  on  each  other.  The  styloid  process  of  the  ulna  may  be  broken,  or  the 
inferior  radio-ulnar  articulation  may  be  separated.  This  latter  complication 
allows  the  lower  fragment  to  roll  freely  upon  the  upper,  and  the  characteristic 
silver-fork  deformity  does  not  appear.     If  the  styloid  process  of  the  ulna  is 


iqi- — Colles's   fracture  of   the  radius  (Pennsylvania  Hospital    case; 
Gaston  Torrance). 


skiagraphed   by  Dr. 


broken,  pressure  over  it  causes  great  pain.  If  a  person  in  falling  strikes  the 
back  of  the  hand  and  a  fracture  of  the  radius  occurs,  the  lower  fragment  is 
driven  upon  the  front  surface  of  the  upper  fragment  and  is  felt  under  the  flexor 
tendons  at  the  wrist.  An  elaborate  study  of  fracture  of  the  radius  with  forward 
displacement  of  the  lower  fragment  has  been  published  by  John  B.  Roberts.* 
Treatment. — In  treating  Colles's  fracture  reduce  the  deformitv  bv  hyper- 
extension to  unlock  the  fragments  and  relax  the  dorsal  periosteum,  and  follow 
by  longitudinal  traction  to  separate  the  fragments,  and  forced  flexion  to  force 
them  into  position.  This  formula  was  introduced  manv  years  ago  by  the  late 
R.  J.  Levis.  It  is  of  the  first  importance  to  thoroughly  reduce  this  fracture, 
and  very  often  it  is  not  thoroughly  reduced.  Imperfect  reduction  means  perma- 
nent deformity,  stifl"ness  of  the  tendons  and  wrist,  and  possibly  an  almo.st  useless 
hand.     The  extremity  can  be  placed  upon  a  Levis  splint  (Fig.  192),  the  posi- 

*Ani.  Jour.  Med.  Sci.,   Ian.,   1897. 


436 


Diseases  and  Injuries  of  Bones  and  Joints 


tion  maintaining  reduction  and  the  tense  extensor  tendons  giving  dorsal  sup- 
port. Some  surgeons  use  Gordon's  pistol-shaped  splint.  The  favorite  splint  in 
Philadelphia  practice  in  the  past  has  been  Bond's  (PI.  6,  Fig.  7).  It  places  the 
hand  in  a  natural  position  of  rest  (semiflexion  of  the  fingers,  semi-extension  of 
the  wrist,  and  deviation  of  the  hand  toward  the  ulna).  Two  pads  are  used: 
a  dorsal  pad  which  overlies  the  lower  fragment,  and  a  pad  for  the  flexor  surface 


Fig.  192.— Levis's  radius-splints,  right  and  left,  for  fracture  of  the  lower  end  of  the  radius. 


which  overlies  the  lower  end  of  the  upper  fragment.  A  bandage  is  applied, 
the  thumb  and  fingers  being  left  free  (Fig.  193).  Passive  motion  is 
begun  upon  the  fingers  in  three  or  four  days,  and  upon  the  wrist  during  the 
second  week.     The  splint  is  removed  in  three  weeks,  and  a  bandage  is  worn  for 

a  week  or  two  more  because  of  the  sweUing. 
In  applying  the  Bond  splint,  do  not  pull  the 
hand  too  much  up  on  the  block,  or  the  frac- 
ture will  unite  with  a  projection  upon  the 
flexor  surface  of  the  extremity  and  the  ten- 
dons of  the  wrist  will  be  apt  to  be  caught  in 
the  callus.  The  most  satisfactory  dressing 
is  the  straight  dorsal  splint  advised  by  Rob- 
erts (Fig.  194).  I  use  it  almost  invariably. 
It  prevents  the  recurrence  of  deformity  and  is 
mechanically  the  proper  mode  of  treatment. 
It  should  be  worn  for  three  weeks.  Undoubt- 
edly more  or  less  stiffness  often  follows  Colles's 
fracture,  and  some  very  able  surgeons  have 
been  .so  impressed  with  the  frequency  of  its 
occurrence  that  they  have  dis[)ensed  with  the  use  of  a  splint.  Sir  Astley 
Cooper  long  ago  spoke  of  placing  the  arm  in  a  sling  as  proper  treatment 
for  fracture  of  the  radius.  Moore,  of  Rochester,  applied  a  cylindrical 
compress  over  the  ulna,  held  in  place  for  .six  hours  with  adhesive  plaster, 
then  cut  the  plaster,  placed  the  forearm  in  a  sling,  and  let  the  hand  hang  over 
the  edge  of  the  sling.     Pilcher  applies  a  band  of  adhesive  plaster  around  the 


Fig.  193.— Bond's  splint  in  Colles's 
fracture. 


Fractures  of  the  Carpus 


437 


wrist  and  supports  the  wrist  in  a  sHng,  but,  as  Storp  says,  dispensary  patients 
are  apt  to  disarrange  this  dressing.  Storp  wraps  a  piece  of  rubber  plaster 
four  inches  wide  around  the  wrist,  and  places  a  second  piece  around  the  first  so 
arranged  as  to  form  a  fold  over  the  radius;  an  opening  is  made  through  the  fold 
for  the  passage  of  a  sling.  In  ten  days  the  plaster  is  removed  and  the  forearm 
is  carried  in  a  sling.  If  a  stiff  joint  and  limited  tendon-motion  eventuate  from 
the  fracture,  use  massage,  frictions,  sorbefacient  ointments,  tincture  of  iodin, 
electricity,  hot  and  cold  douches,  and  the  hot-air  apparatus,  or  give  ether  and 
forcibly  break  up  adhesions.  If  reduction  was  not  thoroughly  effected  and 
too  great  a  length  of  time  has  not  elapsed,  and  the  hand  is  helpless  and  pain- 
ful, the  bone  should  be  refractured.  In  a  young  or  middle-aged  person, 
in  whom  a  useless  hand  has  followed  an  ill-reduced  fracture,  osteotomy  is 
justifiable. 

Fracture  of  both  the  Radius  and  Ulna  near  the  Wrist. — Colles's  frac- 
ture may  be  complicated  by  a  fracture  of  the  ulna  other  than  of  its  styloid  pro- 
cess. 

Symptoms. — In  fracture  of  the  radius  and  ulna  near  the  wrist  the  lower  ends 


Spli 


t 


Fig.  194. — Diagram  showing  ihe  arrangement  of  compresses  and  splint  best  adapted  to  retain  frag- 
ments in  proper  position  after  reduction  (Pilcher). 


of  the  upper  fragments  come  together,  the  upper  fragment  of  the  radius  is  pro- 
nated,  and  the  lower  fragment  of  the  radius  is  drawn  up.  Pain,  crepitus, 
mobility,  shortening,  and  loss  of  function  exist. 

Treatment. — Fracture  of  the  radius  and  ulna  near  the  wrist  should  be 
treated  with  the  straight  dorsal  splint,  as  in  Colles's  fracture. 

Separation  of  the  Lower  Radial  Epiphysis. — This  accident  occurs  in 
children  from  falling  upon  the  palm  of  the  hand.  It  never  happens  after  the 
twentieth  year. 

Symptoms. — In  separation  of  the  lower  radial  epiphysis  the  lower  fragment 
mounts  upon  the  upper  and  produces  a  dorsal  projection  like  Colles's  fracture, 
but  the  hand  does  not  deviate  to  the  radial  side.  The  deformity  resembles  that 
of  a  backward  carpal  dislocation,  but  is  differentiated  from  dislocation  by  the 
unaltered  relation  in  the  fracture  between  the  styloid  processes  and  the  carpal 
bones. 

Treatment. — The  treatment  in  separation  of  the  lower  radial  epiphysis  is 
the  same  as  for  Colles's  fracture. 

Fractures  of  the  carpus  are  not  frequent,  and  they  are  usually  compound. 
The  cause  is  violent  direct  force. 

Symptoms. — Fractures  of  the  carpus  are  indicated  by  pain,  swelling,  evi- 


438  Diseases  and  Injuries  of  Bones  and  Joints 

dences  of  direct  force,  sometimes  crepitus,  loss  of.power  in  the  hand,  and  a  very 
little  displacement. 

Treatment. — Many  compound  comminuted  fractures  of  the  carpus  require 
amputation.  In  an  ordinary  compound  fracture,  asepticize,  drain,  dress  with 
antiseptic  gauze  and  a  plaster-of-Paris  bandage,  cutting  trap-doors  in  the 
plaster  over  the  ends  of  the  drainage-tube.  In  a  simple  fracture  dress  the 
hand  upon  a  well-padded  straight  palmar  splint  (PI.  5,  Fig.  10)  reaching 
from  beyond  the  fingers  to  the  middle  of  the  forearm,  and  place  the  hand 
and  forearm  in  a  sling.  The  splint  is  worn  for  four  weeks,  and  passive 
motion  of  the  wrist  is  begun  in  the  second  week. 

Fractures  of  the  Metacarpal  Bones. — Fracture  of  the  metacarpus  is 
very  common.  One  or  more  bones  may  be  broken.  The  first  metacarpal 
bone  is  oftenest  broken;  the  third  is  rarely  broken  (Hulke).  The  cause  is 
direct  or  indirect  force. 

Symptoms. — The  signs  of  a  metacarpal  fracture  are — dorsal  projection 
of  the  upper  end  of  the  lower  fragment  or  the  lower  end  of  the  upper  frag- 
ment; pain;  crepitus;  and  often  evidences  of  direct  violence. 

Treatment. — To  treat  a  fracture  of  a  metacarpal  bone  reduce  by  extension; 
place  a  large  ball  of  oakum,  cotton,  or  lint  in  the  palm  to  maintain  the  natural 
rotundity,  and  apply  a  straight  palmar  sphnt  like  that  used  for  fracture  of 
the  carpus  (PI.  6,  Fig.  10).  It  may  be  necessary  to  apply  a  compress  over 
the  dorsal  projection.  The  duration  of  treatment  is  three  weeks,  and  passive 
motion  is  begun  after  two  weeks.     A  plaster-of-Paris  dressing  is  often  used. 

Fractures  of  the  Phalanges. — The  phalanges  are  often  broken.  The 
fracture  may  be  compound.     The  cause  usually  is  direct  force. 

Symptoms. — Fracture  of  a  phalangeal  bone  is  indicated  by  pain,  bruising, 
crepitus,  and  mobility,  with  very  httle  or  no  displacement. 

Treatment. — If  the  middle  or  distal  phalanx  is  broken,  mould  on  a  trough- 
like splint  of  gutta-percha  or  of  pasteboard,  which  sphnt  need  not  reach 
into  the  palm.  If  the  proximal  phalanx  is  broken,  carry  the  splint  into 
the  palm  of  the  hand.  Make  the  splint  of  gutta-percha,  pasteboard,  wood, 
or  leather.  The  splint  is  worn  three  weeks.  A  sling  must  be  worn,  otherwise 
the  finger  will  constantly  be  knocked  and  hurt.  Some  cases  require  a  dorsal 
as  well  as  a  palmar  splint.  These  cases  are  dressed  most  satisfactorily  with 
a  silicate  of  sodium  or  plaster-of-Paris  bandage. 

Fracture  of  the  femur  is  a  very  common  injury.  The  divisions  of  the 
femur  are  (i)  the  u[)per  extremity;  (2)  the  shaft;  and  (3)  the  lower  extremity. 

I.  Fractures  of  the  upper  extremity  of  the  femur  are  divided  into 
(a)  intracapsular;  {h)  extracapsular;  (c)  of  the  great  trochanter;  and  {d) 
epiphyseal  separation  (either  of  the  great  trochanter  or  the  head). 

Examination  oj  the  Hip. — It  is  sometimes  though  rarely  necessary  to  give 
ether.  Remove  all  the  patient's  clothing  and  place  him  recumbent  upon  a 
tal>le.  Note  the  position.  Feel  with  care  the  great  trochanter  and  femoral 
neck.  Very  gradually  and  gently  make  movements  to  determine  if  there  is 
impairment,  undue  mobility,  or  crepitus.  Never  make  sudden  or  violent 
movements  in  looking  for  crepitus.  The  diagnosis  can  be  made  even  if 
crepitus  is  not  obtained,  and  rapid  or  violent  movements  may  tear  apart 
an  impaction.  Measure  the  sound  extremity  and  the  injured  extremity. 
The  measurement  is  made  from  the  anterior  superior  spine  of  the  ilium  to 


Intracapsular  Fracture  of  the  Femur 


439 


the  inner  malleolus.     Other  symptoms  to  be  looked  for  are  set  forth  on  pages 
440-442. 

Intracapsular  Fracture  of  the  Femur, — Intracapsular  fracture  of  the 
neck  of  the  femur  is  transverse  or  only  sUghtly  obhque  (Fig.  195),  and  is  not 
unusually  impacted  (Figs.  151,  152,  155).  Stokes  follows  Gordon,  of  Belfast, 
in  classifying  fractures  of  the  femoral  neck.  He  divides  them  into  intracapsular 
and  extracapsular,  and  subdivides  intracapsular  fractures  into  fracture  with 
penetration  of  the  cervix  into  the  head;  fracture  with  reciprocal  penetration; 
intraperiosteal  fracture  at  the  junction  of  the  cervix  and  head;  intraperiosteal 


Fig.  195. — Intracapsular  fracture  of  the  hip  (Pennsylvania  Hospital  case  ;  skiagraphed  by  Dr.  Gaston 

Torrance). 


fracture  of  the  center  of  the  cervix;  extraperiosteal  fracture,  with  laceration 
of  the  cervical  hgaments.  The  last-named  fracture  is  the  most  common. 
The  first  four  forms  may  unite  by  bone,  the  fifth  form  will  not  because  of 
non-apposition,  lack  of  nutrition,  effusion  of  blood,  synovitis,  or  interstitial 
absorption.*  Stokes  claims  that  we  may  have  penetration,  but  not  im- 
paction. The  cause  is  often  slight  indirect  force,  of  the  nature  of  a  twist,  acting 
upon  a  person  of  advanced  years  (more  often  a  woman  than  a  man),  but  not 
unusually  a  fall  upon  the  great  trochanter  is  the  cause.  A  fall  upon  the  knees, 
a  trip,  or  an  attempt  to  prevent  a  fall  may  produce  this  fracture.  It  often 
happens  that  the  fall  is  due  to  the  fracture  rather  than  that  the  fracture 

*  Stokes,  in  Brit.  Med.  Jour.,  Oct.   12,  1895. 


440  Diseases  and  Injuries  of  Bones  and  Joints 

arises  from  the  fall.  Intracapsular  fracture  is  never  caused  by  direct  force 
unless  it  is  due  to  gunshot  violence.  The  aged  are  more  liable  to  intra- 
capsular fracture  than  the  young  or  the  middle-aged,  because,  first,  the  angle 
which  the  neck  forms  with  the  axis  of  the  femur  becomes  less  obtuse  with 
advancing  years,  and  may  even  become  a  right  angle;  this  change  is  more 
pronounced  in  women  than  in  men;  secondly,  the  compact  tissue  becomes 
thinned  by  absorption,  the  cancelli  diminish,  the  spaces  between  them  en- 
large, the  bony  portions  of  the  cancellous  structure  are  thinned  and  destroyed, 
and  the  cancellous  structure  becomes  fatty  and  degenerated.  Sutton  has 
shown  that  in  rare  cases  this  fracture  may  occur  in  the  young,  even  before 
the  union  of  the  epiphyses. 

Symptoms. — In  intracapsular  fracture  there  is  usually  shortening  to  the 
extent  of  from  half  an  inch  to  an  inch;  but  in  some  cases  no  shortening  can 
be  detected.  Shortening  of  a  quarter  of  an  inch  does  not  count  in  making 
a  diagnosis,  for  one  limb  is  often  naturally  a  little  shorter  than  the  other. 
If  the  reflected  portion  of  the  capsule  is  not  torn,  the  shortening  is  trivial 
in  amount  or  is  entirely  absent.  In  some  cases  shortening  gradually  or 
suddenly  increases  some  httle  time  after  the  accident.  This  is  due  to  separa- 
tion of  a  penetration,  tearing  of  the  previously  unlacerated  fibrous  synovial 
reflection,  or  restoration  of  muscular  strength  after  traumatic  paresis  has 
passed  away.  A  gradually  increasing  shortening  arises  from  absorption  of  the 
head  of  the  bone.  Shortening  is  due  chiefly  to  pulling  upon  the  lower  frag- 
ment by  the  hamstring,  the  glutei,  and  the  rectus  muscles. 

Pain  is  usually  present  anteriorly,  posteriorly,  and  to  the  side.  The  area 
of  pain  is  localized,  and  motion  or  pressure  greatly  increases  the  suffering. 

Eversion  exists,  spoken  of  as  "helpless  eversion, "  though  in  a  very  few 
instances  the  patient  can  still  invert  the  leg.  This  eversion  is  due  to  the 
force  of  gravity,  the  limb  rolling  outward  because  the  fine  of  gravity  has 
moved  externally.  That  eversion  is  not  due  to  the  action  of  the  external 
rotator  muscles,  as  was  taught  by  Astley  Cooper,  is  proved  by  the  fact  that 
when  a  fracture  happens  in  the  shaft  below  the  insertion  of  these  muscles 
the  lower  fragment  still  rotates  outward.  This  is  further  demonstrated  by 
the  considerations  that  the  internal  rotators  are  more  powerful  than  the 
external,  that  some  patients  can  still  invert  the  limb  after  a  fracture,  and 
that  eversion  persists  during  anesthesia.*  In  some  unusual  cases  inversion 
attends  the  fracture.  Inversion,  if  it  exists,  is  due  to  the  fact  that  the  limb 
was  adducted  and  inverted  at  the  time  of  the  accident,  and  after  the  accident 
it  remains  in  this  position  (Stokes).  Besides  shortening  and  eversion,  the 
leg  is  somewhat  flexed  on  the  thigh  and  the  thigh  on  tht  pelvis,  the  extremity 
when  rolled  out  resting  upon  its  outer  surface.  Abduction  is  commonly 
present. 

Loss  of  power  is  a  prominent  symptom:  the  limb  can  rarely  be  raised  or 
inverted;  although  in  rare  cases,  when  the  fibrous  synovial  envelope  is  untorn, 
the  patient  may  stand  or  even  take  steps.  Pain  is  not  commonly  severe 
except  upon  motion,  when  it  may  be  localized  in  the  joint.  In  some  cases 
the  p)ain  is  violent.  Crepitus  often  cannot  be  found,  either  because  the 
fragments  cannot  be  approximated,  because  y)enetration  exists,  or  because 
the  bone  is  greatly  softened  by  fatty  change.     To  obtain  crepitus  the  front  of 

*  Edmund  Owen:    "A  Manual  of  Anatomy." 


Intracapsular  Fracture  of  tlie  Femur  441 

the  joint  must  be  examined  while  the  limb  is  extended  and  rotated  inward. 
But  why  try  to  obtain  crepitus?  The  diagnosis  is  readily  made  without  it; 
in  manv  cases  it  cannot  be  detected,  and  the  endeavor  to  obtain  it  inflicts 
pain  and  may  produce  damage.  These  fractures  offer  a  not  very  flattering 
chance  of  repair,  and  efforts  to  find  crepitus  may  produce  serious  damage. 

Altered  Arc  of  Rotation  oj  the  Great  Trochanter  (Desault's  sign). — The 
pivot  on  which  the  great  trochanter  revolves  is  no  longer  the  acetabulum, 
and  the  great  trochanter  no  longer  describes  the  segment  of  a  circle,  but 
rotates  only  as  the  apex  of  the  femur,  which  rotates  around  its  own  axis. 
It  is  needless  to  try  to  obtain  this  sign;  to  do  so  inflicts  violence  on  the  parts. 

Relaxation  oj  the  jascia  lata  (AUis's  sign)  simply  means  shortening.  The 
fascia  lata  is  attached  to  the  ilium  and  the  tibia  (iliotibial  band),  and  when 
shortening  brings  the  tibia  nearer  to  the  ilium  this  band  relaxes  and  permits 
one  to  push  more  deeply  inward  on  the  injured  side,  between  the  great  tro- 
chanter and  the  iliac  crest,  and  near  the  knee  above  the  outer  condyle,  than 
on  the  sound  side.  In  this  examination  each  limb  should  be  adducted. 
Allis  has  pointed  out  another  sign:  when  the  patient  is  recumbent  the  sound 
thigh  cannot  be  raised  to  the  perpendicular  without  flexing  the  leg;  the  in- 
jured thigh  can  be. 

Lagoria's  sign  is  a  relaxation  of  the  extensor  muscles. 

Ascent  oj  the  Great  Trochanter  above  Nelaton''s  Line. — This   line  is  taken 
from  the  anterior  superior  iliac  spine  to  the  most  prominent    part  of  the 
ischial  tuberosity  (Fig.  196).     In  health  the  great 
trochanter  is  below,  and  in  intracapsular  fracture 
it  is  above,  this  line. 

Relation  oj  the  Trochanter  to  Bryant's  Tri- 
angle (Fig.  196). — Place  the  patient  recumbent, 
carry  a  line  around  the  body  on  a  level  with  the 
anterior  superior  iliac  spines,  draw  a  line  from 
the  anterior  iliac  spine  on  each  side  to  the  sum- 
mit of  the  corresponding   great   trochanter,  and       .,.   f '^-  'f  "^  ^  ^'  ^".^"''^ 

.  ilio-femoral  triangle  ;  A  B,  Nela- 

measure  the  base  of  the  triangle  from  the  great       ton's  line  tOwen). 
trochanter  to  the  perpendicular  line  to  determine 

the  amount  of  ascent.  The  difference  in  measurement  between  the  two 
sides  shows  the  amount  of  ascent  of  the  trochanter;  that  is,  shows  the  extent 
of  shortening. 

Morris's  measurement  shows  the  extent  of  inward  displacement.  Measure 
from  the  median  line  of  the  body  to  a  perpendicular  line  drawn  through 
the  trochanter  on  each  side  of  the  body. 

Diagnosis. — The  .v-rays  are  a  valuable  aid  to  diagnosis  (Fig.  195).  Intra- 
capsular fracture  without  separation  of  fragments  may  be  mistaken  for  a 
mere  contusion,  and  the  diagnosis  may  continue  obscure  unless  the  frag- 
ments separate.  Loss  of  function  in  contusion  is  rarely  complete  or 
prolonged,  although  occasionally  the  head  of  the  bone  is  absorbed.  Early 
after  a  contusion,  and  usually  throughout  the  case,  there  is  no  altera- 
tion between  the  relation  of  the  spine  of  the  ilium  and  the  trochanter, 
and  no  shortening.  Some  little  time  after  a  severe  contusion  the  head  of 
the  bone  may  be  absorbed.  Contusion  of  a  rheumatic  joint  leads  to 
much  difficulty  in  diagnosis.     Intracapsular  fracture  may  be  confused  with 


442  Diseases  and  Injuries  of  Bones  and  Joints 

extracapsular  fracture  or  with  a  dislocation  of  the  hip-joint.  Extracapsular 
fracture,  which  is  common  in  advanced  life,  but  is  met  with  in  middle  life 
or  even  occasionally  in  the  young,  results  usually  from  great  violence  over 
the  great  trochanter;  if  non-impacted,  there  are  noted  shortening  of  from 
one  and  a  half  to  three  inches,  crepitus  over  the  great  trochanter,  and  usually, 
but  not  invariably,  eversion;  if  impacted,  there  is  less  eversion,  crepitus  is 
almost  or  entirely  absent,  and  the  shortening  is  limited  to  about  an  inch. 
Great  tenderness  exists  over  the  great  trochanter  in  both  impacted  and  non- 
impacted  fractures.  The  extensor  muscles  are  relaxed.  In  dislocation  on 
the  dorsum  of  the  ilium  the  patient  is  usually  a  strong  young  adult.  There 
is  a  history  of  forcible  internal  rotation.  There  are  inversion  (the  ball  of 
the  great  toe  resting  on  the  instep  of  the  sound  foot),  rigidity,  ascent  of  the 
great  trochanter  above  Nekton's  line,  and  shortening  of  from  one  to  three 
inches.  The  head  of  the  bone  is  felt  on  the  dorsum  of  the  ilium,  and  the  tro- 
chanter mounts  up  toward  the  spine  of  the  ilium,  and  pressure  upon  it 
causes  no  pain.  In  dislocation  into  the  thyroid  notch  there  is  possibly 
eversion,  but  it  is  linked  with  lengthening. 

In  fracture  of  the  hrim  oj  the  acetahnhim  there  is  shortening,  which  occurs 
on  the  removal  of  extension,  inversion,  abduction,  flexion  of  the  knee,  the 
head  of  bone  is  drawn  upward  and  backward  with  the  acetabular  fragment, 
and  there  is  retention  of  the  power  of  eversion  and  of  adduction  (Stokes). 
Crepitus  is  most  distinctly  appreciated  by  a  hand  resting  on  the  ilium.  In 
fracture  of  the  fundus  of  the  acetabulum  there  is  shortening,  and  the  head 
of  the  bone  enters  the  pelvis  (Stokes). 

Prognosis. — The  prognosis  is  not  \'ery  favorable.  Some  aged  patients  die 
in  a  day  or  two  from  shock.  Not  a  few  perish  later  from  h3'postatic  con- 
gestion of  the  lungs,  kidney  failure,  or  exhaustion.  The  majority  of  cases 
recover  with  a  little  shortening,  some  stiffness,  and  a  permanent  limp.  There 
is  a  much  better  chance  for  firm  union  if  the  fracture  is  impacted  than  if 
it  is  not.  Even  if  non-union  results  after  an  intracapsular  fracture,  and  it 
is  not  unusual,  a  patient  may  get  about  fairly  well  with  a  proper  support.  In 
some  cases  after  intracapsular  fracture  rheumatoid  arthritis  develops.  Many 
surgeons  have  maintained  that  bony  union  never  occurs,  but  it  certainly  does 
sometimes  take  place.  Stokes  holds  that  bony  union  is  possible  in  fractures 
with  penetration,  and  even  in  fractures  without  penetration  when  the  frac- 
ture is  within  the  periosteum.* 

Treatment. — In  treating  a  very  feeble  person  for  intracapsular  fracture 
make  no  attempt  to  obtain  union.  Keep  the  patient  in  bed  for  two  weeks; 
give  lateral  support  by  sand-bags;  tie  around  the  ankle  a  fillet,  attach  a 
weight  of  a  few  pounds  to  the  fillet,  and  hang  the  weight  over  the  foot-board 
of  the  bed.  When  pain  and  tenderness  abate,  order  the  patient  to  get  into 
a  reclining- chair,  and  permit  him  very  soon  to  get  about  on  crutches.  If 
hypostatic  congestion  of  the  lungs  sets  in,  if  bed-.sores  appear,  if  the  appetite 
and  digestion  utterly  fail,  or  if  diarrhea  persists,  abandon  attempts  at  cure 
in  any  case,  and  get  the  patient  up  and  take  him  into  the  sunshine  and  fresh 
air,  simply  immobilizing  the  fracture  as  thoroughly  as  possible  by  means 
of  pasteboard  splints  or  plaster-of-Paris.  In  the  vast  majority  of  cases,  no 
matter  how  old  the  patient  may  be,  undertake  treatment.     We  may  be  forced 

*  See  tlie  masterly  paper  of  .Stokes,  before  quoted. 


Intracapsular  Fracture  of  the  Femur 


443 


to  abandon  it,  but  should  at  least  attempt  to  obtain  a  cure.  If  it  is  de- 
termined to  treat  the  case,  place  patient  on  a  hair  mattress,  several  boards 
being  laid  under  it  transversely  in  order  to  prevent  unevenness  and  the  forma- 
tion of  hollows.     A  fracture-bed  is  a  valuable  adjunct  to  treatment. 

Treatment  by  the  extension  apparatus  of  Giirdon  Buck:  Extend  the  knee, 
and  place  the  leg  in  a  natural  posture,  and  put  a  pillow  beneath  the  knee. 
Combine  extension  with  lateral  support  by  means  of  sand-bags.  The  exten- 
sion should  be  gentle,  never  forcible.  It  is  not  wise  to  pull  apart  a  penetration 
in  an  old  person,  but  it  should  always  be  done  in  a  young  or  middle-aged  per- 
son. Place  the  subject  on  a  firm  mattress.  If  the  patient  be  a  man,  shave 
the  leg.  Cut  a  foot-piece  out  of  a  cigar-box,  perforate  it  to  admit  the  passage 
of  a  cord,  wrap  it  with  adhesive  plaster  as  shown  in  Plate  6,  Figs.  15  and 
16,  run  the  weight-cord  through  the  opening  in  the  wood,  and  fasten  a  piece 
of  adhesive  plaster  on  each  side  of  the  leg,  from  just  below  the  seat  of  fracture 
to  above  the  malleolus  (PI.  6,  Fig.  14).  The  plaster  is  guarded  from  sticking 
to  the  malleoli  by  having  another  piece  stuck  to  its  under  surface  opposite 
each  of  these  points.  Apply  an  ascending  spiral  reversed  bandage  over 
the  plaster  to  the  groin  (Fig.  197),  and  finish  the  bandage  by  a  spica  of  the 
groin.     Slightly  abduct  the  extremity.     Put  a  brick   under   each  leg  of  the 


Fig.  197. — Adhesive  plaster  applied  to  make  extension. 


bed  at  its  foot,  thus  obtaining  counter-extension  by  the  weight  of  the  body. 
Run  a  cord  over  a  pulley  at  the  foot  of  the  bed,  and  obtain  extension  by 
the  use  of  weights.  In  an  adult  from  fifteen  to  twenty  pounds  will  probably 
be  necessary  at  first,  but  after  a  few  days  from  eight  to  ten  pounds  will 
be  found  sufficient  (remember  that  a  brick  weighs  about  five  pounds).  Daw- 
barn's  rule  as  to  the  proper  weight  to  be  attached  is  one  pound  for  every 
year  up  to  twenty.  When  the  foot  of  the  bed  is  raised  and  the  weight  to 
make  e-xtension  is  applied,  very  gently  rotate  the  extremity,  put  the  foot 
at  a  right  angle  with  the  leg,  and  make  a  bird's-nest  pad  of  cotton  or  oakum 
to  save  the  heel  from  pressure.  Take  two  canvas  bags,  one  long  enough 
to  reach  from  the  crest  of  the  ihum  to  the  outer  malleolus,  the  other  long 
enough  to  reach  from  the  perineum  to  the  inner  malleolus.  Fill  the  bags 
three-quarters  full  of  dry  sand,  sew  up  their  ends,  cover  the  bags  with  slips, 
and  put  the  bags  in  place  in  order  to  correct  eversion.  The  slips  may  be 
changed  every  third  or  fourth  day.  Keep  the  bed-clothing  from  coming  in 
contact  with  the  foot  by  means  of  a  cradle  (Figs.  19S,  199).  The  bowels 
are  to  be  emptied  and  the  urine  is  to  be  voided  in  a  bed-pan,  unless  using  a 
fracture-bed.  For  two  weeks  the  patient  remains  recumbent,  after  which  time 
he  can  be  propped  up  on  pillows.     Maintain  extension  for  three  weeks,  then 


444 


Diseases  and  Injuries  of  Bones  and  Joints 


simply  maintain  support  by  sand-bags  or  mould  pasteboard  splints  upon 
the  part,  and  keep  up  this  support  three  to  five  weeks  more.  After  removing 
Lhe  extension  he  can  be  transferred  daily  to  a  couch.  In  from  six  to  eight 
weeks  after  the  infliction  of  the  injury  he  can  be  moved  about  in  a  wheeling- 
chair,  the  leg  being  extended  or  the  knee  flexed  in  accordance  with  the  dictates 
of  comfort.  After  a  week  or  so  of  such  movement  a  thick-soled  shoe  is  placed 
on  the  sound  foot  and  the  patient  is  allowed  to  use  crutches;  but  weight  is  not 
put  upon  the  injured  extremity  until  from  ten  to  twelve  weeks  have  elapsed 
from  the  time  of  the  accident.  For  many  months,  at  least,  and  possibly  per- 
manently, he  walks  with    the    aid  of  a  cane.     Union,  if  it  takes    place,  is 


Fig.  199. 
Figs.  198,  199.— Cradle  to  keep  clothing  from  leg,  made  from  two  barrel-hoops  (Scudder). 


usually  cartilaginous,  but  is  sometimes  bony,  and  there  will  surely  be  some 
shortening  and  also  some  stifl'ness  of  the  joint.  Passive  motion  is  not  made 
until  at  least  eight  weeks  have  elapsed  since  the  accident.  Treatment  by 
the  extension  apparatus  is  far  from  satisfactory,  as  it  does  not  afford  sufficient 
immobilization. 

Senn\s  method:  Senn  claims  that  by  his  methofi  of  "immediate  reduction 
and  permanent  fixation"  bony  union  is  obtained  in  fractures  of  the  neck  of 
the  femur  within  the  capsule.  He  "places  the  patient  in  the  erect  position, 
causing  him  to  stand  with  his  sound  leg  upon  a  stool  or  box  about  two  feet 


Intracapsular  F^racture  of  the  Femur 


445 


in  height;  in  this  position  he  is  supported  by  a  person  on  each  side  until 
the  dressing  has  been  applied  and  the  plaster  has  set. 

''Another  person  takes  care  of  the  fractured  limb,  which  in  impacted 
fractures  is  gently  supported  and  immovably  held  until  permanent  fixation 
has  been  secured  by  the  dressing.  In  non-impacted  fractures  the  weight  of 
the  fractured  limb  makes  auto-extension,  which  is  often  quite  sufficient  to 
restore  the  normal  length  of  the  limb;  if  this  is  not  the  case,  the  person  who 
has  charge  of  the  hmb  makes  traction  until  all  shortening  has  been  overcome 
as  far  as  possible,  at  the  same  time  holding  the  limb  in  position,  so  that  the 
great  toe  is  on  a  straight  line  with  the  inner  margin  of  the  patella  and  the 
anterior  superior  spinous  process  of  the  ilium.  In  applying  the  plaster-of- 
Paris  bandage  over  the  seat  of  fracture  a  fenestrum,  corresponding  in  size 
to  the  dimensions  of  the  compress  with  which  the  lateral  pressure  is  to  be 
made,  is  left  open  over  the  great  trochanter. 

"To  secure  perfect  immobility  at  the  seat  of  fractures,  it  is  not  only 
necessary  to  include  in  the  dressing  the  fractured  limb  and  the  entire  pelvis, 
but  it  is  absolutely  necessary  to  also  in- 
clude the  opposite  limb  as  far  as  the  knee 
and  to  extend  the  dressing  as  far  as  the 
cartilage  of  the  eighth  rib. 

''The  splint  (Fig.  200)  is  incorporated 
in  the  plaster-of-Paris  dressing,  and  it 
must  carefully  be  applied,  so  that  the 
compress,  composed  of  a  well-cushioned 
pad  with  a  stiff,  unyielding  back,  rests 
directly  upon  the  trochanter  major,  and 
the  pressure,  which  is  made  b}'  a  set- 
screw,  is  directed  in  the  axis  of  the  femoral 
neck.  Lateral  pressure  is  not  applied 
until  the  plaster  has  completely  set.  Syn- 
cope should  be  guarded  against  by  the 
administration  of  stimulants. 

"  As  soon  as  the  plaster  has  sufficiently 
hardened  to  retain  the  hmb  in  proper  position,  the  patient  should  be  laid 
upon  a  smooth,  even  mattress,  without  pillows  under  the  head,  and  in 
non-impacted  fractures  the  foot  is  held  in  a  straight  position  and  extension 
is  kept  up  until  lateral  pressure  can  be  applied. 

"No  matter  how  snugly  a  plaster-of-Paris  dressing  is  applied,  as  the 
result  of  shrinkage  it  becomes  loose,  and  without  some  means  of  making 
lateral  pressure  it  would  become  necessary  to  change  it  from  time  to  time 
in  order  to  render  it  efficient.  But  by  incorporating  a  splint  in  the  plaster 
dressing  (Fig.  201)  this  is  obviated,  and  the  lateral  pressure  is  regulated, 
day  by  day,  by  moving  the  screw,  the  proximal  end  of  which  rests  on  an 
oval  depression  in  the  center  of  the  pad." 

Treatment  by  Thomases  splint:  Scudder.  in  his  valuable  treatise  on  "The 
Treatment  of  Fractures,"  advocates  in  intracapsular  fracture  the  use  of 
Thomas's  hip  splint.  If  the  bones  are  unimpacted.  the  fragments  are 
brought  into  apposition  by  extension,  inversion,  and  pressure  upon  the 
great    trochanter,  and  the    Thomas  splint  is  bent  to  fit,  is  padded,  and  is 


Fig.  200. — Senn's 
apparatus. 


Fig  201. — Senn's  appa- 
ratus applied. 


446 


Diseases  and  Injuries  of  Bones  and  Joints 


applied  (Figs.  202,  203).  When  the  bed-pan  is  to  be  used  or  the  bed  is  to 
be  smoothed,  the  patient  can  be  Hfted  without  disturbing  the  fracture.  He 
can  be  turned  on  the  sound  side.  If  hypostatic  congestion  is  developing 
raise  the  head  of  the  bed  and  tie  the  splint  to  the  iron  of  the  head  of  the 
bed.  In  addition  to  the  use  of  the  splint  Scudder  advocates  the  making  of 
lateral  pressure  over  the  great  trochanter  by  a  graduated  compress  and 
a  bandage.  The  splint  is  worn  for  six  or  eight  weeks.  It  is  then  removed, 
the  patient  remaining  in  bed  four  weeks  longer  without  any  apparatus 
(Scudder,  from  Ridlon). 

Extracapsular  Fracture  {Fracture  0}  the  Base  oj  the  Neck  of  the  Femur). 
— The  line  of  extracapsular  fracture  is  at  the  junction  of  the  neck  with  the 
great  trochanter,  and  is  partly  within  and  partly  without  the  capsule,  the  frac- 
ture being  generally  comminuted  and  often  impacted.     The  cause  is  violent  di- 


Fig.  202,- 


-Thomas's  single  hip-splint  in  posi- 
tion (Ridlon). 


Fig.  203. — Thomas's  double  hip-splint  in  posi- 
tion (Ridlon). 


rect  force  over  the  great  trochanter  (as  by  falling  upon  the  side  of  the  hip).  This 
fracture  is  most  usual  in  elderly  people,  but  is  not  very  uncommon  in  young 
adults.  Stokes  has  described  six  forms  of  extracapsular  fracture:  extracapsu- 
lar fracture  with  partial  impaction  posterior;  fracture  with  complete  impac- 
tion; fracture  with  partial  impaction  above;  fracture  with  partial  impaction 
below,  the  .shaft  being  split;  .splitting  of  the  neck  longitudinally  without 
impaction;  comminuted  non-impacted  fracture.* 

Symptoms. — When  impaction  is  absent  there  is  marked  crepitus  on 
motion,  which  is  manife.sted  most  distinctly  when  the  fingers  are  placed 
upon  the  great  trochanter;  there  is  .severe  pain,  pressure  upon  the  great 
trochanter  is  very  painful,  swelling  and  ecchymosis  are  marked;  there  is 
absolute  inability  on  the  part  of  the  patient  to  move  the  limb,  and  passive 

*  Brit.  Med.  Jour.,  Oct.  12,  1895. 


Fractures  of  Femoral  Neck  in  Children  447 

movements  cause  violent  pain;  there  is  shortening  to  the  extent  of  at  least 
one  and  a  half  inches,  and  sometimes  to  the  extent  of  three  inches,  which 
shortening  is  made  manifest  by  noting  the  ascent  of  the  trochanter  above 
Nelaton's  line,  by  a  comparison  of  measurements  of  the  injured  limb  and  the 
sound  Hmb,  and  by  measuring  the  base-line  of  Bryant's  triangle  on  each  side. 
Absolute  eversion  usually  exists  with  slight  flexion  both  of  the  leg  and  the 
thigh.  In  some  rare  cases  there  is  inversion.  This  happens  if  at  the  time  of 
the  accident  the  hmb  was  inverted  and  adducted  (Stokes).  Lagoria's  sign, 
Desault's  sign,  and  Allis's  signs  are  present.  All  these  symptoms  follow  vio- 
lent direct  lateral  force.  In  the  impacted  form  of  extracapsular  fracture,  in 
addition  to  the  aid  given  the  surgeon  by  the  history,  there  is  severe  pain, 
which  is  intensified  by  movement  or  pressure;  shortening  to  the  extent  of 
one  inch  at  least,  which  is  not  corrected  by  extension;  great  loss  of  function; 
and  whereas  the  limb  may  be  straight  or  even  inverted,  it  is  usually  everted. 
The  trochanter  is  above  Nelaton's  line,  the  base-line  of  Bryant's  triangle 
is  shortened,  but  not  so  much  as  in  the  unimpacted  form;  there  is  no  crepitus 
unless  the  impaction  is  pulled  apart,  and  the  arc  of  rotation  of  the  great 
trochanter  is  larger  than  in  a  non-impacted  fracture. 

Treatment. — In  impacted  extracapsular  fracture  it  is  best  to  pull  apart 
the  impaction  if  the  patient  is  in  good  physical  condition.  Southam,  of  Alan- 
chester,  in  an  impressive  article,  has  recently  insisted  on  the  absolute  necessity 
of  pulling  apart  an  impaction.  He  gives  ether,  and  when  the  patient  is 
anesthetized  unlocks  the  fragments.*  In  treating  non-impacted  extracapsular 
fracture  make  extension,  raise  the  foot  of  the  bed,  and  applv  the  extension 
apparatus  with  sand-bags  for  three  weeks;  then  apply  a  plaster  dressing. 
Get  the  patient  up  on  crutches  after  the  plaster  has  been  in  place  for  two 
weeks.  Remove  the  plaster  at  the  end  of  four  weeks.  Thomas's  sphnt 
may  be  used  instead  of  Buck's  extension. 

Fractures  of  the  Femoral  Neck  in  Children. — Fracture  of  the  femoral 
neck  in  children  can  scarcely  be  regarded  as  very  unusual,  and  is  certainly 
more  often  encountered  than  is  separation  of  the  upper  epiphysis.  The  acci- 
dent results  from  a  fall  rather  than,  as  in  an  adult,  from  a  twist,  and  it  is  the 
product  of  considerable  violence  rather  than  of  shght  force.  ]\Ianv  such 
fractures  are  impacted  and  most  of  those  which  are  unimpacted  are  of  the 
green-stick  variety.  The  disability  is  not  nearly  so  great  as  in  an  adult;  in 
fact,  it  is  not  unusual  for  the  victim  of  such  an  injury  to  be  able  to  hobble 
about  a  few  days  afterward.  The  symptoms  are  shortening,  some  ever- 
sion, impairment  of  joint-movements,  and  a  limp  when  the  patient  gets 
about.  Fractures  of  the  hip  in  children  are  often  unrecognized  and  lead 
frequently  to  permanent  impairment  because  of  the  development  of  coxa 
vara.     The  .r-rays  should  be  used  in  making  the  diagnosis. 

A  green-stick  fracture  is  treated  with  Thomas's  splint,  and  after  four 
weeks  in  bed  "the  child  may  be  allowed  up,  wearing  a  traction  hip-splint 
for  several  months  until  union  is  so  firm  that  the  danger  from  coxa  vara 
is  practically  eliminated.  A  light  plaster-of-Paris  spica  bandage  from  the 
calf  to  the  axilla  will  maintain  immobility  after  the  splint  is  omitted"  (Scudder, 
on  "The  Treatment  of  Fractures").  .An  impacted  fracture  is  treated  ex- 
actly as  is  a  green-stick  fracture.     In  a  case  of  acute  disability  in  a  child, 

*  Lancet,  Dec.  2i,  1S95. 


448 


Diseases  and  Injuries  of  Rones  and  Joints 


following  fracture  of  the  femoral  neck,  make  a  careful  differentiation  from 
tuberculous  disease  of  the  joint  and  apply  a  traction  sphnt  to  support  the 
body  and  give  rest  to  the  joint.  If  coxa  vara  becomes  marked  and  causes 
great  disability,  osteotomy  is  justifiable. 

Separation  of  the  upper  epiphysis  of  the  femoral  head  is  a  very  rare 
result  of  accident;  it  occurs  most  often  from  disease.  It  is  met  with  in 
early  youth,  results  in  considerable  permanent  shortening  and  perhaps  in 
coxa  vara. 

Symptoms  and  Treatment. — The  symptoms  are  like  those  of  fracture  of 
the  neck,  except  that  the  crepitus  is  soft.     The  treatment  is  as  above  directed. 


Fig.  204. — Deformity  following;  fracture  of  upper  third  of  femur. 


Fractures  of  the  Great  Trochanter. — This  process  may  be  (i)  broken 
off  without  any  other  injury,  but  in  most  cases  (2)  the  line  of  fracture  runs 
through  the  trochanter,  and  leaves  one  [portion  of  the  trochanter  attached 
to  the  head  and  neck  and  the  other  ])art  attached  to  the  shaft  of  the  femur. 
The  cause  is  violent  direct  force  over  the  great  trochanter. 

Symptoms  and  Treatment. — The  symptoms  of  the  second  form  are  similar 
to  those  c>f  extracapsular  fracture.  On  rotating  the  femur  the  lower  part 
of  the  trochanter  moves  with  it,  but  not  the  upper.  The  lower  fragment 
goes  upward  and  backward  and  projects  by  the  side  of  the  sciatic  notch. 


Fracture   of  Shaft  of  Femur  449 

There  are  shortening,  eversion,  crepitus,  and  altered  position  of  the  tro- 
chanter. The  symptoms  of  the  first  form  resemble  those  of  epiphyseal 
separation.  The  treatment  of  the  second  form  is  like  that  in  extracapsular 
fracture,  and  the  first  form  is  treated  like  separation  of  the  epiphysis  of  the 
trochanter.  > 

Separation  of  the  epiphysis  of  the  great  trochanter  is  a  very  rare 
accident.     The  cause  is  direct  violence,  and  the  injury  occurs  only  in  youth. 

Symptoms. — The  trochanter  is  found  to  have  ascended  and  passed  pos- 
teriorly; there  is  no  shortening  of  the  thigh;  all  the  motions  of  the  hip-joint 
can  be  obtained;  if  the  thigh  is  flexed,  abducted,  and  rotated  externally, 
and  the  fragment  is  pushed  downward  and  forward,  cre[)itus  is  obtained — 
soft  in  epiphyseal  separation,  hard  in  fracture. 

Treatment. — In  treating  separation  of  the  epiphysis  of  the  great  trochanter 
flex  the  leg  on  the  thigh  and  the  thigh  on  the  pelvis,  place  the  extremity 
upon  its  outer  surface,  keep  it  fixed  by  some  form  of  retentive  apparatus, 
and  try  to  draw  the  trochanter  downward  and  forward  l^y  adhesive  strips 
or  by  a  pad  and  bandage.  Some  degree  of  lameness  is  inevitable,  even 
after  Bryant's  extension.  Bryant's  extension  directly  upward  may  admit  of 
the  trochanter  being  pulled  into  place  upon  the  bone  (Fig.  209).  Extension 
must  be  applied  for  four  weeks,  and  crutches  and  pasteboard  splints  should 
be  used  for  four  weeks  more. 

2.  Fractures  of  the  shaft  of  the  femur  may  aftect  any  portion  of  the 
shaft,  but  especially  the  middle  third,  and  may  occur  at  any  age.  Fracture 
of  the  upper  third  is  a  rare  accident.  Allis  estimates  that  each  year  in  Phila- 
delphia there  is  i  case  of  fracture  of  the  upper  third  of  the  femur  to  every 
100,000  inhabitants.  Separation  of  the  lower  epiphysis  occasionally  occurs. 
The  cause  of  fractures  in  the  upper  third  is  usually  indirect  force;  fractures 
in  the  lower  third  are  due  to  direct  force;  and  in  fractures  of  the  middle  third 
these  two  causes  are  about  equally  potential.  Fracture  from  muscular  action 
occasionally  occurs.  Oblique  fracture  is  the  usual  variety.  In  many  cases 
the  soft  parts  are  badly  lacerated  and  sometimes  a  great  vessel  is  torn. 

Symptoms. — The  chief  symptom  in  fracture  of  the  shaft  of  the  femur 
is  great  displacement,  except  when  impaction  occurs,  when  the  break  is 
due  to  direct  force,  or  when  the  injury  is  in  a  child.  In  a  child  the  line  of 
fracture  is  often  transverse  and  the  periosteum  ma\-  be  untorn.  Green- 
stick  fractures  occur  in  children.  As  a  rule,  in  fracture  of  the  shaft  of  the 
femur  the  lower  fragment  is  drawn  upward  and  the  upper  end  of  the  lower 
fragment  is  found  posterior  and  somewhat  to  the  inside  of  the  lower  end 
of  the  upper  fragment,  and  the  lower  fragment  also  undergoes  external 
rotation  (the  drawing  up  is  due  to  the  rectus  and  hamstrings;  the  passing 
inward  is  due  to  the  adductor  muscles;  the  rotation  outward  arises  from  the 
weight  of  the  limb).  If  a  fracture  of  the  lower  two-thirds  of  the  shaft  is 
[produced  by  direct  force,  there  is  usually  but  little  deformity,  because  the 
line  of  fracture  is  nearly  transverse.  If  produced  by  indirect  force,  there 
is  often  great  deformity,  the  line  of  fracture  being  oblique.  In  fracture 
of  the  lower  third  of  the  shaft  the  gastrocnemius  pulls  upon  the  condyles 
and  tilts  the  lower  fragment,  so  that  its  upper  end  projects  into  the  popliteal 
space  and  may  damage  the  vessels.     In  fracture  of  the  upi)er  third  the  up[)er 

fragment   is   apt   to   be   thrown   strongly  forward   and   outward    (Fig.    204). 
29 


450 


Diseases  and  Injuries  of  Bones  and  Joints 


Some  attribute  this  to  the  action  of  the  psoas,  iHacus,  and  external  rotator 
muscles,  but  Allis  thinks  it  is  due  chiefly  to  the  lower  fragment  pushing  the 
upper  fragment  into  this  position,  a  part  of  the  tendon  of  the  gluteus  maxi- 
mus  acting  as  a  hinge  for  the  fragments.*  In  rare  cases  the  angular  de- 
formity is  backward.  In  fracture  of  the  shaft  of  the  femur  there  is  complete 
-loss  of  function, 'the  thigh  and  leg  are  slightly  flexed  and  usually  everted. 
In  some  cases  the  leg  and  lower  fragment  are  inverted.  There  are  shorten- 
ing to  the  extent  of  two  or  three  inches,  pain  on  movement,  preternatural 
mobility,   crepitus,  and    obvious  deformity,  and  the  ends  of  the  fragments 


Fig.  205.— Dressing  of  fracture  of  the  femur  in  the  upper  third  with  extension  upon  a  double  inclined 

plane  (Agnew). 


can  be  felt  by  the  surgeon.  In  impaction  there  is  alteration  of  the  axis  of  the 
limb  and  some  shortening.  Always  feel  for  the  pulse  below  the  fracture. 
Treatment. — In  setting  and  dressing  a  fracture  of  the  thigh  ether  should 
be  given  and  the  parts  must  be  handled  with  great  care  to  prevent  a  sharp  end 
from  tearing  the  soft  parts  and  puncturing  the  skin.     The  surgeon  always 

feels  for  the  pulse  below  the  seat  of 
fracture  to  see  if  the  artery  is  damaged. 
In  fracture  of  the  shaft  of  the  femur, 
if  impaction  exists,  the  fragments  must 
be  pulled  apart,  when  the  case  should 
be  treated  exactly  as  is  a  non-impacted 
fracture.     After  a  fracture  of  the  shaft 


of  the  femur  some  amount  of  perma- 
nent shortening  is  almost  inevitable. 
In  fracture  of  the  upper  third  treat- 
ment is  usually  unsatisfactory,  and 
there  is  permanent  shortening  from 
angular  union  or  from  overlapping. 
Horizontal  extensif)n  fails  to  correc*^ 
the  displacement  of  the  upper  frag- 
ment in  fracture  of  the  upper  third. 
The  double  incHned  plane  will  not  correct  the  tilting  of  the  upper  fragment  while 
shortening  exists.  Agnew  used  a  double  inclined  plane  and  corrected  short- 
ening by  the  use  of  extension  in  the  axis  of  the  partly-flexed  thigh  (Fig.  205). 
This  plan  is  the  most  .serviceable  of  those  usually  employed,  but  it  too  fails 

*"  Fracture  in  the  Up]x:r  Third  of  the   Femur   Exchisive  of  the  Neck,"  hy  Oscar   II. 
Allis,  Medical  News;  Nov.  21,  1891. 


Fig.  206. — Smith's  anterior  splint. 


Fractures  of  the  Shaft  of  the  Femur 


451 


to  completely  correct  the  displacement.  If,  notwithstanding  position  and 
extension,  the  upper  fragment  projects,  it  should  be  pushed  into  place  and 
be  retained  if  possible  by  short  splints  bound  upon  the  thigh.  E.xtension 
should  be  continued  for  four  weeks,  a  plaster-of-Paris  bandage  being  used 
for  four  weeks  more,  the  patient  being  then  allowed  to  go  about  on  crutches. 
Some  surgeons,  in  fracture  of  the  upper  third,  apply  a  plaster-of-Paris  bandage 


Fig,  207. — Hodgen's  apparatus  as  applied  by  Dr.  George  S.  Brown. 


to  the  leg,  thigh,  and  pelvis,  extension  being  made  from  the  foot  while  the 
dressing  is  being  apphed.  This  method  does  not  give  good  results  because 
such  extension  will  not  correct  the  tilting  of  the  upper  fragment.  The  anterior 
splint  of  Nathan  R.  Smith  is  used  by  some  in  treating  fractures  of  the  upper 
third  of  the  femur  (Fig.  206).  It  is  bent  to  the  desired  shape,  fastened  to 
the  anterior  surfaces  of  the  leg  and  thigh,  and  hung  to  a  gallows,  the  limb 
being  suspended  at  the  de.sired  height.  This  splint  is  open  to  the  same 
objection  as  the  double  inclined  plane.     In  fact,  in  many  fractures  of  the 


452 


Diseases  and  Injuries  of  Bones  and  Joints 


upper  third  of  the  shaft  of  the  femur  no  apparatus  will  maintain  reduction. 
In  such  cases  it  is  advisable  to  incise,  separate  the  muscles  from  between 
the  fragments,  and  fasten  the  ends  of  the  bone  fragments  together  with 
bone  ferrules,  silver  wire,  kangaroo-tendon,  steel  screws,  steel  pins,  or  a 
bone-clamp.  This  radical  treatment  has  certain  dangers  of  its  own, 
but  it  is  the  only  plan  which  promises  to  secure  a  thoroughly  good  limb. 
In  fracture  of  the  middle  third  or  upper  part  of  the  lower  third  of  the  shaft 
of  the  femur,  the  extension  apparatus  and  sand-bags  will  usually  secure  a 
satisfactory  result  (PI.  6,  Fig.  14).  The  strips  of  adhesive  plaster  are  carried 
to  just  below  the  seat  of  fracture,  and  the  turns  of  the  roller  bandage  should 
be  taken  to  a  little  above  this  point.  Extension  should  be  continued  for  four 
■weeks,  when  the  plaster-of-Paris  bandage  ought  to  be  applied.  The  plaster 
is  kept  in  place  for  four  weeks.  Many  surgeons  use  Hodgen's  splint  in 
treating  fractures  of  the  thigh.  The  Umb  is  suspended  in  a  cradle  and  ex- 
tension is  obtained  by  strapping  the  foot  to  the  cross-bar  of  the  frame  and 
pulling  upon  the  frame  by  cords  (Fig.  207).     Hodgen's  apparatus  as  applied 


Fig.  20S. — Mcliityre's  splint. 


by  Brown,  of  Birmingham,  Ala.,  is  one  of  the  most  satisfactory  methods  of 
treatment  in  fractures  below  the  upper  third.  The  extremity  can  be  raised 
or  lowered  at  will  without  disturbing  the  approximation  of  the  fragments, 
extension  to  the  required  degree  can  be  obtained,  and  the  patient  can  be 
moved  in  Vjed.  I  consider  this  apparatus  the  most  comfortable  appliance 
which  can  be  worn  and  excellent  results  are  obtained  by  its  use.  In  fracture 
of  the  middle  third  or  upper  part  of  the  lower  third  of  the  shaft  if  the  line  of 
fracture  is  transverse  and  there  is  little  deformity,  as  is  seen  often  after  a 
fracture  by  direct  force,  and  often  in  children,  immobilization  in  an  im- 
movable dressing  may  be  all  that  is  required;  but  if  shortening  exists,  exten- 
sion mu.st  be  used.  If  extension  is  used,  continue  it  for  four  weeks  and  then 
substitute  a  plaster-of-Paris  dressing  for  four  weeks.  The  amount  of  weight 
required  is  [)ointed  out  by  Dawbarn:  one  pound  for  each  year  up  to  twenty.* 
In  fracture  near  the  knee-joint  it  may  be  impossible  to  effect  reduction  by 
horizontal  traction.  In  such  a  case  make  traction,  and  while  it  is  being  made 
gradually  bring  the  leg  to  a  right  angle.  Place  the  limb  in  a  double  inclined 
plane  (PI.  6,  Fig.  2).  A  Mclntyre  splint  (Fig.  208)  is  a  useful  form  of  double 
*  Annals  of  Surgery,  Oct.,  1897. 


Fractures  of  the  Shaft  of  the  Femur  in  Children 


453 


Fig.  209. — Bryanl's  exten- 
sion for  fracture  of  the  thigh 
in  a  child. 


inclined  plane.     After  four  weeks  of  the  use  of  a  double  inclined  plane  apply 
a  plaster-of-Paris  dressing,  which  is  to  be  worn  for  four  weeks. 

Fractures  of  the  Shaft  of  the  Femur  in  Children. — In  children  under 
three  years  of  age  the  extension  apparatus  will  not  satisfactorily  immobilize 
the  fragments.  Fractures  of  the  thigh  in  children 
are  reduced  by  extension  and  counter-extension;  a 
well-padded  splint  reaching  from  the  axilla  to  below 
the  sole  of  the  foot  is  applied  to  the  outer  side  of 
the  limb  and  body.  This  splint  is  held  in  place 
by  bandages  which  are  overlaid  with  plaster-of- 
Paris.  It  is  worn  for  four  weeks,  at  which  time  it 
is  removed  and  a  plaster  bandage,  apphed  so  as  to 
include  the  entire  limb,  is  worn  for  four  weeks  more. 
Bryant's  extension  is  very  satisfactory  in  treating 
a  child  (Fig.  209).  Both  the  injured  limb  and  the 
sound  limb  should  be  flexed  to  a  right  angle  with 
the  pelvis,  fixed  by  light  splints,  and  fastened  to 
a  bar  above  the  bed.  The 
weight  of  the  body  pro- 
duces counter-extension 
and  the  child  can  be  easily 
cleaned.* 

Another  plan  is  that  of  Theodore  Dunham.f 
The  child  is  placed  upon  a  table,  and  the  knee  and 
thigh  are  partly  flexed.  After  first  applying  flannel 
rollers,  plaster-of-Paris  bandages  are  applied  from 
the  roots  of  the  toes  to  the  spine  of  the  tibia,  and 
as  a  spica  about  the  upper  part  of  the  thigh  and 
pelvis.  Two  pieces  of  iron,  suitably  bent,  are  used 
to  anchor  the  two  plaster  bandages  together.  One 
end  of  one  iron  is  attached  to  the  plaster  over  the 
groin  and  one  end  of  the  other  iron  is  attached  to 
the  plaster  over  the  front  of  the  leg.  The  free  ends 
of  the  irons  overlap.  At  the  points  over  the  joints 
and  the  front  of  the  leg  where  the  irons  are  to  rest 
masses  of  plaster  are  placed.  The  iron  is  sunk  into 
the  plaster  and  supported  at  each  spot  by  several 
turns  of  a  plaster  bandage.  While  the  irons  are 
being  adjusted  the  thigh  is  so  held  as  to  prevent 
bending  or  rotation,  and  the  hip  and  knee  are  semi- 
flexed. When  the  plaster  has  set,  an  assistant  makes 
extension  on  the  leg  and  another  assistant  makes 
counter-extension  by  pressing  on  the  pelvis.  Any  shortening  is  thus  reduced 
and  the  two  irons  are  lashed  together  with  strong  cord  (Fig.  210). 

Van  Arsdale's  triangular  splint  is  a  very  useful  apphance.  It  is  made  of 
binders'  board.  A.  Ernest  Gallant  t  describes  its  preparation  and  applica- 
tion as  follows:  Measure  the  length  of  the  sound  thigh  from  the  middle  of 

*  Bryant's  "  Practice  of  Surgery.''  f  Pliila.  Med.  Jour.,  April  23,  1S98. 

j  Tour.  Ainer.  Med.  Assoc,  Dec.   iS,   1897. 


Fig.  210. — Dunham's  appa- 
ratus for  treating  fractures  of 
the  thigh  in  infants  and  chil- 
dren. 


454 


Diseases  and  Injuries  of  Bones  and  Joints 


the  groin  to  the  end  of  the  femur.  Draw  upon  cardboard  an  outline  of  a 
double  spade  (playing-card  spade),  Fig.  211.  Each  of  the  four  sections 
(.4,  B,  C,  D)  must  be  equal  to  the  length  of  the  child's  thigh,  the  flanged 
portions  being  equal  to  the  widest  part  of  the  thigh.  The  figure  is  then  cut 
out.     The  cardboard  is  moistened  on  one  side  and  folded  on  the  dotted  line, 

section  A  being  lapped  over 
D,  so  as  to  form  a  triangle. 
It  is  fastened  together  by 
adhesive  plaster.  The  thigh 
is  flexed  and  the  triangle  is 
applied  so  that  one  flanged 
portion  embraces  the  thigh 
and  the  other  flanged  por- 
tion rests  on  the  abdomen. 
The  triangle  is  fixed  in  po- 
sition by  bandages,  figure- 
of-eight  turns  being  made 
around  the  knee  and  around 
the  thigh  and  body.  Plaster 
or  starch  bandages  are  then 
applied  to  fix  the  splint 
firmly.  The  leg  should  be  bandaged  from  the  toe  to  the  knee  to  prevent  swell- 
ing (Fig.  212).  This  splint  is  worn  for  three  weeks.  A  child  wearing  this 
splint  can  sit  on  a  chair,  nurse,  play  on  the  floor  and  crawl  about,  may 
sleep  on  either  side,  and  the  dressing  is  not  soiled  by  the  evacuations. 

If  a  thigh  is  fractured  during  parturition,  or  during  the  first  few  weeks 
of  life,  Wyeth's  dressing  is  very  serviceable.  It  is  applied  as  follows:  The  leg 
is  flexed  on  the  thigh  and  the  thigh  on  the  abdomen.  A  flannel  bandage  is 
applied  so  as  to  include  the  leg,  the  thigh,  and  the  body  from  the  axilla  to 
the  pelvis.  Plaster-of-Paris  is  applied  over  this;  the  dressing  is  worn  for 
four  weeks. 


Fig.  211. — I,  Diagram  showing  outline  of  Van  Arsdale's 
splint;  the  end  band  to  be  folded  on  the  dotted  lines;  each 
section  to  equal  the  length  of  the  child's  thigh.  2,  Dia.gram, 
splint  folded,  fastened  by  rubber  plaster,  flanges  bent  to  em- 
brace the  thigh  and  abdomen,  ready  for  adjustment  (Gallant). 


Fig.  212.— Showing  Van  Arsdale's  triangular  splint   in  position.     Note  the  wide  space  between  the 
dressings  and  the  excretory  passages  (Gallant). 


Fractures  Just  above  the  Condyles  of  the  Femur. — The  line  of  frac- 
ture above  the  condyles  is  well  above  the  epiphyseal  line.  The  femoral  artery 
is  in  danger  from  the  fragments.  The  cause  of  the  break,  as  a  rule,  is  direct 
violence.  Indirect  force  is  sometimes  responsible  (falls  upon  the  feet).  The 
knee-joint  may  be  opened.     The  fracture  is  sometimes  compound. 

Symptoms. — The  upper  end  of  the  lower  fragment  is  drawn  upward  and 
backward,  because  of  the  action  of  the  rectus,  hamstrings,  gastrocnemius, 
and  popliteus.     The  upper  fragment  passes  inward,  and  the  deformity  is 


Fracture  of  the  Patella  455 

verv  manifest.  There  are  shortening,  crepitus,  and  mobility.  The  ends 
of  the  fragments  can  be  felt  by  the  surgeon.  If  the  force  has  been  very  great, 
a  T-fracture  results.  In  T-fracture  the  knee  is  broadened  and  crepitus  is 
obtained  by  moving  the  condyles,  one  up  and  the  other  down.  Always  feel 
for  the  pulse  below  the  fracture. 

Treatment. — In  treating  fracture  above  the  condyles,  reduce  the  deformity 
bv  horizontal  extension.  If  this  fails,  make  traction  at  the  same  time,  gradu- 
ally bringing  the  leg  to  a  right  angle  with  the  thigh.  Place  the  hmb  on  a 
double  inchned  plane  for  five  weeks,  tjien  begin  passive  motion  once  every 
other  day,  restoring  the  limb  to  the  splint  after  the  movements  are  completed. 
At  the  end  of  eight  weeks  after  the  accident  remove  the  dressings,  and,  if  the 
knee-joint  be  stiff,  use  for  some  time  massage,  passive  motion,  hot  and  cold 
douches,  ichthyol  inunctions,  etc.  Bryant  treats  this  fracture  in  extension, 
cutting  the  tendo  Achillis,  if  necessary,  to  amend  deformity.  It  is  occasion- 
ally necessary  to  wire  the  fragments.  Some  cases  demand  amputation  be- 
cause of  injury  to  the  structures  in  the  popliteal  space. 

Fracture  Separating  Either  Condyle, — The  cause  is  direct  force. 

Symptoms  and  Treatment. — The  broken  piece  is  drawn  upward,  the  leg 
bends  toward  the  injury,  crepitus  exists,  the  knee  is  much  broadened,  there 
is  no  shortening,  and  considerable  swelhng  is  sure  to  arise.  In  treating  a 
fracture  separating  either  condyle,  use  a  double  inclined  plane  as  directed 
above. 

Longitudinal  fractures  run  upward  from  the  knee-joint.  The  cause 
is  a  fall  upon  the  feet  or  the  knees. 

Symptoms  and  Treatment. — The  symptoms  of  longitudinal  fracture  are 
often  obscure.  The  femur  is  broadened  when  the  knee  is  flexed.  The  split 
may  be  detected  between  the  condyles.  The  treatment  is  the  straight  posi- 
tion in  plaster  for  eight  weeks. 

Separation  of  the  lower  epiphysis  occurs  only  before  the  twent\-first 
year.     It  is  not  a  very  rare  accident  even  in  children. 

Symptoms. — The  symptoms  in  separation  of  the  lo\ver  epiphysis  are  like 
those  of  transverse  fracture,  but  crepitus  is  moist.  The  lower  fragment  is 
tilted,  so  that  the  articular  surface  looks  forward.  The  lower  end  of  the  upper 
fragment  projects  into  the  popliteal  space.  There  is  danger  to  the  struc- 
tures in  the  popliteal  space  and  that  the  growth  of  bone 
will  be  stunted.     Fee!  for  the  pulse  in  the  leg  or  foot. 

Treatment. — Reduction  may  be  effected  in  some  cases 
by  horizontal  extension.  Occasionally  this  is  impossible.* 
In  such  a  case  adopt  the  plan  of  Hutchinson  and  Barnard, 
make  extension,  and  while  it  is  being  made  graduallv  place 
the  leg  at  a  right  angle  to  the  thigh.  This  is  eft'ected  by  an 
assistant  making  traction  on  the  leg,  while  the  surgeon  clasps 
his  hands  beneath  the  lower  part  of  the  thigh  and  draws  Fig.  213.— Median- 
upward.  The  treatment  for  separation  of  the  lower  epiphy-  '*"'  "'  fracture  of  the 
sis  is  the  use  of  a  double  inclined  plane  as  above  directed,  a^i'ion^fter  tw"^)!' 
In  some  cases  replacement  is  impossible  without  incision. 

Fracture  of  the  patella  is  a  very  common  accident.     The  cause  is  direct 

*See  the  case  reported  by  Jonathan  Hutchinson,  Jr..  atvi  Harold  I..  Barnard,  Lancet, 
May  13,  1:899. 


456 


Diseases  and  Injuries  of  Bones  and  Joints 


force  (producing  vertical,  star-shaped,  or  oblique  lines  of  fracture)  or  mus- 
cular action  (producing  a  transverse  line  of  fracture). 

Transverse  fractures  of  the  patella:  The  knee-cap  is  more  often 
broken  by  muscular  action  than  is  any  other  bone.  When  the  knee  is 
partly  flexed  the  middle  third  of  the  patella  rests  upon  the  condyles  of  the 
femur  and  the  upper  third  of  the  knee-cap  projects  above  them;  when  in  this 
position  a  contraction  of  the  quadriceps  may  easily  cause  a  fracture  near  the 
center  of  the  bone  (Fig.  213).  The  accident  may  be  caused  by  sudden  flexion 
of  the  knee  when  the  quadriceps  is  contracting.  The  most  usual  cause  is  a 
fall  or  an  attempt  of  the  patient  to  save  himself  from  a  fall.     Both  patellar 


Fiff.  214. — Fracture  of  the  patella  (PeiinsN  Ivaiiia  Hospital  rase  ;  skiagraphed  by  Dr.  Gaston  Torrance). 


may  be  broken  at  once.  In  fracture  of  the  patella  the  joint,  and  often  the  pre- 
patellar bursa,  is  opened.  Fractures  by  muscular  action  are  transverse.  The 
injury  is  more  common  in  males  than  in  females,  and  is  extremely  rare  in  the 
very  young  and  the  old.    It  is  an  injury  of  active  manhood  and  middle  life. 

Symploms. — When  the  accident  hap])ens  there  is  often  an  audible  crack. 
As  a  rule,  the  patient  will  not  try  to  use  the  limb,  although  it  is  possible 
for  him  to  stand,  to  walk  backward,  and  to  move  slowly  forward  when 
the  extremity  is  kept  straight.  After  the  accident  there  is  rapid  and 
enormous  swelling,  due  to  the  effusion  first  of  blood  and  then  of  synovia 
and    inflammatory    products   into    and    around  the  joint.      The  patient  is 


Fractures  of  the  Patella 


457 


absolutely  unable  to  raise  the  limb  from  the  bed.  The  fragments  are 
movable  and  usually  widely  separated  (Fig.  214),  this  separation  being 
distinctly  manifest  to  the  touch  unless  swelling  is  great.  The  separation 
is  accentuated  by  fiexion  of  the  leg.  The  separation  may  be  to  the  extent 
of  one  inch  or  even  more.  In  cases  in  which  the  lateral  fibrous  expansions 
and  periosteum  are  but  slightly  torn,  there  may  be  slight  separation  or  no 
separation.  Separation  is  due  in  part  "to  the  retraction  of  the  quadriceps 
and  the  tension  of  the  fascia  lata,  and  in  part  to  distention  of  the  joint  by  blood 
and  exudate."  *  If  fragments  are  not  approximated  and  union  does  not 
occur,  the  separation  becomes  gradually  greater  because  of  the  progressive 


Fig.  215.  — Fracture  of  the  patella  (Pennsylvania  Hospital  case  ;  skiagraphed  by  Dr.  Gaston  Torrance). 


shortening  of  the  muscle  and  the  retraction  of  the  ligamentum  patellar  (Stim- 
son).  In  some  cases  an  anterior  angular  displacement  occurs  because  of 
the  intra-articular  distention  (Fig.  215).  It  may  be  produced  by  the  pressure 
of  bandages  or  strips  of  plaster  when  the  fragments  have  been  brought  to- 
gether. Crepitus  is  detected  if  the  upper  fragment  can  be  pushed  down  until 
it  touches  the  lower  piece;  but  if  swelling  is  great,  or  if  fibrous  tissue  is  inter- 
posed between  the  bones,  crepitus  cannot  be  elicited.  It  is  useless  to  seek 
for  it,  as  the  diagnosis  is  obvious  without  this  sign.  The  anterior  fibro- 
periosteal  layer  is  torn,  and  the  tear  does  not  correspond  exactly  with  the 

*Stimson's  "Treati.se  on  Fractures  and  Dislocations." 


458 


Diseases  and  Injuries  of  Bones  and  Joints 


line  of  fracture.  x-\  portion  of  this  torn  fibroperiosteal  layer  may,  as  Macewen 
pointed  out,  drop  between  the  fragments  and  prevent  union  (Fig.  216).  The 
lateral  expansions  of  the  capsule  are  usually  extensively  torn.  If  union  occurs 

after  a  transverse  fracture  it  will  probably 
be  ligamentous,  and  if  the  patient  gets  about 
too  soon,  even  apparently  well-united  frag- 
ments will  by  degrees  stretch  far  asunder. 

Treatment  of  Transverse  Fractures 
of  the  Patella. — If  in  transverse  fracture  of 
the  patella  the  swelling  is  so  great  as  to  pre- 
\'ent  approximation  of  the  fragments,  reduce 
it  by  bandaging  for  a  day  or  two,  by  using 
ice-bags,  or  by  aspirating  the  joint.  As  a 
rule,  the  blood  does  not  coagulate  for  several 
days.  After  it  coagulates  it  cannot  be  with- 
drawn by  aspiration,  but  only  by  incision. 
When  the  swelling  diminishes,  bring  the  two 
fragments  into  apposition,  pull  them  together 
by  adhesive  plaster,  and  put  on  a  well -padded 
posterior  splint.  Carry  a  piece  of  adhesive 
plaster  over  the  upper  end  of  the  upper  frag- 
ment, draw  the  bone  down  and  fasten  the 
plaster  behind  and  below  the  joint.  Carry 
another  piece  of  plaster  over  the  lower  end  of  the  lower  fragment,  draw  the 
bone  up,  and  fasten  the  plaster  behind  and  above  the  joint.  Carry  a  third 
piece  over  the  junction  of  the  fragments  to  prevent  tilting.  Agnew's  splint 
admirably  accomplishes  this  approximation  (PI.  6,  Figs.  11,12).  A  bandage 
holds  the  splint  in  place,  and  may  be  carried  around  the  knee  by  figure-of- 
eight  turns.  The  heel  is  sometimes  raised  upon  a  pillow  so  as  to  extend  the 
leg  and  to  semiflex  the  thigh,  but  this  is  not  essential.  Remove  and  reapply  the 
dressing  every  few  days,  as  it  inevitably  becomes  loose.     At  the  end  of  three 


Fig.  216. — Transverse  fracture  of 
the  patella  ;  fractured  surface  partially 
covered  by  irregular  flaps  of  torn  apo- 
neurosis (Hoffa). 


Fig.  217. — Needle  specially  designed  to  carry  a  thick  wire.    The  eye  is  drilled  obliquely,  and  should 
receive  only  a  little  loop  on  the  end  of  the  wire  ;  this  loop  should  be  made  previously. 

weeks  remove  the  .sphnt  permanently  and  apply  a  plaster-of-Paris  dressing 
from  just  above  the  ankle  to  the  middle  of  the  thigh,  and  get  the  patient  about 
on  crutches.  The  dressing  is  to  be  worn  for  five  weeks.  After  eight  weeks 
of  treatment  allow  the  patient  to  walk  with  canes,  the  joint  being  kept  fixed 
for  four  weeks  more  by  pa.steboard  splints  or  by  a  light  plaster-of-Paris 
bandage.  For  one  year  after  removing  the  splints  and  plaster  a  lacing  knee- 
cap of  leather  should  be  worn  in  the  daytime  to  su[)port  the  joint.  The  plan 
(^f  |;rolonged  immobilization  renders  more  or  less  joint -stiffness  a  certain 
occurrence,  but  this  is  less  of  an  impediment  than  the  wide  .separation  of  the 
fragments  that  inevitably  attends  an  early  use  of  the  joint.  Bryant,  of  New 
York,  has  devised  an  ambulatory  dressing. 


Treatment  of  Transverse  Fractures  of  the  Patella 


459 


Fig.  218. — Needle  (a)  introduced  behind  the  fragments,  and 
receiving  one  end  (d)  of  the  silver  wire  {6,  c)  (Barker). 


Malgaigne's  hooks  are  practically  obsolete. 

It  is  said  that  John  Rhea  Barton  wired  an  ununited  fracture  of  the  patella 
in  1843.  In  1877  Hector  Cam- 
eron wired  an  ununited  frac- 
ture of  the  patella,  and  a  few 
months  later  Lord.  Lister  oper- 
ated on  a  fracture  of  the  knee- 
cap two  weeks  after  the  acci- 
dent. The  question  of  the 
advisability  of  suturing  a 
recent  fracture  is  very  much 
disputed.  The  ordinary  non- 
operative  plans  of  treatment 
do  not  endanger  life  and  gen- 
erally give  a  good  functional 
result.  The  operative  method 
will  usually  succeed,  and  is 
capable  of  obtaining  a  better 
functional  result  and  of  ob- 
taining it  more  rapidly.  There 
is  some  danger  of  infection, 
and  if  infection  should  occur 
the  results  will  be  most  dis- 
astrous. Some  cases  obviously 
cannot  be  treated  by  the  or- 
dinary method  with  any  chance  of  success;  cases,  for  instance,  in  which  a 

flap  of  fibroperiosteum  intervenes  be- 
tween the  fragments,  or  cases  in  which 
from  some  other  cause  the  bones  cannot 
be  appro .ximated.  Such  cases  should, 
of  course,  be  operated  upon.  But  in 
the  great  majority  of  cases  a  good 
result  will  follow  conservative  treat- 
ment, and  conservative  treatment 
should  be  trusted  to  unless  the  case  is 
in  the  hands  of  a  surgeon  and  in  a 
place  where  every  antiseptic  precaution 
can  be  taken.  We  agree  with  Stimson 
when  he  says  that  operative  methods 
can  be  used  with  confidence  when  sur- 
rounded with  every  protection;  he 
habitually  uses  them,  but  he  ne\'er 
teaches  them  as  proper  routine  prac- 
tice, and  strongly  advises  against  their 
use  except  by  those  who  have  had  ex- 
perience  in  operating,  who  have  formed 
the  habit  of  taking  precautions,  and 
who  have  the  aid  of  skilled  assistants.* 
*  Annals  of  Stngery,  Aug.,  1898. 


Fig.  219. — Needle  (a)  passed  in  front  of  the 
fragments  and  receiving  the  other  end  {c)  of 
the  silver  wire  (/>.  c)  (Barker). 


460 


Diseases  and  Injuries  of  Bones  and   Joints 


Operation  should  only  be  perforiyied  on  healthy  persons  of  suitable  age, 
when  the  separation  is  over  one-half  an  inch  or  when  there  is  much  laceration 
of  the  capsule.*  Barker  believes  strongly  in  wiring  recent  transverse  fractures. 
He  does  it  with  antiseptic  care  soon  after  the  accident,  and  permits  passive 
motion  or  even  slight  active  motion  immediately  after  the  operation.  Massage 
is  begun  the  day  after  the  operation,  and  is  practised  daily  for  two  weeks. 

Barker  t  uses  a  special  needle  (Fig.  217)  and  silver  wire  of  the  thickness  of  a 
No.  I  English  catheter.  This  wire  is  straightened  and  softened  in  a  spirit- 
flame.  He  rubs  the  fragments  together  in  order  to  dislodge  blood  or  fibrous 
material,  and  when  marked  grating  occurs  introduces  the  wire.  A  punc- 
ture with  a  small  knife  is  made  through  the  middle  of  the  upper  attachment  of 
the  patellar  ligament.     The  needle,  not  carrying  any  wire,  is  made  to  enter 

through  this  opening  into  the 
joint,  is  passed  back  of  the  frag- 
ments, pierces  the  tendon  of  the 
quadriceps  at  the  upper  edge 
of  the  upper  fragment,  and  its 
point  is  cut  upon  with  a  knife. 
The  wire  is  inserted  into  the 
eye  of  the  needle  and  the  needle 
is  withdrawn  and  unthreaded. 
The  empty  needle  is  pushed 
through  the  lower  opening,  is 
carried  in  front  of  the  joint,  is 
made  to  emerge  at  the  upper 
opening,  is  threaded  again  and 
withdrawn  (Figs.  218,  219). 
The  wires  are  threaded  into 
bars  and  twisted  (Fig.  220). 
There  are  objections  to  Barker's 
operation:  It  does  not  allow  us 
to  remove  blood-clots  from  the 
joint;  if  a  bit  of  tissue  intervenes 
between  the  fragments,  it  cannot 
be  removed;  and  a  foreign  body  is  left  permanently  in  the  joint. J  If 
an  operation  is  thought  advisable,  we  deem  it  best  to  do  an  open  oper- 
ation, making  a  central  incision,  freeing  the  joint  from  blood-clots  by 
irrigation  with  hot  salt  solution,  removing  all  tissue  from  between 
the  fragments,  drilHng  the  fragments,  passing  silver  wire,  twisting  the 
wire  and  drawing  the  fragments  together,  and  closing  the  wound 
(Fig.  221).  Instead  of  wire,  silk  may  be  used.  In  cases  in  which  there  is  no 
very  strong  tendency  to  separation  the  fragments  can  be  held  together  by  several 
catgut  .sutures  through  the  periosteum  at  the  fractured  edges  or  by  a  strong  cat- 
gut suture  passefl  through  the  ligamentum  patellar  and  the  quadriceps  tendon 
and  carried  in  front  of  the  fracture  (Stimson).    The  limb  should  be  placed  on  a 

*  Powers,  in  Annals  of  Surgery,  July,  i8g8. 

t  See  the  objections  of  Sir  "William  Stokes  to   Barker's  method,   in  Brit.    Med.    Jour.; 
Dec.  3,  1898. 

I  Brit.  Med.  Jour.,  April  il,  1896. 


Fig.  220. — Wire  in  position  round  fragments  and 
threaded  through  metal  bars.  The  lower  and  posterior 
wire  runs  upward  to  the  left  of  the  upper,  ready  for 
twisting  (Barlter). 


Fractures  of  the  Patella  by  Direct  Force 


461 


posterior  splint.  In  seven  or  eight  days  the  superficial  sutures  are  removed  and 
a  plaster-of-Paris  splint  is  appHed.  In  a  few  days  the  patient  gets  about  on 
crutches.  In  a  month  the  dressing  is  cut  down  the  front  and  worn  only  in  the 
daytime,  and  passive  motion  is  begun.  The  sphnt  is  discarded  at  the  end  of 
the  third  month.*  Among  other  operative  procedures  we  may  mention  the 
following:  Encircling  the  fragments  with  a  silk  suture  (the  circumferential 
suture).     This  suture  may  impair  bone  nutrition  and  retard  union.     Ceci  drills 


221. — Wired  fracture  of  the  patella  (St.  Joseph's  Hospital  case  ;  operated  upon  aiul  sUiagraplied 

by  Dr.  Nassau;. 


the  bones  subcutaneously  and  passes  wire  through  the  drill-holes  in  the  form  of 
a  figure-of-eight.  Passing  subcutaneously  a  ligature  around  and  over  the 
fragments  (Butcher).  Incision  and  appro.ximation  of  the  fragments  by  fixa- 
tion-hooks or  metal  {)ins. 

Fractures  of  the  patella  by  direct  force  are  vertical,  stellate,  oblique,  or 
V-shaped,  are  often  incom])lete  and  occasionally  compound  or  comminuted. 

Symptoms. — Fractures  of  the  patella  Ijy  direct  force  are  followed  b\'  dis- 
coloration, sweUing,  great  difficulty  in  movement,  and  much  pain.     There  may 

Stimson,  Annals  of  Surgery,  Aug.,  1898. 


462  Diseases  and  Injuries  of  Bones  and  Joints 

or  may  not  be  crepitus.  The  degree  of  separation  of  the  fragments  depends 
upon  the  direction  of  the  line  of  fracture,  and  the  extent  of  bone  involved. 
Bony  union  is  apt  to  occur  after  such  a  fracture. 

Treatment. — A  fracture  resulting  from  direct  force  may  often  be  treated  with 
a  posterior  splint  and  the  application  of  a  bandage.  If  there  is  any  separation, 
the  fragments  should  be  appro.ximated  by  adhesive  strips,  bandages,  and  com- 
presses. At  the  end  of  three  weeks  remove  the  posterior  splint,  apply  a  plaster- 
of-Paris  .splint,  and  get  the  patient  about  on  crutches.  The  danger  in  these 
cases  is  ankylosis  rather  than  non-union;  hence,  in  the  fourth  week,  cut  the 
plaster  sphnt  down  the  front  and  begin  passive  motion  of  the  knee-joint.  At 
the  end  of  six  weeks  cease  wearing  the  dressing  in  the  daytime,  and  at  the  end 
of  three  months  discard  it  entirely.  In  those  rather  unusual  cases,  in  which  an 
oblique  fracture  with  wide  separation  arises  from  direct  force,  treat  as  advised 
for  transverse  fracture  from  muscular  action.  The  question  of  operation  is 
practically  the  same  as  for  transverse  fracture  from  muscular  action.  In  every 
compound  fracture  of  the  patella,  if  amputation  can  be  avoided,  incise,  irrigate 
the  joint  with  hot  saline  fluid,  suture  the  fragments,  and  drain  for  twenty-four 
to  forty-eight  hours. 

Ununited  and  Badly  United  Fracture  of  the  Patella, — There  is  usually 
a  band  of  union,  but  it  may  be  very  thin  and  the  fragments  may  be  far  asun- 
der. It  is  commonly  taught  that  the  degree  of  functional  impairment  depends 
directly  on  the  amount  of  separation.  This  is  not  strictly  true.  There  may 
be  great  separation,  and  but  little  impairment  of  function,  the  fragments 
being  firmly  united  with  a  dense  fibrous  band.  There  may  be  httle  separation 
and  yet  lameness,  stiffness  of  the  joint,  and  imperfect  power  of  extension. 
The  reason  of  this  has  been  pointed  out  by  Bruns,  of  Tubingen. *  He  says 
there  may  be  complete  failure  of  union,  even  when  the  separation  is  trivial,  and 
failure  of  union  produces  impaired  function.  If  separation  is  considerable,  the 
fragments  are  apt  to  tilt  and  tissue  is  often  interposed  between  them.  Func- 
tional difficulty  is  more  often  met  with  when  the  fragments  are  far  apart  than 
when  they  are  near  together,  because  non-union  is  more  common.  Even  if 
non-union  occurs,  in  some  cases  the  quadriceps  is  still  able  to  act  upon  the  tibia 
by  means  of  the  fascia  lata,  ligaments  at  the  sides  of  the  joint,  or  bands  from 
the  vasti  to  the  lower  fragment.  Besides  non-union,  functional  impairment 
may  be  due  to  anchoring  of  the  upper  fragment  to  the  femur.  The  upper  frag- 
ment is  anchored  to  the  femur  Vjy  the  interposition  of  the  fibrous  investment  of 
the  knee-cap,  which  covers  the  fractured  surface  of  the  upper  fragment  and 
grows  fast  to  the  capsule  of  the  joint  (Bruns). 

The  treatment  of  ununited  and  badly  united  fracture  is  discussed  on  page 
396. 

Fractures  of  the  Leg. — In  leg-fractures  both  bones  or  only  one  bone  may 
be  broken. 

Fractures  of  the  tibia  are  divided  into  (i)  fractures  of  the  u])per  end;  (2) 
separation  of  the  ujjper  epiphysis;  (3)  fractures  of  the  shaft;  (4)  fractures  of  the 
lower  end ;  and  (5)  separation  of  the  lower  epiphysis. 

Fractures  of  the  upper  end  of  the  tibia  are  uncommon.  They  may  be 
transverse,  oblique,  or  vertical,  running  into  the  joint.  The  cause  is  direct 
violence. 

*  "  IVitrage  zur  klinischen  Chirurgie,"  "  Millheilimgen  aus  der  chiriirg.  Klinik  zu 
Tiibingen,"   \M.  iii,   Heft  2,   l8X8. 


Fractures  of  the  Shaft  of  the  Tibia  463 

Symptoms. — In  fracture  of  the  upper  end  of  the  tibia  there  is  contusion  of 
the  soft  parts.  In  a  transverse  fracture  there  are  mobihty  and  crepitus,  but 
there  is  httle  displacement.  In  oblique  fracture  crepitus  and  mobihty  are 
marked,  the  axis  of  the  h'mb  is  ahered,  and  the  fragment  may  be  displaced. 
In  fractures  entering  the  joint  there  is  great  swelling  of  the  knee-joint.  In 
comminuted  fractures,  which  exhibit  marked  signs,  union  is  readily  obtained, 
but  if  the  joint  has  been  damaged  stiffness  is  sure  to  ensue. 

Treatment. — Reduce  displacement  by  extension  and  manipulation.  The 
special  apparatus  used  depends  on  the  case.  In  some  cases  extension  is  re- 
quired, in  some  a  posterior  sphnt  is  applied  and  the  limb  is  suspended  from  a 
gallows,  in  some  a  double  inclined  plane  is  employed,  and  in  some  a  plaster-of- 
Paris  sphnt  is  used. 

The  double  inclined  plane  in  the  form  of  Mclntyre's  splint  is  frequently 
employed,  or  a  double  inclined  plane  in  the  form  of  a  fracture-box  may  be 
preferred.  The  extremity  should  be  immobilized  for  four  weeks,  when  passive 
motion  should  be  begun.  Passive  motion  is  to  be  made  daily,  the  dressing 
being  reapplied  after  each  seance.  In  five  or  six  weeks  the  dressings  are  re- 
moved and  the  patient  allowed  to  go  about  on  crutches.  The  crutches  are 
soon  abandoned  for  a  cane,  and  later  all  support  is  dispensed  with.  If  a 
fracture  extends  into  the  knee-joint  and  the  ill-adjusted  fragments  block  the 
articulation,  the  joint  should  be  opened  and  the  fragments  placed  in  proper 
position. 

Separation  of  the  tubercle  of  the  tibia  is  due  to  violent  contraction  of  the 
quadriceps,  and  occurs  only  in  those  under  twenty  years  of  age.  The  frag- 
ment is  drawn  up  and  can  be  felt,  and  the  patient  is  unable  to  use  the  limb. 
In  a  case  in  which  the  tibial  spine  has  been  torn  off,  the  limb  should  be  placed  on 
a  posterior  straight  splint  and  the  fragment  should  be  pulled  down  into  place 
by  adhesive  strips  and  bandages.  The  splint  should  be  worn  for  five  weeks. 
■  Separation  of  the  Upper  Epiphysis  of  the  Tibia. — This  is  an  injury 
of  extreme  rarity.  It  does  not  seem  to  occur  after  the  sixteenth  year.  It 
is  caused  by  a  twist  or  by  violent  abduction  or  adduction  of  the  leg.  It  may 
lead  to  lessened  growth  of  the  limb.  The  treatment  is  as  for  a  fracture  of 
the  upper  end. 

Fractures  of  the  Shaft  of  the  Tibia. — The  causes  of  these  fractures 
are  direct  force,  indirect  force,  or  torsion.  A  fracture  in  the  upper  part  of  the 
bone  is  usually  transverse;  in  the  lower  part  it  is  usuallv  oblique  (Pickering 
Pick). 

Symptoms. — In  transverse  fracture  of  the  shaft  of  the  tibia  there  is  no 
deformity,  and  the  support  of  the  fibula  may  even  permit  of  walking;  there 
is  fixed  pain;  there  may  or  may  not  be  inequality  of  the  fragments  felt  by 
the  finger;  and  there  are  crepitus,  mobility,  and  often  linear  ecchymosis. 
In  oblique  fractures  there  usually  exist  crepitus,  a  little  mobility,  and  distinct 
deformity.  The  deformity  depends  on  the  direction  of  the  line  of  fracture, 
and,  as  this  line  is  usually  from  above  downward,  inward,  and  a  little  forward, 
the  lower  fragment  usually  passes  behind  the  upper  fragment  and  rotates 
inward. 

Treatment. — In  treating  fractures  of  the  shaft  of  the  tibia,  effect  reduction 
by  making  extension  from  the  foot  and  counter-extension  from  the  knee,  the 
knee-joint  being  in  partial  flexion.     If  there  is  much  swelling,  ])ut  the  limb 


464 


Diseases  and  Injuries  of  Bones  and  Joints 


Fig.  222. — Fracture-box  in   fractures   of  the  bones 
of  the  leg. 


in  a  fracture-box  (PI.  6,  Fig.  i ;  Fig.  222),  swing  the  box  from  a  gallows,  and 
apply  an  ice-bag  for  a  day  or  two.     A  silicate  of  sodium  or  a  plaster-of-Paris 

dressing  is  applied  when  the  swell- 
ing subsides,  or  the  dressing  is  used 
at  once  if  sweUing  is  slight.  As 
soon  as  the  limb  is  immobilized  in 
a  silicate  or  plaster  dressing  the 
patient  gets  about  on  crutches. 
The  dressing  is  removed  after  live 
weeks,  and  the  patient  goes  about 
for  one  week  on  crutches,  lightly 
using  the  foot,  and  then  for  a  time 
with  a  cane.  At  the  end  of  eight 
or  nine  weeks  the  cane  may  often 
be  dispensed  with,  the  amount  of 
use  of  the  leg  being  daily  augmented. 
Fractures  of  the  Lower  End 
of  the  Tibia :  Fracture  of  the  Inner  Malleolus. — The  cause  of  fracture 
of  the  inner  malleolus  is  direct  force  or  traction  upon  the  internal  lateral 
Ugament. 

Symptoms  and  Treatment. — The  symptoms  of  fracture  of  the  inner  malleolus 
are  some  downward  displacement,  depression  above  the  ends  of  the  fragments, 
mobility,  and  crepitus.  The  treatment  is  to  push  the  fragments  into  place 
and  use  side-splints  or  a  fracture-box  for  two  weeks,  when  a  plaster-of-Paris 
or  a  silicate  dressing  may  be  substituted  and  the  patient  be  ordered  to  use 
crutches.  Remove  the  plaster  four  or  five  weeks  after  it  is  applied,  and  direct 
the  patient  to  gradually  bear  his  weight  u])on  the  leg,  as  outlined  above. 

Separation  of  the  lower  epiphysis  of  the  tibia  is  a  rare  accident,  but 
is  commoner  than  separation  of  the  upper  epiphysis.  The  treatment  is  a 
fixed  dressing  for  six  weeks. 

Fracture  of  the  fibula  alone  is  commoner  by  far  than  is  fracture  of 
the  tibia  alone.  Fractures  in  the  upper  two-thirds,  which  are  rare,  are 
usually  due  to  direct  force.  Fractures  in  the  lower  third  are  frequent,  and 
arise  from  indirect  force. 

Fractures  of  the  Upper  Two-thirds  of  the  Fibula. — In  these  fractures 
the  cause  is  direct  force. 

Symptoms. — In  fracture  of  the  upper  two-thirds  of  the  fibula  the  patient 
is  frequently  able  to  walk.  The  bone  is  deeply  situated,  and  displacement 
cannot  often  be  detected.  There  is  a  fixed  pain,  which  is  intensified  by 
movement  and  by  pressure.  Pressure  upon  the  lower  fragment  does  not 
move  the  upper  fragment.  Crepitus  is  sometimes  obtained,  and  a  linear 
ecchymosis  is  apt  to  appear.  The  bone  is  normally  elastic,  hence  slight 
mobility  is  of    no  valu.e  diagnostically. 

Treatment. — In  treating  a  fracture  of  the  up[)er  two-thirds  of  the  iibula 
apply  a  plaster-of-Paris  or  a  silicate  bandage  and  direct  that  it  be  worn  for 
five  weeks.  Weight  is  not  to  be  put  upon  the  foot  for  six  weeks  after  the 
accirlent. 

Fractures  of  the  Lower  Third  of  the  Fibula.— In  these  fractures  the 
cause  is  indirect  force,  especially  twists  of  the  fool.     Forcible  inversion  of 


Pott's  Fracture 


465 


the  foot  pulls  upon  the  external  lateral  ligament  and  the  external  malleolus, 
forces  the  fibula  outward,  and  tends  to  break  it,  the  lower  fragment  being 
displaced  outward.  Forcible  eversion  pulls  the  internal  lateral  ligament  off 
from  the  inner  malleolus  (often  breaks  the  malleolus)  and  fractures  the 
fibula  above  the  ankle,  the  bone  being  displaced  inward. 

Pott's  Fracture. — By  the  term  Pott's  fracture  is  meant  a  fracture  of 
the  lower  fifth  of  the  fibula  produced  by  eversion  and  abduction  of  the  foot. 
Stimson  points  out  that  the  production  of  Pott's  fracture  is  often  aided  by 
the  weight  of  the  body.  The  lesions  which 
arise  depend  upon  whether  the  chief  force  i> 
eversion  or  abduction.  "If  eversion  is  the 
sole,  or  main,  movement,  the  force  is  exerted 
through  the  internal  lateral  ligament  and 
breaks  the  internal  malleolus  squarely  off  at 
its  base;  then  it  presses  the  external  malleolus 
outward,  rupturing  the  tibiofibular  ligament, 
and  breaks  the  fibula  close  above  the  malle- 
olus. Sometimes  instead  of  pure  rupture  of 
the  tibiofibular  ligament  there  is  avulsion  of 
the  portion  of  the  tibia  to  which  it  is  at- 
tached."* Stimson  further  points  out  that  if 
abduction  is  the  preponderating  force  there  is 
an  oblique  fracture  of  the  anterior  portion  of 
the  internal  malleolus  or  more  frequently  rup- 
ture of  the  anterior  portion  of  the  internal 
lateral  ligament.  There  is,  as  in  the  former 
case,  rupture  of  the  tibiofibular  Hgament  and 
an  oblique  fracture  of  the  fibula  several  inches 
above  the  external  malleolus.  It  is  evident 
that  the  degree  of  injury  produced  by  eversion 
and  abduction  depends  on  the  time  at  which 
the  force  is  arrested.  It  may  be  arrested  after 
the  inner  malleolus  has  been  separated  or  the 
anterior  fibers  of  the  deltoid  ligament  torn, 
and  in  this  case  the  tibiofibular  articulation 
remains  intact  and  the  fibula  is  not  broken. 
It  may  cease  after  separating  the  tibiofibular 
articulation,  and  in  this  case  too  the  fibula 
escapes.  It  may  be  continued  until  the  fibula 
breaks.  In  this  fracture  the  astragalus  passes 
outward,  somewhat  backward  and  also  up- 
ward, the  later  deviation  being  due  to  separation  of  the  tibiofibular  articulation. 

Symptoms. — The  foot  is  displaced  outward,  and  a  little  backward  and 
upward,  and  the  inner  malleolus  or  the  tibia  from  which  it  was  torn,  is  ex- 
tremely prominent.  There  is  great  lateral  mobility  and  often  anteroposterior 
mobility  at  the  ankle-joint.  Stimson  points  out  that  there  are  three  points 
where  pressure  is  certain  to  provoke  pain :  in  front  of  the  tibiofibular  ligament, 


Fig.  223. — Pott's  fracture.  Dupuy- 
treii's  splint.  Note  length  of  splint; 
position  of  straps ;  arrangement  of 
padding ;  space  between  foot  and 
splint  (Scudder). 


■A  Practical  Treatise  on  Fractures  and  Dislocations,"  bv  Lewis  A.  Stimson. 


466      '  Diseases  and  Injuries  of  Bones  and   Joints 

at  the  base  or  anterior  border  of  the  inner  malleokis,  and  over  the  seat  of 
fracture  through  the  fibula. 

Treatment. — Thorough  reduction  is  of  the  greatest  importance.  If 
thorough  reduction  is  effected,  a  good  result  will  probably  be  obtained;  but 
if  thorough  reduction  is  not  effected  ^  the  patient  will  be  permanently  crippled 
to  a  greater  or  less  extent.  In  order  to  effect  reduction  it  may  be  necessary 
to  anesthetize  the  patient.  The  deformity  is  corrected  "by  pressing  the 
calcaneum  forward  and  inward;  the  hand  is  placed  against  the  back  and 
outer  side  of  the  heel  and  pressed  forward  and  then  forcibly  inward.  "* 

Some  surgeons,  at  once  after  reduction,  apply  a  plaster-of-Paris  bandage. 
This  treatment  is  objectionable  because  the  deformity  may  be  partially 
reproduced  after  the  application  of  the  dressing,  the  surgeon  being  unable 
to  see  it,  and  unable  to  correct  it. 

If  there  seems  to  be  no  strong  tendency  to  a  recurrence  of  deformity,  a  frac- 
ture-bo.x  can  be  used.  After  reducing  displacement  in  such  a  case,  place  the 
limb  in  a  fracture-box  containing  a  soft  pillow.  A  bird's-nest  pad  of  cotton  or 
oakum  is  made  for  the  heel  (Fig.  222).  A  fillet  around  the  ankle  fastens  the 
foot  to  the  foot-piece  of  the  box;  a  pad  of  oakum  rests  between  the  foot-piece 
and  the  sole.  A  compress  is  placed  below  the  outer  malleolus  and  another  one 
above  the  inner  malleolus.  Close  the  sides  of  the  box  and  tie  them  together 
with  a  bandage,  and  swing  the  box  on  a  gallows.  Every  day  let  down  the  sides 
of  the  box  and  rub  the  leg,  the  ankle,  and  the  foot  with  alcohol.  In  ten  days 
apply  a  plaster-of-Paris  bandage  and  let  the  patient  get  about  on  crutches. 
Remove  the  plaster  at  the  end  of  the  fifth  week  after  the  accident,  and 
let  the  patient  go  about  with  crutches  for  one  week  and  with  a  cane  for  a  week 
longer. 

I  am  accustomed  to  dress  most  cases  of  Pott's  fracture  with  a  Dupuytren 
splint.  This  is  a  straight  spHnt  (PI.  6,  Fig.  9,  and  Fig.  223)  which  reaches 
from  the  head  of  the  tibia  to  below  the  sole  of  the  foot.  This  splint  is  padded, 
and  a  pyramidal  pad  with  the  base  down  is  laid  upon  the  inner  surface  of 
the  leg,  above  the  inner  malleolus,  the  splint  being  put  upon  the  inner  sur- 
face of  the  leg,  over  the  pad.  The  splint  is  fastened  as  shown  in  Plate  6, 
Fig.  9  (and  Fig.  223).  If  the  short  spHnt  shown  in  Plate  6  is  used,  the 
leg  is  semiflexed  upon  the  thigh  and  is  laid  upon  its  outer  surface  on  a  pillow. 
After  ten  days  apply  the  plaster-of-Paris  bandage,  which  is  to  be  worn  as 
above  directed.  Bryant  treats  Pott's  fracture  with  a  posterior  splint,  two 
lateral  splints,  and  a  swing.  Stimson  uses  a  posterior  and  lateral  splint 
of  plaster-of-Paris.  This  splint  does  not  slip,  as  may  Dupuytren's  dressing, 
and  does  not  hide  the  seat  of  fracture  from  view  as  does  complete  encasement 
with  pla.ster-of-Paris.  It  is  a  most  useful  dressing.  The  fracture  may  be 
compound,  a  yjortion  of  the  inner  malleolus  or  of  the  tibia  projecting  through 
the  wound.  If  it  is  necessary  to  introduce  through  and  through  drainage, 
the  foot  must  be  placed  and  kept  at  a  right  angle  to  the  leg.  If  a  com- 
pound fracture  exists,  it  may  be  possible  to  wire  the  malleolus  in  place. 
In  a  reported  case  the  wire  was  passed  through  the  joint  and  around 
the  fragment,  and  the  result  was  good.f  It  would  be  better  in  most  cases 
to  nail  the  fragment  in  place. 

*Stimson's  "  Practical  Treatise  on  Fractures  and  L'islocations  " 
t  Kev.  de  Chir.,  vol.  viii,  1888. 


Fracture  of  both  Bones  of  the  Leg  467 

Fracture  of  both  bones  of  the  leg  is  a  very  common  injury,  is  often 
compound,  and  is  not  unusually  comminuted.  Fractures  by  direct  force, 
such  as  blows  or  kicks,  are  commonest  in  the  upper  half  of  the  leg.  Fractures 
by  indirect  force,  as  by  falls,  are  commonest  in  the  lower  half  of  the  leg. 
In  fractures  from  indirect  force  the  tibia  breaks  first,  and  then  the  fibula 
breaks  at  a  higher  level.  The  point  of  greatest  liabihty  to  fracture  from 
indirect  force  is  the  junction  of  the  lower  and  middle  thirds.  Fractures 
of  the  leg  are  usually  oblique,  but  they  may  be  transverse  if  arising  from 
direct. force.  Spiral,  torsion,  or  V-shaped  fractures  and  longitudinal  breaks 
sometimes  occur.  In  oblique  fractures,  as  a  rule,  the  line  of  fracture  runs 
from  behind,  downward,  inward,  and  a  little  forward. 

Symptoms. — Fracture  of  both  bones  of  the  leg  is  easy  of  recognition. 
The  fibular  fracture  is  detected  as  before  described.  By  running  the  finger 
along  the  crest  of  the  tibia  displacement  will  be  found,  except  in  transverse 
fractures,  when  it  may  not  occur.  The  common  displacement  is  for  the 
lower  fragment  to  ascend  and  pass  behind  the  lower  end  of  the  upper  frag- 
ment and  to  rotate  a  little  outward,  and  for  the  upper  fragment  to  project 
in  front.  The  ascent  of  the  lower  fragment  is  due  to  the  action  of  the  gas- 
trocnemius and  soleus  muscles.  If  the  line  of  fracture  is  in  a  direction  the 
reverse  of  that  which  is  usual,  the  lower  fragment  ascends  in  front  of  the 
lower  end  of  the  upper  fragment.  In  fracture  of  both  bones  of  the  leg  there 
are  marked  mobility  and  crepitus,  severe  pain,  and  inability  to  walk.  In 
fractures  from  direct  force  there  is  more  or  less  damage  to  the  soft  parts. 
A  fracture  of  the  shaft  of  the  tibia  near  the  ankle  is  distinguished  from  a 
dislocation  by  the  fact  that  the  deformity  is  easily  reduced,  but  tends  to 
recur  in  the  fracture,  and,  further,  that  in  a  fracture  the  relations  of  the 
malleoli  to  the  tarsus  are  unaltered,  whereas  in  a  dislocation  they  are  altered. 

Treatment. — If  the  fracture  is  near  the  ankle-joint,  the  action  of  the 
tendo  Achillis  may  maintain  deformity,  and  in  such  cases  the  tendon  must 
be  divided.  In  treating  a  simple  fracture  of  the  lower  two-thirds  of  the 
bones  reduce  by  extension  and  counter-extension,  and  use  a  fracture-box 
(PI.  6,  Fig.  i)  as  in  Pott's  fracture  (Fig.  222),  though  the  compresses  are 
not  required.  If  the  soft  parts  are  bruised,  use  an  ice-bag  for  a  day  or  two; 
if  they  are  abraded,  apply  antiseptic  dressings.  The  fracture-box  should  be 
swung  upon  a  gallows.  After  three  weeks  apply  a  plaster-of-Paris  or  silicate 
of  sodium  dressing  and  let  the  patient  sit  up  in  a  chair  daily  for  one  week; 
at  the  end  of  this  time  the  patient  may  get  about  with  crutches.  At  the  end 
of  six  weeks  after  the  accident  remove  the  plaster,  and  let  the  sufterer  get 
about  on  crutches  for  two  weeks  and  with  a  cane  for  two  weeks  more.  Brinton 
dresses  a  fracture  of  both  bones  of  the  leg  for  two  weeks  in  a  fracture-box, 
for  two  weeks  in  side-splints  made  of  metal,  and  for  two  weeks  in  an  immova- 
ble dressing,  allowing  the  patient  to  get  about  on  crutches  as  soon  as  the 
plaster  is  put  on.  Instead  of  the  fracture-box,  we  may  use  a  posterior  splint, 
two  lateral  splints,  and  a  swing.  Nathan  R.  Smith's  anterior  splint  is  used 
by  some  in  the  treatment  of  fractures  of  the  leg.  Many  surgeons  apply 
plaster-of-Paris  in  the  form  of  an  ambulatory  dressing.  In  this  dressing  a 
solid  apparatus  reaches  to  the  lower  third  of  the  thigh  and  below  the  sole 
of  the  foot.  When  the  patient  walks  the  weight  is  transmitted  to  the  thigh 
(Fig.  227).     In  fractures  of  the  upper  third  of  the  leg  the  Mclntyre  splint 


468  Diseases  and  Injuries  of  Bones  and  Joints 

or  the  double  inclined  plane  is  used.  If  the  fracture  is  compound,  asepticize 
thoroughly,  make  a  counter-opening,  insert  a  drainage-tube,  dress  with 
bichlorid  gauze,  apply  a  plaster  bandage,  and  cut  trap-doors  over  the  openings 
of  the  tube  (see  Fig.  161),  or  dress  with  the  bracketed  splint  and  plaster- 
of-Paris  (Fig.  162).  Remove  the  tube,  as  a  rule,  in  about  forty-eight  hours; 
but  the  patient's  temperature  is  a  better  guide  than  time. 

Fractures  of  the  bones  of  the  foot  are  rather  rare  accidents.  Owing 
to  the  number  of  the  bones  and  to  the  elasticity  of  their  connections,  the 
force  of  blows  and  falls  is  spread  and  dissipated.  Fractures  from  direct 
force  are  often  compound.  The  cause  of  fracture  of  either  the  scaphoid, 
the  cuboid,  or  one  of  the  cuneiform  bones  is  direct  force.  Fractures  of  the 
OS  calcis  and  astragalus  arise,  as  a  rule,  from  indirect  force,  such  as  falls, 
but  the  calcaneum  may  be  broken  by  direct  violence.  In  rare  instances  the 
OS  calcis  has  been  broken  by  contraction  of  the  great  calf-muscles. 

Svmptoms. — In  fracture  of  the  os  calcis  there  are  severe  pain,  swelhng, 
crepitus,  mobihty,  often  an  apparent  widening  of  the  bone,  and  not  unusually 
a  loss  of  the  arch  of  the  foot  (Pick).  In  some  cases  the  posterior  fragment 
is  drawn  up  by  the  calf-muscles,  and  in  other  cases  there  is  deformity.  In 
fracture  of  the  astragalus  displacement  may  occur  which  resembles  that  of 
a  dislocation.  Crepitus  may  or  may  not  be  detected.  It  can  be  ehcited, 
as  a  rule,  by  rotating  the  foot  while  the  heel  is  firmly  held.  If  crepitus  cannot 
be  detected,  it  is  not  certain  that  a  fracture  is  present,  though  the  patient 
may  be  unable  to  stand  and  there  may  be  sweUing  and  pain  on  pressure. 
The  x-rays  will  make  the  diagnosis  certain.  Fractures  of  the  other  bones 
are  difficult  of  detection.  There  may  or  may  not  be  crepitus,  which,  if  it 
exists,  is  hard  to  locahze;  there  is  pain  on  standing  and  on  pressure,  and  there 
is  bruising  of  the  soft  parts. 

Treatment.— To  treat  a  fracture  of  the  os  calcis  when  no  deformity  exists, 
use  a  fracture-box  for  two  weeks,  maintaining  the  foot  at  a  right  angle  to 
the  leg;  then  put  on  an  immovable  dressing,  and  let  it  be  worn  for  four 
weeks.  In  fracture  of  the  os  calcis  with  drawing  up  of  the  posterior  fragment 
flex  the  leg  upon  the  thigh,  extend  the  foot,  and  maintain  this  position  by 
means  of  a  band  around  the  thigh,  the  band  being  fastened  by  means  of 
a  cord  to  a  slipper  (PI.  7,  Fig.  5),  the  leg  resting  upon  its  outer  side.  At 
the  end  of  two  weeks  apply  plaster-of-Paris,  and  let  it  be  worn  for  four  weeks. 
Many  cases  require  incision  and  naihng  or  wiring  of  the  fragments  together. 
If  the  projecting  fragment  of  the  os  calcis  cannot  be  forced  into  place,  and 
if  it  makes  dangerous  pressure  upon  the  skin,  excise  it;  if  it  does  not  make 
pressure  which  threatens  sloughing,  place  the  joint  in  a  position  favorable 
for  ankylosis,  and  immobilize.  In  a  fracture  of  the  astragalus  use  a  fracture- 
box  and  then  an  immovable  dressing,  as  in  fracture  of  the  os  calcis  without 
deformity.  Fractures  of  the  other  bones  of  the  tarsus  are  almost  invariably 
compound,  and  the  injury  may  require  drainage  and  immovable  dressing, 
excision  of  bones,  or  even  amputation. 

Fractures  of  the  metatarsal  bones  are  almost  invariably  due  to  direct 
force  and  are  almost  always  compound.  Robert  Jones  has  published  skia- 
graphs of  a  fracture  of  the  fifth  metatarsal  bone  from  indirect  force.  Crepitus 
may  be  absent  because  of  impaction  or  fixation  by  interosseous  ligaments. 
Jones  says  such  a  fracture  may  be  produced  by  the  pressure  of  the  body- 


Synovitis  469 

weight  on  an  inverted  foot  the  heel  of  which  is  raised  ("  Annals  of  Sur- 
gery,"  June,  1902).  When  only  one  bone  is  broken,  displacement  is 
slight,  there  is  severe  pain  on  motion  and  pressure,  and  crepitus  can 
generally  be  obtained.  Pain  is  produced  by  flexing  the  toes,  putting 
weight  upon  the  toes,  as  in  walking,  and  by  inverting  or  everting  the  foot. 
A  simple  fracture  of  a  metatarsal  bone  is  treated  by  an  immovable  dress- 
ing for  four  weeks.  Fractures  from  crushes  usually  demand  excision  or 
amputation. 

Fractures  of  the  phalanges  of  the  toes  are  due  to  direct  force  and 
are  often  compound.     They  may  require  immediate  amputation. 

Treatment. — In  a  compound  fracture  where  amputation  is  unneces.sarv, 
drain  with  strands  of  catgut  for  forty-eight  hours  and  dress  antiseptically ; 
at  the  end  of  this  time  apply  over  the  bichlorid  gauze  a  gutta-percha  or  a 
pasteboard  spHnt  extending  from  beyond  the  end  of  the  toe  to  well  up  upon 
the  sole  of  the  foot,  and  fix  the  sphnt  in  place  with  a  spiral  bandage  of  the 
toe  and  instep.  The  splint  is  to  be  worn  for  four  weeks.  In  a  simple  fracture 
fasten  the  injured  toe  to  an  adjacent  toe  or  toes  by  a  plaster  bandage  and 
wear  the  dressing  for  three  weeks. 

3.  Diseases  of  the  Joints. 

Synovitis  is  a  primary  inflammation  of  the  synovial  membrane  alone. 
If  other  structures  besides  the  synovial  membrane  are  involved,  the  con- 
dition is  known  as  "  arthritis. "  Two  forms  of  simple  synovitis  exist — namely, 
acute  and  chronic.     Some  surgeons  speak  also  of  subacute  cases. 

Acute  Simple  Synovitis. — The  causes  of  acute  simple  synovitis  are  con- 
tusions, sprains,  twists,  and  overuse.  The  causative  influence  of  exposure 
to  cold  or  damp  has  been  much  debated.  It  seems  probable  that  in  some 
cases  cold  produces  vasomotor  paresis  of  the  vessels  of  the  synovial  mem- 
brane, a  condition  which  may  be  followed  by  inflammation.  In  synovitis 
the  synovial  membrane  is  red  and  swollen,  and  the  joint  contains  an  excess 
of  turbid  fibrinous  fluid.  If  the  inflammation  advances,  arthritis  arises  and 
sometimes  blood  is  eff'used. 

Symptoms. — A  prominent  symptom  of  acute  synovitis  is  pain,  which  is  in- 
creased by  motion  of  the  joint,  by  pressure  upon  the  articulation,  and  by  a 
dependent  position  of  the  limb,  and  which  is  worse  at  night.  Pressure  upon 
the  cartilage  does  not  cause  pain,  but  friction  of  the  synovial  membrane  at 
once  develops  it.  The  patient  places  the  limb  in  the  position  which  gives 
the  greatest  ease,  and  in  this  position  the  part  becomes  more  or  less  fixed 
as  the  muscles  about  the  joint  are  rigid.  A  fluctuating  swelling  is  noted  in 
a  superficial  joint,  most  marked  between  the  ligaments,  which  swelling  bulges 
out  the  synovial  area  and  hides  or  obscures  the  articular  heads  of  the  bones. 
The  swelling  is  due  early  to  extensive  .secretion  of  synovia,  and  later  to  effusion 
of  liquor  sanguinis.  Bulging  takes  place  at  points  where  the  capsule  is  thin, 
and  at  such  points  fluctuation  may  be  detected.  Fluctuation  in  the  elbow 
is  sought  for  posteriorly.  Fluctuation  in  the  knee  is  sought  for  on  either 
side  in  front.  A  large  effusion  in  the  knee  floats  the  patella  up  from  tlie 
condyles.  A  small  effusion  in  the  knee  can  be  detected  by  Fiske's  plan, 
which  is  as  follows:  Tell  the  patient  to  bend  forward  at  the  hips,   resting 


4/0  Diseases  and  Injuries  of  Bones  and  Joints 

each  hand  on  the  front  of  the  corresponding  thigh.  The  anterior  structures 
of  the  joint  are  relaxed,  and,  by  tapping  the  patella,  even  a  small  effusion 
can  be  discovered.  Bulging  cannot  be  distinctly  observed  in  the  hip  or 
shoulder,  unless  effusion  is  great.  The  skin  over  the  joint  is  rarely  reddened, 
but  feels  hot  to  the  hand  of  the  observer  (over  superficial  joints,  but  not 
over  the  shoulder  and  hip);  the  joint  is  partly  flexed;  fever  exists,  varying 
in  degree  with  the  size  of  the  joint,  the  acuteness  of  the  attack,  and  the  nature 
of  the  cause.  Suppuration  rarely  follows  simple  synovitis,  but  it  may  do  so, 
the  area  of  synovitis  being  a  point  of  least  resistance  to  organisms  carried  by 
the  blood  or  lymph.  If  suppuration  takes  place  rigors  occur,  there  is  a  septic 
temperature,  and  the  joint  soon  gives  evidences  of  containing  pus.  These 
e\idences  are  violent  pain,  increased  tenderness,  dusky  discoloration  if  the 
joint  be  superficial,  greater  muscular  spasm,  periarticular  edema,  and  con- 
stitutional symptoms  of  sepsis.  Traumatic  synovitis  without  infection  tends 
toward  cure  without  suppuration  if  the  patient  is  healthy,  and  after  it  anky- 
losis is  rare. 

Treatment. — In  treating  acute  synovitis  immobilize  the  joint.  In  severe 
cases  place  it  in  such  a  position  that  the  limb  will  still  be  useful  even  if  anky- 
losis occurs.  In  mild  cases  immobilize  in  the  position  of  rest,  applv  leeches, 
and  use  the  ice-bag  or  the  Leiter  coil.  After  a  day  or  two  apply  gentle  pres- 
sure, intermittent  heat,  and  iodin  and  ichthyol.  If  the  eft'usion  is  very  great 
and  persistent,  and  pressure,  heat,  and  sorbefacients  fail  to  remove  it,  aspirate 
with  antiseptic  care.  If  effusion  recurs  after  respiration,  apply  a  plaster-of- 
Paris  dressing  or  use  flying  blisters  and  massage.  A  rubber  bandage  is  often 
useful  toward  the  termination  of  a  case. 

Chronic  Synovitis. — Chronic  synovitis  follows  acute  synovitis  or  it  may 
be  chronic  from  the  start.  Many  cases  called  chronic  synovitis  are  in  truth 
tuberculous  disease.  The  synovial  membrane  looks  nearly  natural,  but  is 
edematous,  and  the  joint  contains  an  excess  of  fluid.  If  the  quantity  of  fluid 
is  large,  the  disease  is  called  "hydrops  articuli,"  or  '"dropsy."  A  large 
amount  of  fluid  in  the  knee-joint  "floats"  the  patella  upward.  Tuberculous 
infection  is  apt  to  occur  in  very  prolonged  cases.  In  prolonged  chronic 
synovitis  the  synovial  membrane  thickens  in  some  places,  softens  in  others, 
is  often  adherent,  and  the  villous  processes  hypertrophy.  If  the  membrane 
becomes  extensively  softened  (pulpy  degeneration),  the  softened  areas  bulge 
and  caseation  eventually  occurs.  In  the  knee-joint  a  traumatic  synovitis  is 
sometimes  linked  with  inflammation  oj  the  semilunar  cartilages.  Roux  tells 
us  that  this  inflammation  may  be  produced  by  a  squeeze,  a  twist,  or  a  direct 
force,  but  a  squeeze  is  the  common  cause.  Hyperextension  of  the  knee  may 
squeeze  the  cartilage,  and  so  may  attempting  to  rise  from  a  stooping  posture.* 
If  this  injury  has  taken  place,  the  disability  will  be  prolonged. 

Symptoms. — In  chronic  synovitis  pain  is  absent  or  is  only  present  during 
exercise  or  from  pressure,  and  is  slight  even  then;  there  is  some  limitation 
of  movement;  passive  motion  may  develop  creaking  or  joint-crepitus;  fluc- 
tuation is  apparent;  there  is  atrophy  in  the  muscles  about  the  joint;  and  the 
hypodermatic  needle  will  draw  out  a  viscid,  straw-colored  or  bloody  fluid. 

Treatment. — For  hydrops  use  rest  and  pressure.  Pressure  may  he  ob- 
tained by  the  application  of  Martin's  rubber  bandage.  A  plaster-of-Paris 
*Gaz.  des  Hop.,  No.  125,  1895. 


Chronic  Synovitis 


471 


dressing  is  probably  the  best  way  to  combine  rest  and  compression.  Mas- 
sage, douches,  frictions,  passive  movements,  and  flying  blisters  should  be 
used.  Painting  the  joint  with  iodin  and  spreading  over  it  blue  ointment, 
and  rubbing  in  ointment  of  ichthyol  (50  per  cent,  with  lanolin)  may  do  good. 
Counter-irritation  by  the  actual  cautery  is  a  valuable  expedient.  Chronic 
synovitis  is  often  greatly  benefited  by  the  use  of  a  hot-air  apparatus.  The 
limb  is  wrapped  in  flannel  and  is  placed  in  an  oven.  The  oven  is  heated 
by  Bunsen  burners.  The  temperature  is  raised  to  about  300°  F.,  and  the 
limb  is  subjected  to  this  for  one  hour.  The  oven  should  be  used  daily,  and 
as  the  patient  becomes  accustomed  to  it  even  a  higher  degree  of  heat  can  be 
tolerated.     This  high  degree  of  heat  can  be  borne  only  when  it  is  perfectly 


Fig.  224. — Sprague  hot  dry -air  apparatus. 


dry.  Any  moisture  scalds  the  patient.  The  Lentz  oven  has  in  it  ventilation 
openings  to  get  rid  of  moisture  and  the  sweat  is  taken  up  by  the  flannel.  This 
flannel  must  not  be  applied  so  thickly  as  to  keep  the  heat  notably  from  the 
joint  nor  must  so  little  of  it  be  used  as  to  permit  of  its  soaking  with  sweat. 
Fig.  224  shows  the  Sprague  hot  dry-air  apparatus,  and  Fig.  225  exhibits  a 
cross-section  of  the  same  apparatus.  Dr.  H.  A.  Wilson  inserts  in  the  oven 
humidin,  a  product  obtained  in  the  purification  of  salt,  which  material  entirely 
absorbs  the  moisture.  Cotton  should  not  be  used  to  wrap  the  limb,  because,  if 
the  bottom  of  the  oven  becomes  red-hot,  the  cotton  may  ignite  and  burn  the 
patient.  A  physician  or  nurse  should  constantly  watch  the  apparatus  during 
its  employment.*  Aspiration  and  the  subsequent  use  of  a  plaster-of-Paris 
*  H.  A    W  il.sciii,  ill  .Annals  of  Surgerv,  Feb.,   1S99 


4/ 


Diseases  and  Injuries  of  Bones  and  Joints 


bandage  may  be  tried  in  some  cases.  Some  surgeons  advise  aspiration, 
washing  out  with  salt  solution,  injecting  a  5  per  cent,  solution  of  carbohc 
acid,  and  immobilizing.  Incision  and  drainage  constitute  a  radical  but 
proper  plan,  in  cases  unamended  by  simpler  methods.  If  pulpy  degenera- 
tion exists,  perform  an  excision  or  an  erasion.  If  pus  forms,  incise  at 
once  and  drain.  Internally,  treat  any  existing  diathesis  and  give  nutritious 
food,  tonics,  and  stimulants. 

Arthritis. — By  this  term  is  meant  not  only  inflammation  of  a  synovial 
membrane,  but  also  of  other  structures  composing  and  surrounding  a  joint. 
It  mav  follow  a  traumatic  synovitis;  it  may  be  due  to  pus  organisms,  to  tubercle 
bacilli,  to  infectious  diseases  (gonorrhea  and  typhoid  fever),  to  rheumatism, 

to  gout,  to  syphilis,  and  to  lesions 
of  the  spinal  cord.  Arthritis  may 
be  either  acute  or  chronic. 

Tuberculous  Arthritis  (White 
Swelling;  Strumous  Joint;  Pulpy 
Degeneration). — Pathology  and 
Symptoms. — T  h  e  predisposing 
causes  of  tuberculous  arthritis 
may  be  strains,  blows,  twists,  or 
cold.  The  real  cause  is  the  bacil- 
lus of  tubercle.  A  single  joint 
is  attacked.  Other  joints  may 
subsequently  become  involved  so 
that  several  suffer  simultaneously, 
but  it  is  rare  that  the  process  is 
active  in  more  than  one  joint  at 
the  same  time.  During  the  course 
of  tuberculous  disease  of  a  joint 
phthisis  is  not  common,  although 
it  not  unusually  develops  after 
the  joint  is  well.  The  same  is 
true  of  tuberculous  glands.  Dur- 
ing the  existence  of  phthisis  or 
tuberculous  glands  tuberculous 
arthritis  does  not  frequently  arise. 
The  primary  infection  with  tu- 
bercle bacilli  is  usually  in  the 
bone,  though  it  may  be  in  the  synovial  membrane,  the  joint-capsule, 
or  the  structures  about  the  joint.  If  the  primary  infective  focus  is 
in  the  bone,  and  it  usually  is,  a  portion  of  the  cartilage  is  destroyed  and 
the  joint  is  (opened,  or  a  sinus  forms  and  perforates  the  synovial  mem- 
brane. When  tuberculous  inflammation  attacks  the  synovial  membrane 
granulation-tissue  is  formed,  and  the  capsule  and  [)eriarticular  structures 
soon  become  involved  in  the  process;  the  parts  thicken  and  .soften  from 
caseation,  and  they  may  be  covered  with  tubercles,  though  but  little  fluid  is 
usually  effused  into  the  joint.  Some  few  cases  yiresent  large  joint-effusions, 
but  in  most  cases  fluctuation  is  absent  and  capsular  thickening  is  not  mani- 
fest.    Soon  after  tuberculous  arthritis  begins  the  joint  becomes  rigid,  irrita- 


Fi^:.  225. — Cross-section  of  Sprague  hot  dry-air 
apparatus  :  a,  a.  Air  intakes  ;  b,  circulating  air  space  ; 
H,  jacketed  space  for  products  of  combustion  ;  g,  treat- 
ment chamber  ;  m,  m,  cork  ribs  ;  n,  n,  perforations  ad- 
mitting heated  air;  o,  base  holding  apparatus;  p,  p. 
gas-burners. 


Arthritis  473 

tion  having  induced  muscular  spasm.  This  reflex  rigidity  fixes  the  joint 
more  or  less  completely,  and  atrophy  of  the  rigid  muscles  soon  begins.  There 
is  usually  pain  in  tuberculous  arthritis,  but  it  may  be  referred  to  a  distant 
part.  For  instance,  in  hip-joint  disease  the  pain  is  often  referred  to  the  inner 
side  of  the  knee,  and  in  Pott's  disease  of  the  spine  the  pain  may  be  referred 
to  the  abdomen.  Attempts  at  motion  demonstrate  the  limitation  of  move- 
ment due  to  muscular  rigidity  and  also  produce  pain.  A  child  that  suffers 
from  a  tuberculous  joint  is  apt  to  be  restless  in  sleep,  moaning  and  tossing, 
and  to  wake  at  times  crying  out  in  terror  (night-cries  and  night-terrors). 
In  the  ordinary  form  of  arthritis  there  occurs  what  is  known  as  "  gelatiniform 
degeneration";  the  granulation  tissue  is  formed  in  large  amount  as  fungous 
growths;  the  structures  are  markedly  edematous  and  softened;  the  relaxed 
ligaments  yield  under  pressure;  the  natural  contour  of  the  joint  is  lost,  and 
it  becomes  spindle-shaped;  all  the  structures,  articular  and  periarticular, 
are  glued  into  one  mass;  the  skin  about  the  joint  is  white,  thick,  and  ad- 
herent, and  in  it  one  or  more  large  veins  are  seen;  fluctuation  or  pseudo- 
fluctuation  is  noted  when  caseation  has  occurred;  pain  is  not  often  severe, 
but  it  can  usually  be  elicited  by  certain  motions  or  by  firm  pressure,  but  the 
pain  will  always  be  severe  when  the  epiphysis  is  involved;  the  temperature 
of  the  part  is  somewhat  elevated;  deformity  results  from  destruction  of  bone, 
cartilage,  and  ligament,  from  muscular  spasms,  and  from  the  habitual  assump- 
tion of  certain  attitudes  to  secure  relief  from  pain.  There  is  soon  impair- 
ment of  joint-motions.  When  the  products  of  a  tuberculous  arthritis  caseate, 
the  thick  liquid  seeks  exit  by  forming  sinuses  from  which  caseous  pus  flows. 
If  a  sinus  becomes  infected  with  pyogenic  cocci,  and  the  joint  itself  becomes 
their  prey,  acute  suppuration  arises  in  the  joint,  and  constitutional  involve- 
ment is  pronounced  and  perilous  to  life. 

In  pannous  synovitis  a  large  effusion  is  formed,  there  is  but  little  granu- 
lation tissue,  though  the  tubercles  are  present  in  large  numbers,  and  the 
ligaments  and  structures  about  the  joint  are  slightly  or  not  at  all  implicated. 

A  non-tuberculous  chronic  synovitis  produces  great  swelling  and  distinct 
thickening  of  the  capsule  with  obhteration  of  the  outlines  of  the  joint,  but 
there  are  no  spasm,  no  atrophy,  no  limitation  of  motion,  no  severe  pain,  and 
no  tendency  to  subluxation  (Shaffer).  A  tuberculous  arthritis  rarely  causes 
distinct  fluctuation,  does  not  thicken  the  capsule,  causes  reflex  muscular 
spasm,  rigidity  of  the  joint,  muscular  atrophy,  severe  pain  on  movement,  and 
eventually  subluxation  (Shaft"er).  In  syphilitic  arthritis  there  is  usually 
some  fluctuation,  distinct  enlargement  of  the  joint,  hmitation  of  motion,  no 
reflex  spasm,  trivial  atrophy,  but  distinct  pain  on  motion  (James  K.  Young, 
"Therapeutic  Gazette,"  June  15,  1902).  Acute  rheumatism  attacks  more 
than  one  joint,  is  very  rare  in  childhood,  and  produces  high  fever.  The 
.T-rays  aid  in  the  diagnosis  of  tuberculous  arthritis  and  enable  us  to  tell  the 
extent  of  bone-involvement. 

Diagnosis  and  Prognosis. — The  diagnosis  in  a  tuberculous  joint  is  often 
difficult,  and  sometimes  impossible,  and  the  prognosis  is  always  grave.  In 
only  a  very  few  cases,  even  when  recognized  early,  is  a  cure  obtained  without 
some  impairment  of  joint-function.  The  best  that  can  usually  be  accom- 
plished is  a  cure  with  more  or  less  ankvlosis,  fibrous  or  bony;  and  often 
ankylosis  is  complete.     Long  after  the  disease  is  apparently  cured,  it  may 


474  Diseases  and  Injuries  of  Bones  and  Joints 

break  forth  anew.  Tuberculous  lesions  may  arise  in  a  distant  organ,  or 
general  tuberculosis  may  occur.  Caseation  is  apt  to  produce  severe  con- 
stitutional disorder.  Infection  by  pus  organisms  gives  rise  to  grave  danger 
of  septicemia.  Death  is  not  unusual  from  exhaustion,  from  septicemia, 
from  disseminated  tuberculosis,  from  tubercle  in  an  important  organ,  or  from 
amyloid  disease. 

Treatment. — Constitutionally,  the  treatment  is  directed  against  the  tuber- 
culous diathesis.  The  patient  should  be  placed  under  good  hygienic  con- 
ditions. A  change  of  climate  is  often  of  the  greatest  importance.  Many 
cases  do  well  at  the  seaside;  others  require  high  altitudes.  Locally,  rest  is  of 
the  first  importance,  and  it  is  maintained  for  many  weeks.  Rest  is  best 
secured  by  traction,  and  traction  is  applied  or  maintained  by  splints,  by 
plaster-of-Paris  bandages,  or  by  extension  appliances.  The  hot-air  apparatus 
may  be  of  some  benefit.  If  it  is  employed  it  should  be  used  daily,  the  Hmb 
being  immobilized  during  the  remainder  of  the  twenty-four  hours.  Bier's 
plan  of  inducing  congestive  hyperemia  may  do  good  (page  185).  Aspiration 
can  be  used  for  fluid  accumulations.  Caseous  masses  are  often  let  alone, 
or  an  aspirator  is  used  and  the  joint  drained,  washed  out  with  saline  solution, 
and  injected  with  an  emulsion  of  iodoform  and  glycerin  (10  per  cent.).  From 
I  to  2  drams  are  injected  into  the  joint  of  a  child,  from  2  to  5  drams  into  the 
joint  of  an  adult  (see  page  27).  This  treatment  is  moie  serviceable  in  tuber- 
culosis of  the  small  joints  than  in  disease  of  the  large  articulations.  Injec- 
tions of  balsam  of  Peru  or  of  iodoform  emulsion  about  the  joint  once  a  week 
are  efficient  in  some  cases.  If  these  means  fail,  if  the  patient  gets  worse,  or 
if  the  condition  of  the  sufferer  renders  dangerous  the  prolonged  conservative 
course,  operate,  removing  the  entire  diseased  area  by  erasion,  by  excision, 
or  by  amputation.  Always  remember  that  an  incomplete  operation  or  a 
partial  removal,  unless  it  consists  of  simple  drainage,  is  worse  than  no  opera- 
tion, as  it  opens  the  portals  to  systemic  infection,  and  may  be  responsible 
for  the  development  of  general  tuberculosis,  septicemia,  or  pyemia. 

Tuberculosis  of  Special  Joints.— Tuberculosis  of  the  Sacro- 
iliac Joint  (Sacro-iliac  Disease). — This  is  an  uncommon  affection,  and  is 
especially  rare  before  the  age  of  fifteen.  The  disease  may  begin  in  the  joint, 
may  arise  in  adjacent  bones,  or  may  result  from  a  cold  abscess  burrowing 
into  the  joint.  In  some  cases  it  is  associated  with  extensive  disease  of  the 
pelvic  bones.  The  disease,  if  undetected,  may  lead  to  dissemination  of 
tubercle,  to  abscess,  or  even  to  death. 

Symptoms  are  often  obscure.  The  disease  is  frecjuently  confounded  with 
vertebral  caries,  hip-joint  disea.se,  or  sciatica.  The  patient  limps  on  walking, 
but  can  stand  on  either  leg;  there  is  pain  in  the  sacro-iliac  joint,  about  the 
hip,  and  down  the  thigh;  tenderness  is  manifest  on  pressure  over  the  joint 
and  on  pushing  the  ilia  together;  there  is  fulness  over  the  sacro-iliac  joint; 
but  the  hip  is  not  flexed  unless  iliac  abscess  exists.* 

Treatment. — Rest  in  bed  for  months,  using  also  a  felt  ca.se  for  the  pelvis. 
Counter-irritation  by  blisters  and  the  actual  cautery.  In  .some  cases  injection 
of  iodoform;  in  others,  incision  and  curetting.  I  have  operated  on  six  cases, 
with  one  death.  In  one  case  in  the  Jeffer.son  Medical  College  Hosj)ital  the 
abscess  was  pointing  in  both  the  back  and  loin.     Bcjth  areas  were  incised, 

*See  A.  G.  Miller,  Edirjlnirgh  Med.  Jour.,  May,  1895. 


Tuberculosis  of  the  Hip-jiiint 


475 


the  diseased  bone  was  removed  and  the  boy  uhimately  recovered  (Fig.  226). 
In  another  case  the  abscess  pointed  in  the  loin.  The  treatment  was  as 
previously  set  forth,  and  the  patient,  a  woman,  recovered. 

Tuberculosis  of  the  Hip-joint  (Hip  Disease;  Morbus  Coxarius;  Morbus 
Coxie;  Coxitis;  Hip- joint  Disease). — The  primary  lesion  may  be  in  the 
synovial  membrane,  but  it  is  more  often  in  the  bone.  It  may  begin  in  the 
acetabulum;  it  may  begin  in  the  femur.  If  it  begins  in  the  femur,  it  usually 
arises  on  "the  distal  side  of  the  epiphyseal  cartilage"  (Senn).  Sometimes 
I)rimary  tuberculosis  arises  in  the  trochanter  major,  and  never  involves 
the  joint.  When  the  synovial  membrane  becomes  involved  at  any  point, 
spreading  throughout  the  joint  is  rapid.  In  many  cases  the  articular  carti- 
lages are  attacked,  and  in  some  cases  the  epiphyseal  cartilage  is  destroyed. 
It  is  commonest  in  children,  but  it  may  arise  in  adults  and  even  occasionally 
in  those  of  advanced  years;  62  per  cent,  of  cases  arise  in  children  under  ten 


Fig:  226. — Sacro-iliac  disease;  operated  upon  and  cured. 


years  of  age  and  So  per  cent,  of  cases  occur  before  the  twentieth  year 
(Bryant).  Traumatism  and  cold  may  be  predisposing  causes.  The  disease 
strongly  tends  to  caseation  and  the  formation  of  sequestra. 

Symptoms. — It  has  been  usual  to  divide  the  disease  into  three  stages:  (i) 
the  stage  of  microbic  deposition  and  multiplication,  the  products  of  the 
bacilli  causing  irritation  and  new  growth;  (2)  the  stage  of  progression,  with 
formation  of  masses  of  granulation  tissue  and  efltusion  into  the  joint;  and  (3) 
the  stage  of  caseation,  with  destruction  of  the  joint  and  often  of  the  structures 
about  it.  Bradford  and  Lovett  *  protest  against  this.  They  say:  "It  has 
been  customary  to  divide  hip-disease  into  stages,  and  to  ascribe  to  these 
stages  certain  definite  svmptoms.  Neither  from  a  clinical  nor  a  pathological 
point  of  view  is  it  desirable  to  attempt  such  a  division."  As  H.  Augustus 
Wil.son  says:  "Tuberculous  bone  and  joint  disease  should  be  considered  as 

*  *'  Ortliopedic  Surgery." 


4/6  Diseases  and  Injuries  of  Bones  and  Joints 

the  primary  invasion  or  incipiency,  and  all  other  symptoms  should  be  re- 
garded as  results  and  not  as  an  integral  and  necessary  part  of  the  trouble." 

The  symptoms  of  incipient  coxalgia  are  slight  and  may  be  overlooked 
entirelv.  In  a  child  there  are  night-terrors;  on  getting  about  in  the  morning 
the  child  shows  no  lameness,  but  a  limp  develops  during  the  day,  and  the  httle 
one  soon  grows  tired  while  playing  and  lies  down  to  rest.  There  is  a  slight 
limp;  some  adductor  spasm  is  noted,  and  pain  may  be  complained  of  at  night 
in  the  hip,  in  the  front  of  the  thigh,  or  at  the  inside  of  the  knee.  Tapping  the 
sole  of  the  foot,  the  thigh  and  leg  being  extended,  may  develop  pain,  just  as 
it  will  develop  pain  in  any  inflammatory  involvement  of  the  joint.  But  the 
employment  of  this  method  is  objectionable.  It  may  injure  a  joint  already 
damaged  by  the  tuberculous  process,  and  it  gives  no  information  which 
cannot  be  obtained  by  a  safer  mode  of  investigation.  After  all,  pain  on 
tapping  the  sole  of  the  foot  means  only  what  muscular  rigidity  means,  and 
muscular  rigidity  is  always  present  and  is  easily  demonstrable  by  careful  man- 
ipulation.    The  diagnosis  in  this  stage  is  more  or  less  problematical. 

As  the  disease  progresses  more  positive  symptoms  are  observed.  The 
hmp  grows  worse;  the  adductor  muscles  are  rigid;  the  hip  is  broadened  by  an 
effusion  into  the  joint,  and  fluctuation  may  possibly  be  detected;  the  thigh- 
muscles  are  atrophied;  the  extremity  is  pushed  forward,  abducted,  and  everted 
(the  patient  tilts  the  pelvis  so  as  to  rest  his  weight  on  the  sound  hmb).  In 
some  few  cases  adduction  exists  rather  than  abduction.  The  abduction,  which 
is  usual,  releases  tension  of  the  fascia  lata,  and  thus  abolishes  pressure  upon 
the  joint  through  lessening  of  pressure  upon  the  great  trochanter  (Alhs). 
The  thigh  is  somewhat  flexed.  This  flexion  relaxes  the  psoas  muscle  and 
prevents  pressure  of  its  tendon  upon  the  front  of  the  joint  (Allis).  Pain 
exists,  often  sudden  or  starting,  and  is  located  in  the  joint,  on  the  front  of 
the  thigh,  and  to  the  inner  side  of  the  knee  in  the  course  of  the  obturator 
nerve;  the  pain  is  aggravated  at  night;  and  full  extension  and  complete  ab- 
duction are  not  possible.  The  gluteal  muscles  waste,  and  the  gluteal  crease 
is  on  a  lower  level  than  is  that  of  the  sound  side.  The  gluteal  crease  may 
be  nearly  or  quite  effaced,  because  of  hypertrophy  of  the  subcutaneous  layer 
(Alexandroff).  Jarring  of  the  heel  when  the  extremity  is  in  extension  causes 
pain  in  the  hip.  The  above  symptoms  arise  chiefly  from  unconscious  efforts 
to  obtain  ease,  from  joint-effusion,  reflex  irritation,  and  involuntary  or  spas- 
modic muscular  contractions.  There  is  an  appearance  of  lengthening,  or 
shortening,  but  it  is  only  apparent,  not  real.  The  real  position  is  shown  on 
Plate  7,  Fig.  4.  The  fluid  effusion  may  be  absorbed  or  may  find  its  way 
externally  by  means  of  sinuses.  The  latter  condition  is  known  as  "abscess 
of  the  hip."  The  absorption  of  the  exudate  or  the  rupture  of  the  capsule 
permits  the  contracting  muscles  to  bring  the  head  of  the  femur  into  firm  con- 
tact with  the  acetabulum  or  its  brim;  the  bones  are  worn  away  and  de- 
stroyed, shortening  re.sults,  abduction  gives  way  to  adduction,  and  flexion  is 
increased,  as  shortening  occurs. 

In  advanced  cases  of  coxalgia  the  head  of  the  femur  passes  upward  and 
outward  upon  the  rim  of  the  acetabulum,  the  thigh  is  flexed  and  fixed,  and 
attempts  at  extension  when  the  i)atient  is  recumbent  cause  the  pelvis  to  tilt 
forward  and  occasion  a  marked  lumbar  curve  (PI.  7,  Fig.  2),  which  is  due 
to  the  pelvis  moving  with  the  femur  as  if  ankylosed,  and  which  disappears  on 


Tuberculosis  of  the  Hip-joint 


477 


flexion.  In  this  condition  adduction  occurs  because  of  the  ascent  and  move- 
ment outward  of  the  head  of  the  bone.  Shortening  is  marked.  After  a  hip- 
abscess  finds  an  external  outlet  pyogenic  infection  is  very  apt  to  take  place 
and  suppuration  arises,  which  is  followed  by  that  state  which  is  designated 
as  "hectic."  If  a  cure  follows  advanced  coxalgia,  partial  or  complete  anky- 
losis takes  place;  if  death  ensues,  it  may  be  due  to  septicemia,  tuberculosis 
of  the  viscera,  exhaustion,  or  amyloid  degeneration. 

Diagnosis  is  very  easy  in  well-established  cases  of  hip  disease,  but  very 
difficult  when  the  disease  is  incipient.  Always  make  a  systematic  and  thor- 
ough examination.  Undress  the  patient  and  place  him  recumbent  with  his 
legs  extended,  upon  a  table  or  a  hard  mattress.  Note  if  the  heels  are  level 
and  if  the  iliac  spines  are  on  the  same  level  (a  depressed  spine  on  the  affected 
side  means  abducted  extremity,  the  degree  of  which  is  determined  by  carrying 
the  limb  out  until  the  spines  are  horizontal;  elevation  of  the  iliac  spine  on  the 
afifected  side  means  adduction,  the  amount  of  which  is  determined  by  adducting 
the  Umb  until  the  spines  are  horizontal;  Fig.  227).     Try  all  the  movements  be- 


Fig.  227. — Positions  in  hip-joint  disease  (after  the  plan  of  Howard  Marsh  and  Treves):  a. — ef, 
lumbar  spine  ;  A  rf,  limb  fixed  in  flexion  and  abduction— useless  for  walking.  B.—  cy.  lumbar  spine. 
Patient  corrects  the  condition  in  Figure  .-^  by  curving  the  lumbar  spine  forward  and  rotating  the 
pelvis  on  its  transverse  axis,  thus  making  the  femur  point  downward.  The  lumbar  spine  is  curved 
laterally,  the  pelvis  ascending  on  the  sound  side  and  descending  on  the  affected  side  (apparent  length- 
ening), c. — b  d,  limb  fixed  in  flexion  and  adduction,  d. — e  f,  curve  of  lutnbar  spine  to  correct  con- 
dition in  Figure  c  (apparent  shortening). 


longing  to  the  joint,  to  detect  any  hmitations;  observe  if  bringing  down  the 
knee  produces  lordosis  (PL  7,  Figs,  i,  2);  look  for  swelling  and  for  muscular 
wasting;  feel  if  the  head  of  the  bone  is  enlarged;  determine  if  motion  pro- 
duces pain  or  if  pressure  develops  tenderness;  and  always  carefully  elicit  the 
history  of  the  attack,  of  the  person,  and  of  the  family. 

Hip  disease  may  be  confounded  with  spinal  caries  in  which  a  psoas  or  a 
lumbar  abscess  has  formed,  with  sacro-iliac  disease,  with  infantile  paralysis, 
with  congenital  dislocation  of  hip,  with  lordosis  from  rickets,  with  gluteal 
abscess,  and  with  bursitis  of  the  gluteal  bursse.  In  hip  disease  there  is 
always  some  lameness;  pain  may  be  severe  or  may  be  absent  entirely,  and 
may  be  in  the  hip  or  be  referred  to  the  front  of  the  thigh  or  the  inner  side  of  the 
knee.  Always  remember  that  the  pain  is  not  characteristic,  and  that  pain  in 
the  same  localities  may  arise  from  aneurysm  of  the  femoral  or  iliac  arteries, 
from  abscess  in  Scarpa's  triangle,  from  caries  of  the  lumbar  vertebras,  from 
sacro-iliac  disease,  and  from  cancer  of  the  rectum.  Altered  position  of  the 
limb,  limitation  of  movement  in  the  hip-joint,  muscular  wasting,  and  swelling 
soon  arise  in  hip-joint  disease. 


4/8  Diseases  and  Injuries  of  Bones  and  Joints 

In  disease  of  the  sacro-iliac  joint  examination  shows  that  the  movements 
of  the  hip-joint  are  unhmited  and  produce  no  pain,  and  that  pain  is  developed 
by  pressure  over  the  sacro-ihac  articulation  and  by  pressing  the  ilia  together. 
In  infantile  paralysis  there  is  no  pain,  but  there  is  paralysis  with  great  muscular 
atrophy,  which  comes  on  with  considerable  rapidity.  In  spinal  caries  with  psoas 
abscess  the  evidences  of  disease  of  the  vertebrae  are  clear  and  a  collection 
of  pus  is  located  in  the  groin  external  to  the  femoral  vessels.  The  tuberculous 
pus  of  hip-abscess  generally  gathers  under  the  tensor  vaginae  femoris  muscle, 
but  it  may  reach  Scarpa's  triangle  by  passing  through  the  cotyloid  notch  or 
through  the  bursa  under  the  psoas  muscle;  it  may  even  appear  under  the  glutei. 
Matter  from  a  caseating  acetabulum  may  reach  the  interior  of  the  pelvis  and 
appear  above  Poupart's  ligament. 

In  gluteal  bursitis  the  symptoms  last  for  many  months,  and  do  not  remit 
as  the  symptoms  of  early  hip  disease  are  apt  to  do.  The  pain  is  but  moderate, 
and  is  aggravated  by  exercise,  but  passes  away  on  going  to  bed,  and  is  felt  back 
of  the  hip  and  back  of  the  knee.  There  are  a  certain  amount  of  limitation  of 
motion  and  a  positive  limp,  which  arises  early.  In  marked  cases  fluctuation 
can  be  detected  in  the  upper  gluteal  region.* 

Prognosis. — If  the  case  of  hip  disease  is  seen  early,  the  chances  of  cure  are 
excellent  in  children,  in  whom  the  disease  may  be  arrested  at  any  stage.  The 
longer  the  duration  of  the  disease  and  the  older  the  subject,  the  more  unfavor- 
able is  the  prognosis.  Many  months  will  be  required  to  elapse  before  a  cure 
can  be  effected,  and  advanced  cases  only  get  well  by  means  of  ankylosis  with 
shortening  and  deformity.  Hip  disease  may  recur  years  after  apparent  cure, 
and  a  person  who  has  hip  disease  runs  a  strong  chance  of  developing  visceral 
tuberculosis. 

Complications. — The  compHcations  that  may  accompany  hip  disease  are  the 
following:  Abscess,  as  above  noted.  Tuberculous  meningitis,  or  the  condition 
known  as"  acute  hydrocephalus  "or  "water  on  the  brain,"  may  arise  during  the 
progress  of  the  case  or  after  apparent  cure,  and  is  apt  to  ensue  upon  incomplete 
operations.  It  is  almost  inevitably  fatal.  Phthisis  pulmonalis  is  a  rare  compli- 
cation, but  is  a  common  sequence,  being  apt  to  arise,  sooner  or  later,  after  the 
hip  disease  is  cured.  Amyloid,  lardaceous,  or  waxy  degeneration  oj  viscera  fol- 
.lows  upon  profuse  and  long-continued  suppurations,  and  is  apt  to  arise  in  the 
liver,  spleen,  kidneys,  or  intestinal  mucous  membrane.  Tuberculosis  is  not  the 
only  cause  of  amyloid  degeneration,  syphilis  being  responsible  for  at  least  30  per 
cent,  of  all  cases.  In  amyloid  disease  of  the  liver  this  organ  is  much  enlarged 
smooth,  painless,  and  of  increased  consistency;  there  is  no  jaundice,  the  spleen 
is  apt  to  be  enlarged,  and  albuminuria  is  the  rule.  In  amyloid  kidney  large 
amounts  of  pale  urine  of  low  specific  gravity  are  voided;  albumin  is  usually 
present  in  large  amount,  but  may  be  absent;  globulin  may  often  be  found,  as 
may  also  hyaline,  fatty,  or  granular  casts;  the  patient  is  anemic,  and  dropsy 
usually  exists.  Test  the  hyaline  casts  with  iodin  for  amyloid  material. 
Amyloid  changes  are  usually  slow  in  onset,  but  they  may  be  rapid;  they  are 
commoner  in  men  than  in  women,  and  are  most  frequently  encountered  in  in- 
dividuals between  the  ages  of  ten  and  thirty.  Slight  amyloid  change  may 
be  recovered  from,  but  an  extensive  degeneration  brings  about  a  fatal  result. 

*  See  E.  G.  lirackett's  iniportant  pa]jer  on  "(iluteal  Jjiirsitis,"  in  tlie  Transactions  of 
the  American  Orthopedic  Association,  vol.  x. 


Tuberculosis  of  the  Hip-joint 


479 


Dickinson's  theory  of  how  this  tissue-change  is  caused  is  that  the  flow  of  pus 
drains  off  from  the  body  the  alkahne  salts,  especially  the  salts  of  potassium, 
which  drainage  results  in  visceral  depositions  of  de-alkalinized  fibrin. 

Treatment. — Antituberculous  treatment  is  used  in  all  cases.  In  incip- 
ient hip  disease  the  treatment  consists  in  rest.  Place  the  patient  upon  a  solid 
mattress  and  apply  extension.  In  children  under  ten  years  of  age,  use  a 
weight  of  from  three  to  five  pounds;  in  individuals  between  ten  and  twenty, 
use  a  weight  of  from  five  to  eight  pounds.  A  long  splint  is  often  applied 
to  the  sound  side  to  keep  the  patient  recumbent  and  horizontal.  Always 
use  a  cradle  to  hold  up  the  bed-clothing.  Apply  the  extension  in  the  long 
axis  of  the  Hmb,  the  extremity  being  placed  in  the  line  of  the  deformity  due  to 
disease  and  being  supported  by  pillows.  In  lordosis  from  thigh-flexion,  raise 
the  limb  until  the  iliac  spine  is  straight  (PI.  7,  Fig.  6).  If  the  spine  is  depressed 
on  the  affected  side,  abduct  the  limb  (PL  7,  Fig.  8);  if  the  spine  is  elevated, 
abduct  the  limb  until  the  spines  are  horizontal  (PI.  7,  Fig.  7).  The  object  of 
extension  is  to  overcome  muscular  spasm  and  so  put  the  part  in  a  condition  of 
physiological  rest.  Muscular  spasm  is  a  great  factor  in  destroying  structures. 
Spasm  presses  the  parts  together,  and  as  a  result  of  pressure  plus  bacterial 
action  destruction  occurs.  The  extension  and  traction  tire  out  the  muscles 
and  cause  spasm  to  cease.  Extension  will  remove  flexion  in  two  weeks  in  a  re- 
cent case  and  in  the  course  of  some  months  in  an  older  case.  As  flexion  is  relieved 
remove  the  pillows  and  lower  the  leg,  but  keep  up  extension  in  the  long  axis 
of  the  thigh.     Abduction  and  adduction  cannot  be  removed  by  extension. 

Abduction  demands  no  special  treatment.  In  a  movable  joint  it  will  dis- 
appear, and  in  an  ankylosed  joint  it  is  an  advantage,  compensating  by  apparent 
lengthening  for  the  shortening  due  to  bone-absorp- 
tion or  to  stunted  growth  of  the  limb.  Adduction 
requires  an  addition  of  several  pounds  to  the  exten- 
sion weight,  the  use  of  a  long  splint  on  the  sound 
limb,  and  the  drawing  up  of  the  sound  side  by  a  rope 
and  pulley  toward  the  head  of  the  bed.  The  weight 
used  to  pull  the  sound  side  toward  the  head  of  the  bed 
is  equal  to  that  used  to  pull  the  damaged  side  to  the 
foot  of  the  bed.  This  expedient  is  used  for  a  month 
or  six  weeks.  In  old  cases  where  the  weight  will  not 
bring  about  extension,  anesthetize  the  patient,  gently 
straighten  the  limb  a  very  httle,  and  reapply  the 
weight. 

Extension  in  a  mild  case  must  be  continued  for 
three  months  after  the  symptoms  have  disappeared, 
and  in  a  severe  case  the  period  must  be  six  months. 
The  weight  is  gradually  taken  off;  if  symptoms  recur, 
the  weight  is  reapplied ;  it  they  do  not  recur,  apply  a 
traction  splint  or  a  plaster  dressing,  put  a  high-heeled 
boot  on  the  sound  limb,  and  send  the  patient  out  on 

crutches.  In  young  children  extension  can  be  made  while  the  child  is  in  a 
wheeled  carriage,  thus  enabling  the  patient  to  go  out  in  the  fresh  air  and  sun- 
light. The  general  treatment  is  tonic  and  restorative.  The  joint  is  so  deeply 
placed  that  external  applications  are  useless.  In  the  treatment  of  hip  dis- 
ease Thomas's  spHnt  (Fig.  2 28)  is  used  by  many,  and  it  may  be  combined 


Fig.22S.- 


-Thomas's  posterior 
splint. 


48o 


Diseases  and  Injuries  of  Bones  and  Joints 


with    weight   extension;    or    Sayre's   splint    (Fig.    229)    may   be    employed. 
Wyeth's  apparatus  (Fig.  230)  is  a  favorite  with  many  American  surgeons. 

If  the  limb  is  in  good  position,  or  has  been  brought  into  good  position,  either 
by  weight  extension  or  straightening  under  ether,  plaster-of-Paris  is  a  useful 
dressing.  It  is  applied  from  the  toes  up,  and  includes  the  entire  extremity  and 
also  the  pelvis.  A  patient  wearing  plaster  may  get  about  on  crutches  when 
the  sole  of  the  foot  of  the  sound  extremity  is  raised  by  the  wearing  of  a 
thick-soled  shoe.  If  a  case,  in  spite  of  treatment,  does  not  improve  or  be- 
comes worse,  use  intra-articular  injections  of  iodoform.  Always  try  these 
injections  before  doing  a  resection.     Sometimes  they  succeed,  and  if  they  do 


P'ig.  229. — Sayre's  long  splint. 


Fig.  230. — W>eUi's  coniliiiiatioii  method. 


resection  is  unnecessary.  Asepticize  the  surface,  carry  a  small  aspirating 
needle  into  the  joint,  irrigate  the  joint  with  salt  solution,  and  inject  a  sterile 
emulsion  of  iodoform  and  glycerin  (10  per  cent.).  In  one  week,  if  reaction 
has  ceased,  repeat  the  injection.  In  another  week  repeat  it  again.  It  may 
be  necessary  to  give  from  ten  to  twenty  injections.  The  proper  spot  for 
puncture  is  thus  determined:  Draw  a  line  from  a  point  half  an  inch  outside 
of  the  middle  of  Poupart's  ligament  to  the  outer  edge  of  the  great  trochanter. 
Puncture  at  the  middle  of  the  outer  half  of  this  line  (De  Vos). 

If  an  absce.ss  forms,  incise  it  with  the  most  thorough  antiseptic  care,  let  the 
fluifj  drain  away,  irrigate  the  cavity  with  salt  solution,  remove  any  .sequestra, 
inject  with  iodoform  emulsion,  sew  up  without  drainage,  and  dress  antiseptic- 
ally.  In  .some  cases  the  sequestrum  is  extra-articular.  In  some  cases  no 
sequestrum  is  found.     If  this  method  fails  drainage  must  be  employed.     The 


HIP-JOINT    DISEASE. 


Plate  7. 


I,  2.  Effects  on  the  Lumbar  Spine  of  Flexing  and  Extending  the  Diseased  Leg  in  Hip  Disease 
(Albert).  3,  4.  Positions  in  Coxalgia  (Albert).  5.  Strap-and-.slipper  Apparatus  for  Fracture  of  Pos- 
terior Portion  of  the  Calcaneum  (after  Hamilton).  6.  Extension  in  Hip  Disease  (Treves).  7.  Exten- 
sion of  the  Limb  in  a  Flexed  and  Adducted  Position  (Treves).  S.  Extension  of  the  Limb  in  a  Flexed 
and  Abducted  Joint  (Treves). 


Knee-joint  Disease 


481 


old  plan  of  not  operating  until  rupture  was  seen  to  be  inevitable  was  bad.  To 
open  early  and  antiseptically  often  means  rapid  healing,  the  prevention  of 
burrowing,  a  lessened  danger  of  visceral  infection,  and  an  earlier  cure.  Hectic 
will  rarely  arise  if  the  abscess  is  opened  with  antiseptic  care. 

Excision  of  the  hip  is  to  be  performed  w^hen  the  head  of  the  femur  is  de- 
tached and  lies  loose  in  the  joint;  when  profuse  suppuration  continues  for  a 
long  time,  and  other  methods  fail  to  arrest  it;  when  amyloid  disease  is  begin- 
ning; or  when  very  faulty  position  is  inevitable  without  operation.  Excision 
is  an  operation  of  considerable  danger,  and  the  older  the  person,  the  greater  the 
danger.  Schede  advocates  arthrectomy  in  some  cases  as  a  substitute  for  re- 
section. Senn  tells  us  that  opinion  as  to  resection  has  greatly  changed  of  late, 
and  it  is  now  taught  that  the  operation  is  advisable  in  all  cases  where  fixa- 
tion, extension,  intra-articular  and  parenchymatous  injections  have  failed  to 
arrest  the  disease  (Senn  on  "Tuberculosis  of  Bones  and  Joints"),  \^'hen 
there  is  extensive  disease  of  the  femur,  when  excision  has  been  tried  and  has 
failed,  or  when  the  patient  has  not  the  recuperative  power  to  withstand  the 
long  siege  of  illness  following  excision,  amputate.*  Amputation  of  the  hip- 
joint  for  tuberculous  disease  is  a  very  successful  procedure. 

Knee-joint  Disease  (White  Swelling). — After  the  hip,  the  knee  is,  of  all 
joints,  the  commonest  site  for  tuberculous  disease.  Knee-joint  disease  can 
begin  as  a  synovitis,  but  oftener  begins  as 
tuberculous  inflammation  of  the  femoral  or 
the  tibial  epiphysis.  Tuberculous  disease 
rarely  attacks  the  bone  on  the  diaphys- 
eal side  of  the  epiphyseal  line;  a  single 
focus  only  exists  as  a  rule,  and  a  seques- 
trum is  rarely  formed.  In  very  rare  in- 
stances the  patella  or  the  semilunar  carti- 
lage is  primarily  attacked.  It  may  begin  at 
any  age,  but  is  most  common  in  children 
and  young  adults.  If  an  acute  synovitis 
ushers  in  the  case,  there  may  be  a  large 
eflfusion  into  the  knee-joint  and  partial 
flexion,  but  sweUing  is  usually  slight  in 
knee-joint  disease.  Pulpy  degeneration  of 
the  synovial  membrane  occurs;  the  joint 
enlarges;  the  ligaments  soften;  the  skin 
becomes  edematous,  and  muscular  spasm 
arises.  The  leg  becomes  flexed ;  the  bones 
displaced  backward  and  outward,  the  foot 

everted;  and  lameness  arises,  due  chiefly  to  deformity.  Pain  may  be  absent, 
is  often  slight,  and  is  rarely  severe.  When  the  disease  begins  in  the  bone  or 
an  epiphysis  there  are  pain,  tenderness,  lameness,  swelling,  inability  to  extend 
the  limb  completely,  sudden  spasmodic  muscular  contractions,  and  final  in- 
volvement of  the  joint.  When  an  abscess  forms,  it  may  destroy  the  joint 
very  rapidly  or  it  may  break  externally. 

Treatment. — In  treating  knee-jt)int  disease  employ  general  antituberculous 
treatment  and  locally  apply  iodoform  ointment  or  guaiacol.     A  useful  plan  is  to 

*  See  the  admirable  article  of  Howard  Marsh  in  Treves's  "  Manual  ot   Surgery."' 
31 


Fig.  231.— Sayre's 
knee  splint  applied. 


Fig.  232.— Hutch- 
inson's knee-joint 
splint. 


482 


Diseases  and  Injuries  of  Bones  and  Joints 


make  a  mixture  of  guaiacol  and  tincture  of  iodin  or  guaiacol  and  olive  oil  (i :  4). 
Once  a  day  the  surface  of  the  knee  is  exposed  by  removing  dressings,  is 
painted  with  this  mixture,  and  the  painted  surface  is  covered  with  cotton-wool. 
Rest  is  of  the  first  importance,  and  may  be  secured  by  the  application  of  splints 
(Figs.  231,  2;^2),  the  use  of  extension  (Fig.  233),  or  the  employment  of  a  plaster- 
of-Paris  bandage.  In  any  case  the  patient  must  be  kept  in  bed  for  a  few  weeks; 
he  may  then  be  permitted  to  go  out  upon  crutches,  wearing  a  high-heeled  shoe 
upon  the  foot  of  the  sound  limb.  In  cases  in  which  treatment  is  begun  early 
the  disease  may  often  be  arrested  in  from  eight  to  twelve  months.  If  the  symp- 
toms do  not  abate  after  a  number  of  weeks,  or  if  the  condition  grows  worse  and 
caseation  occurs,  aspirate,  irrigate,  and  inject  iodoform  emulsion.  Intra-arti- 
cular  injections  are  not  unusually  curative.  Insert  the  needle  in  the  angle  be- 
tween the  outer  edge  of  the  patella  and  the  ligament  of  the  patella  (De  Vos). 
Repeat  the  injection  in  one  week  if  reaction  has  abated,  and  continue  as  di- 
rected for  the  injection  of  the  hip-joint.  If  this  plan  fails,  incise  the  capsule, 
remove  all  fragments  and  tuberculous  foci,  irrigate  with  normal  salt  solution, 
inject  iodoform  emulsion,  and  sew  up  without  drainage  (Neuber's  plan).  A 
more  severe  case  requires  drainage.     If  these  means  fail,  or  if  the  case  is  too 


Fig.  233. — Sayre's  double  extension  of  the  knee-joint 


far  advanced  to  permit  of  their  use,  open  the  joint  and  perform  an  excision 
or  an  erasion  (page  544).  Some  cases  demand  amputation,  which,  if  the  pa- 
tient's health  is  much  impaired,  is  to  be  preferred  to  excision.  Amputation 
is  preferred  to  excision  in  very  young  children  and  aged  people. 

Ankle-joint  disease  may  begin  in  the  synovial  membrane,  in  the  tibial 
epiphysis,  or  in  the  tarsus,  but  the  origin  is  usually  synovial.  The  symptoms 
are  pain,  swelling,  lameness,  limitation  of  joint-movements,  and  atrophy  of  the 
calf-muscles.     Caseation  often  occurs,  and  sinuses  form. 

Treatment. — The  treatment  consists  in  the  employment  of  antituberculous 
remedies,  applications  of  guaiacol  or  iodoform  ointment  over  the  joint,  and 
rest  obtained  by  means  of  splints  or  plaster-of-Paris  bandages.  Caution  the 
patient  to  avoid  standing  upon  the  diseased  extremity.  Injections  of  iodoform 
emulsion  may  do  good.  Insert  the  needle  below  the  outer  malleolus.  When 
caseation  occurs,  it  is  advisable  to  open  the  joint,  wash  out  with  normal  salt 
solution,  inject  iodoform  emulsion,  sew  up  the  incision,  and  put  up  the  ankle- 
joint  in  plaster.  When  joint-disorganization  occurs,  perform  an  excision  or 
an  erasion.  Some  cases  demand  amputation  (Syme's  amputation  being  pre- 
ferred by  some,  amputation  above  the  ankle  being  approved  by  many).  Os- 
teoplastic resection  is  sometimes  advised  (Wladimiroff-MikuHcz  operation). 


Elbow-joint  Disease  483 

Shoulder-joint  disease  is  not  common;  it  is  rare  in  children  and  is  com- 
monest in  adults ;  it  begins  either  in  the  synovial  membrane  or  in  the  head  of  the 
humerus.  The  glenoid  cavity  is  rarely  attacked.  Pain  is  slight,  atrophy  of 
the  deltoid  and  other  muscles  is  noted,  the  joint  is  stiff,  and  the  scapula  follows 
the  motions  of  the  humerus.  Caries  sicca  is  the  usual  cause  of  destruction. 
In  many  cases  swelHng  is  not  obvious,  the  joint  shrinking  because  of  destruc- 
tion of  the  head  of  the  bone  and  contraction  of  the  capsule  (Senn).  Abscess- 
formation  is  unusual.  If  an  abscess  forms,  't  may  open  in  the  axilla,  through 
the  deltoid  muscle,  or  at  some  far  distant  point. 

Treatment. — In  treating  shoulder-joint  disease  employ  antituberculous 
remedies  and  hygienic  measures,  and  apply  to  the  skin  over  the  joint  guaiacol 
or  iodoform  ointment.  Put  on  a  shoulder-cap,  apply  the  second  roller  of 
Desault,  and  hang  the  hand  in  a  shng.  Maintain  rest  for  at  least  four  months. 
Aspiration  and  injection  of  iodoform  emulsion  are  of  great  ser\ice  in  svnovial 
tuberculosis.  The  needle  is  entered  below  the  acromion,  while  the  arm  is 
held  against  the  side  and  the  forearm  is  at  right  angles  to  the  arm  and  across  the 
front  of  the  chest  (De  \'os).  If  caseation  occurs,  open  the  joint,  remove  tuber- 
culous foci,  wash  ^^•ith  hot  saline  fluid,  inject  iodoform  emulsion,  and  close 
without  drainage,  or,  in  a  rather  severe  case,  drain.     In  rare  instances  dead 


Fig.  234. — Stromeyer's  anterior  angular  splint. 

bone  will  have  to  be  gouged  away.  Caries  sicca  may  occur.  Excision  is 
sometimes  required. 

Elbow-joint  disease  may  begin  in  the  humerus  or  the  ulna.  The  head 
of  the  radius  is  rarely  the  primary  focus.  In  some  cases  the  svnovial  mem- 
brane is  first  attacked.  The  disease  is  most  frequent  in  young  adults.  The 
joint  is  swollen,  its  movements  are  somewhat  limited,  muscular  wasting  is  pro- 
nounced, and  pain  is  generally  sHght.     Tuberculous  pus  may  form. 

Treatment. — In  treating  elbow-joint  disease,  employ  antituberculous  foods, 
drugs,  and  hygienic  measures;  iodoform  ointment  or  guaiacol  locally;  rest  by 
means  of  an  anterior  angular  sphnt  (Fig.  234)  and  a  triangular  sling.  SpUnts 
are  to  be  worn  for  from  four  months  to  a  year.  Injection  of  iodoform  emulsion 
may  be  useful.  Insert  the  needle  for  injection  by  the  side  of  the  olecranon.  It 
may  become  necessary  to  open  the  joint.  If  the  condition  is  found  to  admit  of 
it,  Neuber's  plan  should  be  followed;  but  if  there  is  advanced  disease  of  the 
joint,  drain  with  a  tube  or  perform  an  erasion  or  an  excision. 

Wrist-joint  disease  may  arise  at  any  age,  and  is  sometimes  met  with  in 
late  middle  life,  or  even  in  old  age.  The  joint  presents  a  puffy  swelling,  loses 
its  normal  contour,  and  becomes  spindle-shaped.  Hand-movements  are  im- 
paired, pronation  and  supination  cannot  completely  or  satisfactorily  be  per- 


484  Diseases  and  Injuries  of  Bones  and  Joints 

formed,  the  joint  is  stiff  and  partly  flexed,  the  grasp  is  enfeebled,  pain  may  be 
severe  or  slight,  the  skin  is  usually  hot,  and  muscular  atrophy  is  marked.  This 
form  of  tuberculosis  may  begin  in  the  synovial  membrane,  in  the  bones,  or  in 
the  tendon-sheaths. 

Treatment  comprises  the  usual  antituberculous  measures  and  drugs,  and 
the  local  application  of  guaiacol  or  iodoform  ointment.  Apply  a  Bond  splint 
and  sling  or  put  on  a  plaster-of-Paris  bandage,  and  maintain  strict  rest  for  from 
four  to  six  months.  Aspiration  and  injection  of  iodoform  emulsion  are  useful. 
Enter  the  needle  at  the  dorsal  edge  of  the  radial  styloid  process,  and  again  at 
the  upper  edge  of  the  pisiform  bone  (De  Vos).  In  some  cases  it  is  well  to  in- 
cise, wash  with  salt  solution,  inject  iodoform  emulsion,  and  close  without  drain- 
age. Severe  cases  demand  incision  and  drainage  with  the  maintenance  of 
rest.  A  moderate  amount  of  caries  is  treated  by  drainage  and  rest.  Extensive 
caries  requires  excision.     Necrosis  demands  removal  of  sequestra. 

Acute  Suppurative  Arthritis. — This  infection  is  usually  due  to  the 
staphylococcus  pyogenes  aureus  or  to  the  streptococcus  pyogenes,  which  find 
entrance  by  means  of  a  wound,  by  the  spontaneous  evacuation  into  a  joint  of 
the  products  of  an  osteomyelitis,  by  extension  of  suppurative  inflammation 
through  contiguous  structures  or  by  the  blood-stream.  In  this  disease  all 
the  joint-structures  are  involved  and  suppuration  rapidly  appears.  It  is  very 
rarely  due  to  gonorrhea,  and  sometimes  to  septicemia. 

Symptoms. — The  symptoms  of  acute  suppurative  arthritis  are  usually  a 
chill  followed  by  fever  and  a  rapid  pulse.  There  is  severe  pain,  which  is  ag- 
gravated by  motion  and  is  worse  at  night ;  discoloration,  heat,  and  edema  of  the 
skin;  partial  flexion  of  the  joint;  fluctuation;  and  marked  constitutional  symp- 
toms of  sepsis.  The  joint  tends  to  rapid  disorganization,  and  fatal  septicemia 
is  very  apt  to  occur.     In  pyemic  arthritis  several  joints  become  infected. 

Treatment. — The  treatment  in  septic  arthritis  consists  in  prompt  incision, 
evacuation,  antiseptic  irrigation,  drainage,  antiseptic  dressing,  and  immo- 
bilization. Cure  is  followed,  as  a  rule,  by  ankylosis,  but  in  cases  treated 
early  the  joint  may  be  preserved. 

Infective  arthritis  arises  in  the  course  of  an  acute  infectious  disease 
(such  as  erysipelas,  typhoid  fever,  pneumonia,  influenza,  mumps,  dysentery, 
diphtheria,  measles,  scarlatina,  variola),  and  may  be  due  to  pyogenic  cocci, 
to  the  specific  micro-organism  of  the  acute  infectious  disease,  or  purely  to 
microbic  products.  Joint-inflammation  arising  in  the  course,  or  as  a  sequel, 
of  an  acute  infectious  disease  may  or  may  not  suppurate. 

Symptoms  and  Treatment. — If  no  suppuration  takes  place,  the  symptoms 
of  the  attack  resemble  those  of  rheumatism;  if  suppuration  occurs,  the  symp- 
toms are  the  same  as  those  of  acute  suppurative  arthritis,  with  which  disease 
this  form  of  infective  arthritis  is  identical.  Suppuration  rarely  occurs. 
Ashby  has  well  de.scribed  the  arthritis  which  sometimes  follows  scarlatina. 
It  involves  the  wrists,  finger-jtjints,  tendons  of  the  forearms,  the  knees,  ankles, 
or  spine.  The  joints  are  painful,  but  are  rarely  much  swollen  or  discolored 
(Howard  Marsh).  We  can  distinguish  infective  arthritis  from  rheumatism 
by  the  fact  that  it  does  not  migrate,  and  is  uninfluenced  by  antirheumatic 
remedies. 

Treatment  oj  Injeclive  Arthritis. — The  treatment  of  a  mild  case  is  iden- 
tical with  that  used  for  simple  synovitis:  if  there  is  much  fluid  in  the  joint. 


Gonorrheal  Arthritis  or  Gonorrheal  Rheumatism  485 

aspirate  and  wash  out  with  normal  salt  solution.  If  pus  forms,  open,  irri- 
gate, and  drain. 

Typhoid  Arthritis. — This  disease  is  a  form  of  infective  arthritis.  That 
the  organism  of  typhoid  may  inflame  the  joints  is  proved,  and  it  seems  certain 
that  it  can  cause  suppuration,  although  its  pathogenic  power  has  been  disputed. 
Some  claim  that  mixed  infection  induces  suppuration.  The  typhoid  bacilli 
enter  the  bones  in  many  typhoid  cases  and  sometimes  cause  bone-disease. 
Joint-disease  is  more  common  than  bone-disease.  Typhoid  disease  of  a  joint 
begins  when  the  fever  is  abating,  and  more  than  one  joint  may  be  involved. 
Typhoid  joints  may  recover  permanently,  may  become  ankylosed,  may  dislo- 
cate, or  the  joint-disease  may  lead  to  a  fatal  sepsis.  In  slight  cases  the  syn- 
ovial membrane  only  is  involved;  in  more  severe  cases  capsule,  cartilages, 
ligaments,  and  even  bones  are  involved.  Some  cases  suppurate.  Keen  tells 
us  that  septic  typhoid  arthritis  results  from  a  mixed  infection  with  typhoid 
bacilli  and  pyogenic  bacteria,  and  is  identical  in  symptoms  and  progress 
with  an  ordinary  septic  arthritis.  The  same  author  points  out  that  typhoid 
arthritis  proper  may  be  monarticular  or  polyarticular,  the  monarticular  form 
being  the  most  common,  and  the  hip-joint  being  the  articulation  most  Hable 
to  attack.  In  most  cases  typhoid  arthritis  causes  but  little  pain.  The 
swelling  is  marked,  although  in  the  hip  it  is  concealed.  Pus  rarely  forms. 
Keen  calls  attention  to  the  fact  that  in  the  eighty-four  cases  he  collected, 
spontaneous  dislocation  occurred  in  forty-three,  nearly  all  in  the  hip.* 

Treatment. — A  mild  case  is  treated  as  a  simple  synovitis.  If  diagnostic 
puncture  obtains  fluid  free  from  bacteria,  no  more  radical  method  than 
aspiration  is  required.  If  the  fluid  contains  bacteria,  incision  and  drainage 
are  demanded. 

Gonorrheal  Arthritis  or  Gonorrheal  Rheumatism. — During  the  prog- 
ress of  gonorrhea  the  development  of  a  painful  joint  does  not  of  necessity 
prove  the  existence  of  gonorrheal  rheumatism,  for  ordinary  rheumatism  is 
just  as  likely  to  arise  when  a  man  has  clap  as  when  he  has  not  this  malady. 
Furthermore,  the  term  is  inaccurate,  as  gonorrheal  rheumatism  is  not  rheu- 
matism at  all,  but  is  an  infective  disorder  of  the  joints  or  of  the  synovial 
membranes,  the  infective  material  being  contained  primarily  in  the  urethral 
discharge.  Gonorrheal  rheumatism  is  one  of  the  forms  of  infective  arthri- 
tis. Occasionally  this  form  of  arthritis  arises  from  gonorrheal  ophthalmia 
(Heiman's  case);  it  sometimes,  though  rarely,  arises  during  the  height  of 
a  gonorrhea,  but  it  is  more  frequently  met  with  in  chronic  cases  or  when 
the  intensity  of  the  inflammation  is  abating  in  acute  cases.  Men  suffer 
from  gonorrheal  arthritis  far  more  frequently  than  do  women,  and  the 
seizure  is  very  apt  to  recur  again  and  again.  In  some  cases  many  joints 
are  involved,  but  in  most  cases  only  a  few  joints  suffer.  Osier  states  that 
the  knees  and  ankles  are  most  apt  to  be  involved  in  gonorrheal  rheuma- 
tism, and  that  this  form  of  arthritis  is  peculiar  in  often  attacking  joints 
that  are  apt  to  be  exempt  in  acute  rheumatism  ("  the  sternoclavicular,  the 
intervertebral,  the  temporomaxillary,  and  the  sacro-iHac").  There  are  two 
forms  of  gonorrheal  rheumatism,  an  acute  and  a  chronic  form.  The 
poison  reaches  the  joint  by  way  of  the  blood.  In  some  cases  gonococci  are 
found  in  the  joint  fluid;  in  other  cases  they  are  not  found.  I  am  inclined 
*  Keen  on  "  The  Surgical  Complications  and  Sequels  of  Typhoid  Fever." 


486  Diseases  and  Injuries  of  Bones  and  Joints 

to  believe  that  in  the  milder  cases,  which  recover  without  genuine  pus-forma- 
tion, only  toxins  are  present  in  the  joint.  In  the  severe  cases  the  organisms 
themselves  exist  in  the  articular  fluid.  Osier  suggests  that  the  non-sup- 
purative  cases  are  due  to  the  action  of  toxins  taken  up  from  the  area  of 
primarv  infection,  and  that  the  suppurative  cases  are  due  to  infection  with 
pvogenic  bacteria.  Endocarditis  may  occur  and  it  is  due  always  to  micro- 
organisms and  not  to  toxins. 

Changes  in  and  about  the  Joint. — The  inflammation  of  gonorrheal  arthritis 
may  be  located  around  rather  than  in  the  joint,  and  especially  in  the  tendon- 
sheaths.  Suppuration  is  unusual,  but  it  may  occur  in  joints  and  in  tendon- 
sheaths.  Cultivation  of  the  exudate  may  or  may  not  show  the  gonococci. 
Cover-glass  preparations  stained  by  Gram's  method  may  show  gonococci. 

Symptoms. — The  acute  form  attacks  as  a  rule  but  a  single  joint,  but  may 
attack  several  joints.  The  joint  trouble  begins  with  great  suddenness,  and 
is  often  ushered  in  by  chilly  sensations  or  by  a  distinct  chill.  Moderate 
fever  arises.  The  pain  in  the  joint,  severe  from  the  first,  becomes  atrocious. 
If  superficial  joints  suffer  the  skin  over  them  becomes  red  and  hot,  and 
periarticular  edema  soon  presents  itself.  The  fluid  in  the  joint  is  in  most 
cases  serous,  but  may  become  purulent.  If  pus  forms  the  fever  becomes 
very  high  and  chills  may  occur. 

A  chronic  condition  may  follow  the  acute,  but  the  condition  may  be 
chronic  from  the  start.  The  symptoms  resemble  those  of  the  acute  form, 
but  are  far  milder,  although  acute  exacerbations  may  occur.  The  joint-fluid 
is  usually  serous.*  In  gonorrheal  arthritis  there  may  be  transitory,  inter- 
mittent, and  wandering  pain  in  and  about  the  joint,  without  any  other  symp- 
tom; one  or  more  joints  may  become  swollen  and  painful,  and  moderate 
fever  may  develop.  One  joint,  especially  the  knee,  may  swell  to  an  enormous 
extent,  pain,  periarticular  edema,  redness,  and  fever  being  absent  (hydrar- 
throsis, or  dropsy  of  the  joint).  Suppuration  in  this  form  of  the  disease  sel- 
dom occurs.  The  tendons,  the  tendon-sheaths,  the  bursae,  and  the  periosteum 
may  inflame.  Whether  the  joints  are  inflamed  or  not  inflamed,  the  tendon- 
sheaths  about  the  wrist  and  ankle  and  the  retrocalcaneal  bursse  may 
suffer.  In  some  cases  numerous  bursae  are  involved.  A  case  of  gonorrheal 
arthritis  is  often  very  hard  to  check.  It  may  last  for  a  long  period,  and 
tends  to  recur  again  and  again.  Iritis,  pleuritis,  endocarditis,  and  pericar- 
ditis have  been  observed  as  complications. 

The  diagnosis  between  gonorrheal  arthritis  and  acute  rheumatism  rests 
chiefly  on  the  great  chronicity,  the  slight  degree  of  fever,  the  excessive  ten- 
dency to  recurrence,  and  the  absence  of  profuse  acid  sweats  in  gonorrheal 
rheumatism;  and  on  the  shorter  course,  the  higher  fever,  the  profuse  acid 
sweats,  the  lesser  tendency  to  rapid  recurrence,  the  greater  proneness  to 
symmetrical  involvement,  and  the  great  liability  to  cardiac  and  visceral 
complications  in  rheumatic  fever.  Furthermore,  in  gonorrheal  arthritis  a 
gonorrheal  infection  (urethral  or  ocular)  certainly  exists  or  recently  existed; 
in  ordinary  rheumatism  a  urethral  discharge  may,  of  course,  happen  to  be 
present.  Gonorrheal  arthritis  is  apt  to  affect  certain  joints  which  acute 
rheumatism  rarely  attacks. 

Treatment. — The   salicylates,    the   alkalies,    and    salol    are   useless;  iron, 

*  .See  Schuller  in  Aerztl.  Pract.,  No.  17,   1896. 


Acute   Rheumatic   Arthritis  487 

arsenic,  and  strychnin  are  possibly  of  some  benefit.  Quinin  is  helpful  in 
some  cases.  lodid  of  potassium  seems  to  be  of  a  certain  amount  of  value. 
The  inflamed  joints  should  be  wrapped  in  cotton  and  bandaged,  and  every 
day  a  little  blue  ointment  should  be  rubbed  into  the  skin  about  them.  If 
the  inflammation  lingers,  use  the  hot-air  oven,  massage,  and  gentle  passive 
motion,  apply  blisters,  or  counter-irritate  with  the  hot  iron.  If  the  inflamma- 
tion still  lingers,  or  if  it  becomes  worse,  aspirate,  wash  out  the  joint  with  hot 
normal  salt  solution,  and  inject  iodoform  emulsion.  If  pus  forms,  incise, 
irrigate,  drain,  and  immobilize.* 

Pneumococcus  Arthritis. — This  is  a  rare  condition,  although  Herrick. 
has  collected  52  cases  ("Amer.  Jour,  of  Med.  Sciences,"  July,  1902).  Ex- 
amination of  the  blood  may  or  may  not  discover  pneumococci,  and  pneumo- 
cocci  may  be  found  in  the  blood  during  pneumonia  when  the  joints  are  free 
from  disease.  The  inflammation  may  attack  any  joint,  but  is  most  apt  to 
arise  in  a  joint  weakened  by  previous  injury  or  damaged  by  rheumatism  or 
gout.  Alcoholics  are  more  prone  to  suft"er  than  others.  In  a  great  majority 
of  cases  the  disease  is  associated  with  lobar  pneumonia,  but  Cole's  case 
proves  that  the  lung  may  be  free  ("American  Medicine,"  May  31,  1902). 
As  a  rule,  a  single  large  joint  is  attacked,  and  the  knee  is  most  liable  to 
sufi'er.  The  synovial  membrane  alone  may  be  involved  or  cartilages  may 
suffer  and  bone  be  attacked.  The  fluid  may  be  serous,  but  is  usually  puru- 
lent (Herrick).  I  have  seen  2  cases:  in  one  case  the  knee  only  was  in- 
volved; in  the  other,  both  knees,  one  elbow  and  one  shoulder  were  attacked. 
In  Cole's  series  of  41  cases,  13  exhibited  involvement  of  more  than  one  joint. 
The  inflamed  joint  is  frequently  completely  destroyed.  Pneumococcus  ar- 
thritis develops,  as  a  rule,  soon  after  the  crisis  of  pneumonia,  but  Herrick 
says  it  may  arise  as  late  as  three  weeks  after  the  crisis. 

The  diagnosis  is  made  by  the  history  of  pneumonia,  the  development 
of  septic  symptoms  and  the  signs  of  joint  inflammation.  It  is  confirmed 
by  aspiration  and  examination  of  the  fluid.  The  disease  is  very  fatal.  In 
Herrick's  series  of  cases  over  65  per  cent,  were  fatal.  In  Cole's  series  of 
cases  there  were  28  deaths  and  13  recoveries.  Even  if  the  patient  recovers, 
the  convalescence  is  prolonged  and  more  or  less  ankylosis  is  to  be  expected. 

Treatment. — A  non-purulent  effusion  may  be  treated  by  aspiration,  if 
bacteria  are  not  found  in  the  fluid.  If  the  aspirated  fluid  contains  bacteria, 
the  joint  should  be  opened  and  drained. 

Acute  Rheumatic  Arthritis;  Rheumatic  Fever  or  Acute  Rheuma- 
tism.— Acute  rheumatism  is  a  self-limited  febrile  malady  whose  character- 
istic features  are  polyarthritis,  profuse  acid  sweats,  and  a  tendency  to  heart- 
involvement.  There  is  some  evidence  to  indicate  that  acute  rheumatism  is 
a  form  of  infective  arthritis.  John  O 'Conor  f  believes  that  acute  rheuma- 
tism is  a  condition  ''  something  similar  to  gonorrheal  arthritis  and  pyemia, 
the  germ  or  toxin  gaining  admission  to  the  body  through  the  tonsil  or  other 
microbic  trap-door,  and  that  the  joint  invasion  is  promptly  followed  by  a 
form  of  infective  arthritis  accompanied  with  general  toxemia;  and,  further- 
more, the  infected  joints  serve  as  incubators,  where  the  poison  is  elaborated 

*See  Schuller,   Aerztl.    Pract.,    No.    17,    1896,   and   Monats.   iiber  d.    Krankheiten   d. 
Harn-  und  Sexual- Apparatus,  1 897,  p.  30. 
f  Lancet,  Jan.  24,  1903. 


488  Diseases  and  Injuries  of  Bones  and  Joints 

and  passed  into  the  circulation  and  thus  conveyed  to  other  articulations  and 
to  the  heart." 

Symptoms  of  Acute  Rheumatism. — In  acute  rheumatism  the  case  begins 
with  malaise  and  fever,  and  one  or  more  joints  become  affected.  The  in- 
flammation spreads  from  joint  to  joint,  is  apt  to  be  symmetrical,  and  when 
it  arises  in  fresh  joints  usually  disappears  quickly  in  those  previously  affected. 
The  temperature  is  high,  the  skin  sweats  profusely,  the  joints  are  red,  swollen, 
hot,  and  excruciatingly  painful,  and  the  structures  about  the  joints  are  edema- 
tous. After  a  short  time  the  inflammation  subsides  in  one  joint  and  passes 
into  another,  the  joint  first  attacked  regaining  its  functions.  Suppuration 
does  not  take  place.  Anemia  is  pronounced,  exhaustion  is  profound,  the 
sweat  is  sour,  the  saliva  is  acid;  the  urine  is  acid,  scanty,  high-colored,  often 
contains  albumin,  and  is  deficient  in  chlorids.  Cardiac  disease  is  apt  to 
be  produced  (endocarditis,  pericarditis,  or  myocarditis).  Nodules  may  form 
upon  fibrous  structures,  hyperpyrexia  is  not  unusual,  and  cerebral  or  pul- 
monary complications  may  occur. 

Chronic  rheumatism  rarely  follows  repeated  attacks  of  acute  rheumatism, 
but  rather  arises  insidiously  in  people  who  have  been  exposed  to  cold  and 
damp,  who  have  suffered  from  poverty,  hardship,  and  privation,  or  have  had 
much  worry.  The  capsule  and  tendon-sheaths  thicken,  and  there  is  usually 
but  little  effusion  in  the  joint,  but  the  articulation  becomes  stiff  and  painful. 
The  joint-cartilages  are  occasionally  eroded.     Muscular  atrophy  occurs. 

Symptoms  oj  Chronic  Rheumatism. — In  chronic  rheumatism  the  affected 
joints  are  stiff  and  painful  and  are  a  little  swollen,  but  not  red.  Dampness 
and  cold  aggravate  the  symptoms.  One  joint  or  many  may  be  affected, 
but  usually  several  are  involved.  Passive  movements  cause  the  joint  to 
creak  and  develop  crepitus  in  the  tendon-sheaths.  The  muscles  are  wasted. 
The  joints  may  ankylose.  Anemia  is  usually  pronounced.  There  is  no 
fever  and  no  tendency  to  suppuration,  and  the  disease  is  incurable. 

The  treatment  of  acute  rheumatism  comprises  the  use  of  alkalies,  sali- 
cylates, etc.  (See  a  book  upon  practice  of  medicine.)  O'Conor  is  a  believer 
in  incising  and  draining  the  inflamed  joints;  and  if  the  theory  of  an  infective 
origin  is  correct,  this  treatment  is  rational.  I  have  never  ventured  to  do  it, 
but  would  consider  the  advisability  of  doing  so  if  the  ordinary  treatment 
proved  futile.  O'Conor  operates  early  and  believes  that  this  is  the  real  way 
to  arrest  the  disease  and  prevent  complications,  but  his  views  have  not  met 
with  general  acceptance.*  In  chronic  rheumatism  maintain  the  general 
health  of  the  patient,  give  courses  of  iron,  arsenic,  and  strychnin,  and  an 
occasional  course  of  iodid  of  potassium  or  a  salt  of  lithium,  and,  if  possible, 
send  him  every  winter  to  a  warm  chmate.  Turkish  baths  give  considerable 
temporary  relief.  The  waters  and  regimen  of  Carlsbad  and  Vichy  are  of 
positive  though  temporary  benefit,  and  the  sufferer  may  obtain  relief  at  the 
hot  springs  of  Virginia.  The  patient  must  avoid  damp  and  must  wear 
woolens.  Frictions,  the  douche,  massage,  flying  blisters,  counter-irritation 
with  the  hot  iron,  ichthyol  ointment,  and  mercurial  ointment  are  of  benefit. 
Subjecting  the  diseased  joint  to  a  very  high  temperature  by  placing  it  daily 
in  a  hot-air  apparatus  often  does  great  good.  In  partial  ankylosis  it  is  proper 
in  some  cases  to  give  ether  and  break  up  the  adhesions. 

*  Lancet,  Jan.  24,  1903. 


Osteo-arthritis  489 

Gouty  arthritis,  which  appears  especially  in  the  smaller  joints  (as  the 
fingers  and  the  metatarsophalangeal  joints  of  the  great  toes),  is  due  to  a 
deposition  of  urate  of  sodium  in  the  joint  and  in  the  periarticular  structures. 
The  irritant  urate  of  sodium  causes  inflammation,  inflammation  leads  to 
the  formation  of  granulation  tissue,  granulation  tissue  is  converted  into 
fibrous  tissue,  and  the  fibrous  tissue  contracts  and  thus  deforms  the  joint 
and  limits  its  mobility.  A  great  mass  of  urates  in  a  joint  constitutes  a 
"chalk-stone. " 

Symptoms. — The  premonitory  symptoms  may  be  observed  for  a  day  or 
so,  but  the  acute  seizure  usually  occurs  early  in  the  morning,  the  patient, 
as  a  rule,  being  aroused  by  excruciating  pain  in  the  metatarsophalangeal 
articulation  of  one  of  the  great  toes.  The  joint  swells,  and  the  skin  over 
it  feels  hot  to  the  touch  and  become  red  and  shiny.  There  is  often  considerable 
fever.  After  a  few  hours  the  intensity  of  the  seizure  abates,  only  to  recur 
again  with  renewed  violence  early  the  next  morning,  these  remissions  and 
recurrences  taking  place  for  six  or  eight  days,  when  the  attack  subsides. 
In  patients  with  chronic  gout  many  joints  are  stiffened  and  deformed  as 
a  result  of  repeated  attacks.  Chalk-stones  form,  and  the  skin  above  them 
may  ulcerate.  Such  patients  are  chronic  dyspeptics,  have  high-tension 
pulses,  their  hearts  are  hypertrophied,  and  their  urine  contains  albumin 
and  casts. 

The  treatment  of  gouty  arthritis  belongs  to  the  physician,  and  not  to 
the  surgeon,  although  to  the  latter  the  symptoms  of  the  disease  should  be 
known,  so  that  it  may  be  diagnosticated  from  other  maladies. 

Osteo-arthritis  (Rheumatoid  Arthritis;  Arthritis  Deformans;  Rheumatic 
Gout;  Paget's  Disease). — In  this  disease,  which  is  not  a  combination  of 
gout  and  rheumatism,  the  synovial  membrane  and  cartilages  are  affected, 
the  periarticular  structures  are  involved,  and  masses  of  new  bone  are  formed. 

Osteo-arthritis  has,  as  John  K.  Mitchell  pointed  out,  a  probable  nervous 
origin.  It  arises  especially  in  persons  who  have  been  worried,  driven,  and 
harassed.  There  is  apt  to  be  muscular  atrophy,  trophic  lesions  of  the  hair 
and  nails  are  Hkely  to  appear,  and  the  symptoms  are  disposed  to  be  sym- 
metrical. The  causative  lesion  fias  not  been  determined.  The  disease  is 
commoner  in  women  than  in  men.  The  greatest  hability  exists  between 
the  ages  of  twenty  and  thirty,  but  children  may  acquire  the  disease,  and 
it  may  also  be  developed  in  people  beyond  middle  life.  Apes  in  captivity 
may  develop  it.  Arthritis  deformans  may  attack  the  rich  or  the  poor;  it 
does  not  result  from  gout,  nor  does  it  often  follow  rheumatism;  it  is  not 
caused  by  damp  and  cold ;  and  only  in  rare  cases  does  it  arise  after  traumatism 
of  a  joint. 

Osteo-arthritis  differs  from  gout  in  the  entire  absence  of  urate  deposit, 
and  it  differs  from  chronic  rheumatism  in  the  extensive  alterations  in  the 
joint-structures.  The  changes  begin  in  the  cartilage;  the  cartilage-cells 
multiply,  the  intercellular  substance  degenerates,  the  pressure  of  the  bone 
causes  thinning,  and  at  length  the  cartilage  is  entirely  destroyed  and  the 
bone  exposed.  The  exposed  bone  is  altered  in  shape,  is  hardened,  and 
is  worn  away  in  the  center,  the  periphery  increasing  in  thickness  by  ossific 
deposit ;  the  center  deepening  by  absorption.  The  margins  are  not  only 
thickened,  but  are  bulged  and  lengthened  by  deposit.     The  fringes  of  the 


490  Diseases  and  Injuries  of  Bones  and  Joints 

s^Tiovial  membrane  hypertrophy  and  multiply,  and  some  of  them  are  apt 
to  break  oflf  (loose  cartilages).  The  capsule  and  the  ligaments  of  the  joint, 
as  a  rule,  become  fibrous  and  contract;  but  they  may  soften,  relax,  and 
permit  of  dislocation.  The  joint  usually  contains  no  effusion,  but  in  some 
cases  there  is  great  effusion  (hydrarthrosis).  The  tendons  about  the  joint 
may  become  fibrous  and  contracted,  they  may  ossify,  they  may  be  separated 
from  the  bone,  or  they  may  be  destroyed  entirely.  Deformity  is  marked 
and  motion  is  hmited.  The  fingers,  when  involved,  show  nodules  on  the 
sides  of  the  joints  (Heberden's  nodules).  The  vertebras  may  be  involved. 
Almost  all  the  joints  may  suft'er.     Suppuration  does  not  occur. 

Symptoms. — Charcot  divides  osteo-arthritis  into  three  forms,  and  gives 
their  symptoms,  as  follows: 

1.  Heberden's  nodosities,  which  condition  is  commoner  in  women  than 
in  men,  comes  on  between  the  ages  of  thirty  and  forty,  and  is  especially 
common  in  neurotic  subjects.  The  interphalangeal  joints  become  the  victims 
of  attacks  of  moderate  swelling  and  of  some  tenderness,  which  attacks  are 
not  severe,  but  recur  again  and  again.  After  a  time  small  hard  swellings 
(nodosities)  appear  upon  the  sides  of  the  dorsal  surfaces  of  the  second  and 
third  phalanges,  remain  permanently,  and  slowly  increase  in  size.  The 
joints  become  stiff  and  creak  on  movement,  the  cartilages  are  destroyed, 
and  contractions  and  rigidity  develop,  but  there  is  no  fever  and  the  larger 
joints  are  not  involved.     The  malady  is  incurable. 

2.  Progressive  rheumatic  gout,  which  may  be  acute  or  chronic.  The  acute 
form  begins  as  does  rheumatic  fever.  There  are  moderate  fever  and  swelling, 
without  redness,  of  a  number  of  joints,  of  bursae,  and  of  tendon-sheaths; 
the  joints  are  stiff  and  crepitate,  and  are  apt  to  be  symmetrically  involved; 
muscular  atrophy  begins  early  and  rapidly  becomes  decided;  pain  is  slight. 
This  acute  form  is  apt  to  arise  in  young  women  after  pregnancy,  but  is  not 
unusual  at  the  climacteric  and  in  children.  Anemia  always  exists.  The 
case  is  apt  to  advance  progressively  until  a  number  of  joints  are  firmly  locked, 
when  it  may  become  stationary.  Another  pregnancy  will  develop  anew  the 
acute  symptoms.  In  the  chronic  form  swelling  and  pain  on  movement  are 
noted  in  certain  joints.  The  involvement  fs  apt  to  be  symmetrical.  Attacks 
of  swelling  and  pain  alternate  with  periods  of  quiescence,  but  the  disease 
does  not  cease  its  advance.  Articulation  after  articulation  is  attacked  by 
the  malady  until  almost  all  the  joints  are  involved;  deformity  and  stiffness 
become  pronounced,  and  pain  may  or  may  not  be  severe.  There  is  no  fever. 
Muscular  atrophy  is  marked. 

3.  Partial  rheumatic  gout  attacks  one  articulation,  and  it  is  most  often 
met  with  in  old  men.  It  may  fix  itself  on  the  vertebral  column,  on  the  knee, 
on  the  shoulder,  on  the  elbow,  or  on  the  hip.  The  joint  grates,  and  becomes 
stiff,  swollen,  and  deformed;  the  muscles  atrophy;  there  is  usually  pain,  but 
fever  is  absent. 

Osteo-arthritis  or  partial  rheumatic  gout  of  the  hip-joint  seldom 
occurs  before  the  age  of  forty-five,  but  is  occa.sionally,  though  very  rarely,  met 
with  in  persons  under  twenty-five.  If  the  disease  arises  in  an  elderly  person, 
it  is  often  called  morbus  coxce  senilis.  In  some  cases  only  the  hip-joint 
is  attacked;  in  many  cases  other  joints  are  also  diseased.  Osteo-arthritis 
of  the  hip  may  follow  an  injury.     Usually  the  di.sease  is  unconnected  with 


Charcot's  Disease  491 

traumatism,  begins  very  gradually,  and  advances  slowly.  There  is  pain, 
often  mistaken  for  sciatica,  in  and  about  the  joint,  and  there  is  increasing 
stiffness.  The  pain  and  stiffness  are  worse  when  the  patient  first  moves 
after  resting.  Lameness  becomes  noticeable,  and  grating  can  be  detected 
in  and  about  the  joint.  The  symptoms  become  gradually  worse,  although 
at  times  they  may  seem  to  improve  for  brief  periods.  The  lameness  and 
the  stiffness  are  greatly  aggravated,  and  the  pain  becomes  very  severe,  even 
when  at  rest.  Shortening  takes  place,  the  great  trochanter  ascends  above 
Nelaton's  hne,  the  limb  is  usually  abducted,  but  in  very  rare  cases  is  ad- 
ducted,  and  finally  ankylosis  occurs. 

Partial  rheumatic  gout  of  the  vertebral  articulations  causing  fixation  is 
called  "spondylitis  deformans"  (p.  645). 

Treatment. — Osteo-arthritis  cannot  be  cured,  but  in  some  cases  it  remains 
stationary  for  many  years.  Treat  the  anemia  by  iron,  arsenic,  nourishing 
food,  and  have  the  patient  be  out  in  the  fresh  air  as  much  as  possible.  De- 
bility is  met  by  the  administration  of  strychnin.  Hot  baths  of  mineral  water 
do  good.  It  is  claimed  that  the  hot-air  apparatus  is  of  service.  Douches 
improve  these  cases,  but  electricity  is  useless.  Counter-irritants  do  no  good. 
Massage  retards  the  progress  of  the  case,  relieves  the  pain,  aids  in  the  ab- 
sorption of  effusion,  and  delays  fixation.  During  an  acute  exacerbation  the 
joint  should  be  put  at  rest  for  a  time  and  evaporating  lotions  applied.  In 
an  exacerbation  in  disease  of  the  hip  the  patient  should  be  put  to  bed  and 
have  extension  applied.  The  patient  is  unfortunately  liable  to  develop  the 
opium-habit.  If  dropsy  of  a  joint  arises,  try  compression  with  a  Martin 
bandage,  and,  if  this  fails,  aspirate  and  wash  out  the  joint  with  a  2  per  cent, 
solution  of  carbolic  acid.  Patients  with  rheumatic  gout  do  best  in  a  warm, 
dry  climate.  Cod-liver  oil  does  good,  as  it  improves  nutrition  and  hence 
retards  the  progress  of  the  disease.  Do  not  be  tempted  to  immobilize  the 
joints  beyond  a  day  or  two :  fixation  only  hastens  ankylosis.  Howard  Marsh  * 
points  out  that,  as  a  rule,  but  little  good  comes  from  manipulation.  He 
makes  the  following  exceptions:  When  one  joint  only  is  affected;  when  the 
joint  is  very  stiff  but  not  very  painful;  when  the  patient  is  in  good  general 
health  and  is  not  beyond  middle  age. 

Charcot's  Disease  (Tabetic  Arthropathy;  Charcot's  Joint;  Neuropathic 
Arthritis). — This  condition  is  an  osteo-arthritis  due  to  trophic  disturbance, 
arising  in  a  sufferer  from  locomotor  ataxia,  and  is  anatomically  identical 
with  osteo-arthritis,  which  was  described  above.  The  knee  is  most  apt  to 
be  attacked,  and  the  hip  suffers  more  often  than  any  joint  but  the  knee. 
The  disease  begins  acutely,  often  as  a  sudden  effusion,  which  after  a  time 
disappears.  Pain  is  slight  or  is  absent,  there  is  no  constitutional  involvement, 
and  the  condition  is  unconnected  with  injury.  The  bones  and  cartilages  are 
rapidly  destroyed;  fracture  is  apt  to  occur;  the  joint  creaks  and  grates; 
the  softening  and  relaxation  of  the  Hgaments  permit  an  extensive  range  of 
movement;  great  deformity  ensues;  dislocation  is  apt  to  occur;  muscular 
atrophy  is  decided ;  and  pus  occasionally,  though  very  rarely,  forms. 

Treatment. — The  treatment  of  Charcot's  disease  consists  in  the  wearing 
of  an  apparatus  to  sustain  the  joint.  Resection  is  recommended  bv  some, 
but  most  surgeons  do  not  advise  its  performance. 

*  "  Diseases  of  the  Joints  and  Spine." 


492  Diseases  and  Injuries  of  Bones  and  Joints 

Osteo-arthropathie  Hypertrophiante  Pneumique  (Marie's  Disease). — 
A  condition  associated  with,  and  possibly  springing  from,  pulmonary  disease, 
and  characterized  by  enlargement  of  joints,  thickening  of  the  finger-ends, 
and  the  formation  of  a  dorsolumbar  kyphosis.  The  joints  are  painful,  the 
skin  undergoes  pigmentation,  and  profuse  perspiration  is  often  present.  The 
head  entirely  escapes  in  this  disease,  which  immunity  marks  a  distinction 
from  acromegaly. 

Hysterical  joint  (Brodie's  joint)  is  a  condition  mostly  encountered  in 
young  women.  The  disease  occurs  most  commonly  in  the  knee  and  the 
hip,  and  often  follows  a  slight  injury  which  acts  as  an  autosuggestion,  a  latent 
hysteria  being  awakened  into  action  and  localized,  though  severity  of  the 
injury  does  not  determine  the  severity  of  the  symptoms.  The  disease  may 
ensue  upon  a  synovitis  or  an  arthritis,  or  may  arise  without  apparent  cause. 
The  patient  complains  of  pain  in  and  stiffness  of  the  joint,  resists  passive 
motion  strenuously,  and  claims  that  it  causes  much  pain.  There  is  occasion- 
ally some  muscular  atrophy  from  want  of  use,  and  the  joint  is  a  little  swollen. 
The  skin  is  hyperesthetic,  and  a  light  touch  causes  more  pain  than  does 
deep  pressure.  The  muscles  may  be  rigid.  The  joint  may  be  maintained 
either  in  flexion  or  in  extension,  but  it  is  rarely  in  the  exact  degree  of 
flexion  assumed  for  ease  in  a  true  joint-inflammation,  and  the  position  is  apt 
to  be  changed  from  day  to  day  or  from  hour  to  hour.  The  skin  is  usually 
pale  and  cool,  but  may  be  red  and  hot,  because  of  hyperemia.  A  periodi- 
cally developed  heat  may  be  observed,  especially  at  night,  accompanied  ap- 
parently by  much  pain.  The  alleged  pain  in  some  cases  is  neuralgia,  but 
in  most  cases  is  a  pain-hallucination.  There  is  no  effusion  into  the  joint, 
and  swelling  does  not  exist,  although  occasionally  there  is  slight  periarticular 
edema.     In  some  rare  cases  organic  disease  arises  in  a  hysterical  joint. 

Hysterical  phenomena  are  seldom  isolated,  but  are  associated  with  certain 
stigmata  which  may  be  latent.  These  stigmata  are  concentric  contraction 
of  the  visual  fields,  pharyngeal  anesthesia,  convulsions,  hysterogenic  zones, 
globus  hystericus,  clavicus  hystericus,  zones  of  anesthesia,  especially  hemi- 
anesthesia, and  hyperesthetic  areas.  Such  patients  are  predisposed  by  in- 
heritance, and  have  previously,  as  a  rule,  had  nervous  troubles.  Hysterical 
phenomena,  be  it  remembered,  lack  regularity  of  evolution,  and  are  pro- 
duced, altered,  or  abolished  by  mental  influences  and  physical  sensations 
which  are  without  effect  in  causing,  modifying,  or  curing  organic  disease. 
The  general  health,  as  a  rule,  is  good,  but  neurasthenia  may  coexist.  In 
examining  these  patients  the  observer  will  note  that  the  symptoms  disappear 
when  the  attention  is  diverted;  that  they  are  out  of  all  proportion  to  the 
local  evidences  of  disease;  that  there  is  no  sign  of  joint-destruction;  and 
that  a  light  touch  may  cause  more  pain  than  does  firm  pressure.  If  the 
patient  is  anesthetized,  perfect  joint  mobility  will  be  found. 

Treatment. — The  treatment  for  a  hysterical  joint  comprises  attention  to 
the  general  health,  the  employment  of  nourishing  and  easily  digested  food, 
the  prevention  of  constipation,  and  the  administration  of  tonics  if  they  are 
needed.  The  surgeon  must  dominate  his  patient's  mind  and  make  her 
realize  that  he  is  master  of  the  case.  He  is  to  be  an  inexorable  but  just 
ruler — never  a  brutal  or  a  cruel  one.  If  possible,  send  the  patient  away 
from  the  harmful  sympathies  of  her  home  and  let  her  have  the  rest  treatment 


Articular  Wounds  and  Injuries  493 

of  S.  Weir  Mitchell.  Local  remedies  applied  to  the  joint  do  harm,  as  a  rule, 
by  concentrating  afresh  the  patient's  attention  upon  the  articulation,  although 
the  hot  iron  sometimes  does  good.  Suggestion  in  the  hypnotic  state  may 
be  tried.  The  use  of  morphin  should  be  avoided  as  being  the  worst  of 
enemies.  Never  immobilize  the  joint,  and  always  use  massage,  passive 
motions,  and  frictions. 

Neuralgia  of  the  joints  as  an  independent,  isolated  affection  is 
extremely  rare,  though  as  a  complication  of  other  diseases  it  is  by  no  means 
uncomrnon.  Neuralgia  is  more  common  outside  of  the  joints  than  in  them,  and 
periarticular  neuralgia  is  especially  frequent  about  the  knee  and  the  ankle. 
Joint-neuralgia  may  arise  in  any  person,  but  it  is  more  commonly  present  in 
young  neurotic  females.  The  pain  may  be  persistent,  or  it  may  occur  in  peri- 
odic storms,  and  it  is  often  associated  with  neuralgia  in  other  parts.  The  pain 
may  be  dull  and  aching,  but  it  is  more  often  sharp  and  shooting.  Joint-neural- 
gia is  associated  with  tenderness  on  pressure,  soreness  on  motion,  often  with 
transitory  swelling  without  redness,  and  sometimes  with  numbness  of  the  ex- 
tremities. The  diagnosis  depends  on  the  temperament  of  the  patient,  the  sud- 
den onset  of  the  pain,  the  absence  of  constitutional  symptoms,  and  the  free 
mobility  of  the  joint,  especially  under  ether.  Articular  neuralgia  may  depend 
upon  disease  or  injury  of  the  central  nervous  system,  upon  malaria,  syphilis, 
neurasthenia,  rheumatism,  gout,  hysteria,  and  neuritis,  and  may  be  due  to 
reflected  irritation,  especially  from  the  ovaries,  the  uterus,  or  the  rectum. 

Treatment. — The  treatment  to  be  observed  in  joint-neuralgia  is  to  main- 
tain the  general  health.  Examine  for  a  possible  exciting  cause,  and,  if  found, 
remove  it.  Give  a  long  course  of  iron,  quinin,  and  strychnin  or  arsenic. 
In  rheumatic  or  gouty  subjects  administer  suitable  drugs  and  insist  upon 
the  use  of  a  proper  diet.  During  the  attack  use  phenacetin.  Morphin  must 
occasionally  be  given  in  severe  cases,  but  be  careful  of  it,  and  never  tell  the 
patients  they  are  taking  it,  as  there  is  a  possibility  of  their  forming  the  opium- 
habit.  Locally,  employ  frictions,  ointment  of  aconite,  heat,  and  keep  upon 
the  part  a  piece  of  flannel  soaked  in  a  mixture  of  soap  liniment,  laudanum,  and 
chloroform  (Gross).  Never  allow  the  joint  to  stiff'en;  any  tendency  to  stiff- 
ness should  be  met  by  daily  massage,  frictions,  passive  motion,  and  hot  and 
cold  douches.  In  some  rare  cases  nerve-stretching  or  neurectomy  becomes 
necessary. 

Articular  Wounds  and  Injuries. — A  penetrating  wound  is  very 
serious,  and  it  may  be  due  to  a  compound  fracture,  to  a  compound  dislocation, 
to  a  gunshot-wound,  or  to  a  stab.  If  a  bursa  near  a  joint  be  injured,  secondary 
penetration  may  occur  as  a  result  of  suppuration.  In  a  penetrating  wound, 
besides  pain,  hemorrhage,  and  swelling,  there  is  a  flow  of  synovial  fluid. 
A  small  amount  of  synovia  flows  from  an  injured  bursa,  a  large  amount 
from  an  open  joint. 

Treatment. — If  a  joint  is  opened  aseptically  (as  when  incised  by  the 
surgeon),  the  wound  heals  nicely  under  rest  and  antisepsis.  If  a  joint  is 
opened  by  a  septic  body,  suppurative  arthritis  is  apt  to  arise,  and  the  surgeon 
endeavors  to  prevent  it  by  asepticizing  the  surface,  irrigating  the  joint,  drain- 
ing, applying  antiseptic  dressing,  and  securing  rest.  Normal  salt  solution 
is  the  best  agent  for  irrigation,  as  it  does  not  injure  joint-endothelium.  Active 
antiseptics  are  apt  to  lessen  tissue-resistance,  and  thus  may  actually  favor 


494  Diseases  and  Injuries  of  Bones  and  Joints 

infection.  In  gunshot-wounds  inflicted  by  pistol  bullets  or  sporting  rifle 
bullets,  if  antisepsis  is  not  employed,  suppuration  is  inevitable;  hence  military 
surgeons  in  the  past,  as  a  rule,  have  advocated  amputation  or  excision  in 
gunshot-splinterings  of  large  joints.  Recent  experience  shows  that  the  wound 
of  a  large  joint  produced  by  a  hard-jacketed  and  small-caliber  bullet  may  heal 
with  little  trouble.  In  articular  wounds  the  surface  is  sterilized,  and  usually 
the  wound  is  enlarged,  the  finger  is  introduced  to  discover  and  remove  for- 
eign bodies,  through-and-through  drainage  is  secured,  a  tube  is  inserted, 
the  joint  is  irrigated,  antiseptic  dressings  are  appHed,  and  the  extremity  is 
placed  upon  a  splint.  Very  severe  joint-injuries  demand  resection  or  even 
amputation.  Ankylosis,  more  or  less  complete,  often  follows  a  gunshot- 
wound  of  a  joint.  If  the  joint  suppurates,  the  drainage  must  be  made  more 
free,  sinuses  must  be  slit  up  and  packed,  sloughs  must  be  cut  away,  dead 
bone  must  be  gouged  out,  and  the  patient  must  be  placed  upon  a  stimulant 
and  tonic  plan  of  treatment.  The  above  remarks  do  not  apply  to  wounds 
inflicted  with  the  modern  military  projectile.  Such  wounds  are  not  of  neces- 
sity infected,  and  recovery  may  be  prompt  and  uneventful  if  the  surface  is 
sterilized  and  antiseptic  dressings  and  splints  are  applied. 

Sprains. — A  sprain  is  a  joint-wrench  due  to  a  sudden  twist  or  traction, 
the  ligaments  being  pulled  upon  or  lacerated  and  the  surrounding  parts 
being  more  or  less  damaged.  A  sprain  is  often  a  self-reduced  dislocation 
(Douglas  Graham).  The  joints  most  hable  to  sprains  are  the  knee,  the 
elbow,  and  the  ankle.  The  smaller  joints  are  also  often  sprained,  but  the 
ball-and-socket  joints  are  infrequently  sprained,  their  normal  range  of  free 
movement  saving  them;  they  do  occasionally  suffer  severely,  however,  as  a 
result  of  abduction.  In  a  bad  sprain  the  ligaments  are  torn;  the  synovial 
membrane  is  contused  or  crushed;  cartilages  are  loosened  or  separated; 
hemorrhage  takes  place  into  and  about  the  joint;  muscles  and  tendons  are 
stretched,  displaced,  or  lacerated;  vessels  and  nerves  are  damaged;  the  skin 
is  often  contused;  and  portions  of  bone  or  cartilage  may  be  detached  from 
their  proper  habitat,  though  still  adhering  to  a  ligament  or  tendon  (sprain- 
fractures).  Sprains  are  commonest  in  young  persons  and  in  adults  with 
weak  muscles.  They  happen  from  sudden  twists  and  movements  when  the 
muscles  are  relaxed.  A  large  part  of  the  support  of  joints  comes  from  muscles, 
and  when  they  are  suddenly  caught  unawares  they  do  not  properly  support 
the  joint,  and  a  sprain  results.  A  joint  once  sprained  is  very  liable  to  a 
repetition  of  the  damage  from  slight  force.  Sprains  are  common  in  a  limb 
with  weak  muscles,  in  a  deformed  extremity  in  which  the  muscles  act  in 
unnatural  lines,  and  in  a  joint  with  relaxed  ligaments. 

Symptoms. — There  is  severe  pain  in  the  joint,  accompanied  by  general 
weakness.  Nausea,  vomiting,  and  even  syncope  may  occur.  There  is  im- 
pairment or  loss  of  ability  to  move  the  joint.  The  above-described  condition 
is  succeeded  by  a  season  of  relief  from  pain  while  at  rest,  numbness  being  com- 
plained of,  and  pain  on  motion  being  severe.  Swelling  ari.ses  very  early  if 
much  blood  is  effused.  In  any  case  swelling  begins  in  a  few  hours.  Extensive 
effusion,  by  separating  joint-surfaces,  produces  slight  lengthening  of  the  limb. 
Movements  of  the  joint  become  difficult  or  impossible;  the  tear  in  the  ligament 
may  sometimes  be  distinctly  detected  by  the  examining  fingers;  pain  and  ten- 
derness become  intense;  joint-crepitus  will  he  manifested;  and  in  a  day  or  two 


Treatment  of  Sprains 


495 


discoloration  becomes  marked.  Moullin  and  others  have  pointed  out  that 
when  a  muscle  is  strained  the  skin  above  it  becomes  sensitive,  especially  at 
tendinous  insertions  over  joints.  As  muscles  are  invariably  strained  when  a 
joint  is  sprained,  there  is  always  some  cutaneous  tenderness.  There  is  also 
tenderness  over  a  sprained  joint  due  to  capsular  injury,  bands  of  adhesions,  etc. 
Tenderness  is  apt  to  arise  at  certain  reasonably  fixed  points:  in  a  hip-joint  in- 
jury it  is  found  behind  the  great  trochanter,  in  a  knee-joint  injury  by  the  side 
of  the  patella,  in  an  ankle-joint  injury  to  the  inner  side  of  the  external  malleolus 
(Gulp).  When  the  vertebral  articulations  are  sprained,  the  muscles  of  the 
back  are  rigid,  the  skin  is  often  sensitive,  pain  may  be  awakened  by  pressure  or 
by  certain  movements,  but  there  is  no  sign  of  cord  injury  in  an  uncomplicated 
case. 

Diagnosis  and  Prognosis. — Sprain-fractures  can  be  diagnosticated  with 
certainty  only  by  the  .v-rays.  In  the  diagnosis  of  a  sprain,  fracture  and  dis- 
location must  be  considered.     In  fracture,  crepitus  and  mobiHty  exist;  in  dis- 


Fig.  235. — Gibney's  method  of  strapping  in  sprains  of  the  ankle. 


location,  rigidity.  The  diagnosis  of  sprain  should  be  made  by  a  consideration 
of  the  joint  involved,  of  the  age,  of  the  nature  of  the  force,  of  the  length  of  the 
limb,  of  the  fact  that  the  patient  could  use  the  joint  for  at  least  a  short  time  after 
the  accident,  and  of  the  local  feel  and  movements  of  the  part.  In  some  cases 
examine  under  ether,  in  some  apply  the  x-rays.  Many  injuries  about  the  ankle 
which  we  would  have  formerly  regarded  as  sprains,  are  often  shown  bv  the 
.T-rays  to  be  fractures.  The  prognosis  depends  on  the  size  of  the  joint,  on 
the  extent  of  laceration,  on  the  amount  of  intra-articular  hemorrhage,  and  on 
the  age  of  the  patient.  The  danger  is  ankylosis.  In  rare  cases  after  a  sprain 
of  the  hip-joint  osteo-arthritis  arises.  In  some  few  cases  after  a  sprain  of  the 
hip  the  head  of  the  bone  undergoes  absorption. 

Treatment. — In  a  mild  sprain  apply  at  once  a  silicate  or  plaster-of-Paris 
dressing.  The  first  indication  after  the  infliction  of  a  severe  sprain  is  to  arrest 
hemorrhage  and  limit  inflammation.  For  the  first  few  hours  apply  pressure  and 
an  ice-bag.   Wrap  the  joint  in  absorbent  cotton  wet  with  iced  water,  applv  a  wet 


496  Diseases  and  Injuries  of  Rones  and  Joints 

gauze  bandage,  and  put  on  an  ice-bag.  After  some  hours  place  the  extremity 
upon  a  splint  and  to  the  joint  apply  flannel  kept  wet  with  lead-water  and  lau- 
danum, iced  water,  tincture  of  arnica,  alcohol  and  water,  or  a  solution  of 
chlorid  of  ammonium.  These  evaporating  lotions  produce  cold.  Instead  of 
them,  an  ice-bag  may  be  used  for  a  day  or  two.  Leeches  around  the  joint  do 
good.  Constitutionally,  employ  the  remedies  for  inflammation.  Morphin  or 
Dover's  powder  is  given  for  the  pain.     Judicious  bandaging  limits  the  swelling. 

After  a  day  or  two,  if  the  symptoms  continue  or  if  they  grow  worse,  use  hot 
fomentations,  the  hot-water  bag,  plunge  the  extremity  frequently  in  very  hot 
water,  or  apply  heat  by  Leiter's  tubes.  When  the  acute  symptoms  begin  to 
subside,  rub  stimulating  liniments  upon  the  joint  once  or  twice  a  day  and 
employ  firm  compression  by  means  of  a  bandage  of  flannel  or  rubber.  Fric- 
tions should  be  made  from  the  periphery  toward  the  body.  Many  cases  do 
well  at  this  stage  under  the  local  use  of  ichthyol  and  lanoHn  (50  per  cent.), 
tincture  of  iodin,  or  blue  ointment.  Later  in  the  case  use  hot  and  cold  douches, 
massage,  frictions,  passive  motion,  and  the  bandage.  Passive  motion  is  begun 
a  day  or  so  after  swelling  ceases.  If  massage  causes  the  swelling  to  return, 
abandon  it  for  several  days  and  then  try  it  again.  Blisters  are  used  when 
tender  spots  persist  and  stiffness  is  manifest.  If  stiffness  becomes  marked, 
move  the  joint  forcibly.  Give  iodid  of  potassium  and  tonics  internallv,  and 
insist  on  open-air  exercise.  If  the  person  is  gouty  or  rheumatic,  use  appro- 
priate remedies.  Van  Arsdale  treats  sprains  by  massage  almost  from  the  start. 
Gibney  treats  them  by  strapping  with  adhesive  plaster.  Gibney's  dressing  is 
of  great  service  in  a  sprain  of  the  ankle  (Fig.  235).  Many  sprains  may  be 
put  up  in  an  immovable  dressing  the  first  day  or  two  after  the  accident.  If  the 
joint  contains  much  blood,  aspiration  should  be  practised  before  the  dressing  is 
applied. 

The  hot-air  oven  is  a  very  valuable  method  for  treating  recent  sprains,  and 
the  swelling,  pain,  and  stiffness  which  follow  sprains,  of  the  extremities.  The 
sprained  extremity  is  placed  in  an  oven,  and  the  part  is  subjected  to  heat  for  an 
hour.  The  next  day  the  treatment  is  repeated,  and  on  as  many  subsequent 
days  as  may  be  necessary.  In  an  acute  sprain  the  pain  often  disappears  during 
the  first  application  of  heat.  In  the  intervals  between  the  use  of  the  oven  the 
extremity  should  be  at  rest  upon  a  splint. 

Ankylosis. — When  a  joint-inflammation  eventuates  in  the  formation  of 
new  tissue  in  and  about  the  joint,  contraction  of  this  tissue  limits  or  destroys 
joint-mobility,  producing  the  condition  known  as  "ankylosis."  Ankylosis  may 
be  complete  (bony)  or  incomplete  (fibrous) ;  it  may  arise  from  contractures  in 
the  joint  (true  or  intra-articular  ankylosis)  or  from  contractures  in  the  struc- 
tures external  to  the  joint  Cfalse  or  extra-articular  ankylosis). 

True  or  intra-articular  ankylosis  may  arise  from  any  cause  which  pro- 
duces joint-inflammation  with  formation  of  new  tissue,  and  may  be  due  to 
wounds,  contusions,  sprains,  dislocations,  fractures  in  or  near  a  joint,  movable 
bodies  in  a  joint,  tubercle,  gout,  rheumatism,  or  syphilis.  Proper  immobiliza- 
tion of  a  healthy  joint  may  cause  some  stiffness,  but  not  ankylosis.  Dr.  O. 
W.  Phelps*  points  out  that  experiments  made  by  himself  in  association  with 
Dr.  W.  Gilman  Thompson  and  Dr.  J.  C.  Cardwell  show  that  immobilization 
of  a  normal  joint  will  not  produce  ankylosis  in  five  months,  and  that  when  a 

*  R.ailway  Surgeon,  July  26,  1898. 


Fibrous  Ankylosis  497 

healthy  joint  becomes  ankylosed,  it  is  due  to  some  pathological  cause.  Im- 
proper immobilization  may  produce  and  maintain  intra-anicular  pressure, 
and  such  pressure  may  destroy  the  head  of  the  bone  and  the  socket,  and 
ankylosis  will  result.  Further,  Phelps  shows  that  muscular  atrophy  is  sure  to 
follow  prolonged  immobilization.  Even  a  proper  immobilization  of  a  healthy 
joint  will,  if  prolonged,  cause  muscular  atrophy,  but  the  weakness  and  stiffness 
will  pass  away  entirely  under  the  influence  of  proper  treatment.  Firm  immo- 
bilization with  pressure  may  produce  disastrous  results.  Ankylosis  is  more 
apt  to  take  place  in  a  hinge-joint  than  in  a  ball-and-socket  joint.  In  ankylosis 
from  a  general  cause  (as  rheumatic  gout)  many  joints  are  apt  to  suffer.  Anky- 
losis mav  be  due  to  fibrous  tissue,  and  is  then  usually  partial;  it  may  be  due  to 
chondrification  of  fibrous  tissue,  and  is  then  incomplete;  it  may  be  due  to  ossi- 
fication of  fibrous  tissue,  and  is  then  complete,  the  joint  being  entirely  immo- 
bile (osseous  or  bony  ankylosis) .  The  entire  joint  may  be  converted  into  bone. 
Only  one  small  joint-surface  may  contain  adhesions  (limited  adhesions),  or  the 
entire  joint-surface  may  be  bound  up  in  them  (diffused  adhesions).  In  what 
is  known  as  spondylitis  deformans  there  is  bony  ankylosis  of  the  vertebrae. 
Arthritis  ossificans  is  a  progressive  bony  ankylosis  in  which  numerous  joints  are 
involved,  and  are  finally  completely  obliterated.  It  is  essentially  the  same 
disease  as  spondylitis  ossificans  and  is  an  ossifying  arthritis.* 

Fibrous  ankylosis  may  follow  aseptic  inflammation ;  bony  ankylosis  is  apt 
to  follow  infections.  Though  slight  motion  is  usually  possible  in  fibrous  anky- 
losis, in  some  cases  it  may  be  impossible.  A  joint  immovable  from  fibrous 
ankylosis  is  distinguished  from  a  joint  immovable  from  bony  ankylosis  by  the 
fact  that  in  the  former  attempts  at  motion  are  productive  of  pain,  and  subse- 
quently of  inflammation.  The  incapacity  resulting  from  ankylosis  is  due,  first, 
to  the  impairment  or  destruction  of  joint-function,  and,  secondly,  to  the  fixa- 
tion at  an  inconvenient  angle  (a  fixed  flexed  knee  is  worse  than  a  fixed  extended 
knee ;  a  fixed  extended  elbow  is  worse  than  a  fixed  partly  flexed  elbow) . 

Treatment. — The  effort  should  always  be  made  to  prevent  ankylosis  by 
treating  carefully  any  joint-inflammation  and  by  beginning  passive  motion  and 
massage  at  the  proper  time.  To  limit  inflammation  is  to  prevent  ankylosis. 
An  inflammatory  exudate  exists  in  and  about  the  tendons  and  ligaments,  and 
even  in  the  joint.  Early  massage  and  gentle  movements  remove  this  exudate 
before  it  is  organized,  and  if  organization  of  the  exudate  does  not  occur,  anky- 
losis wiU  not  follow  the  injury  or  disease.  In  an  acutely  inflamed  joint,  how- 
ever, passive  motions  must  not  be  made,  the  part  is  kept  at  rest  until  acute 
symptoms  subside,  but  gentle  massage  can  be  used  daily.  When  fibrous 
ankylosis  arises  it  may  be  improved  or  cured  by  the  use  of  the  hot-air  oven, 
passive  motion,  active  movements,  massage,  frictions  with  stimulating  lini- 
ments, inunctions  of  ichthyol  or  mercurial  ointment,  hot  and  cold  douc"hes,  and 
electricity.  Some  cases  may  be  straightened  out  slowly  by  screw-splints  or  by 
weights  and  pulleys.  Fibrous  ankylosis  of  the  elbow  is  best  treated  by  using 
the  joint.  Fibrous  ankylosis  is  often  corrected  by  forcible  straightening.  If 
the  tendons  are  much  contracted,  tenotomy  should  be  performed  two  or  three 
days  before  forcible  straightening  is  attempted.  Before  straightening  forcibly 
always  administer  an  anesthetic.     Suppose  a  .case  of  ankylosis  of  the  knee: 

"'•See  Dr.  Joseph  Griffith,  in  Jour,  of  Pathology  and  Bacteriology,  for  December,  1S96, 
and  March  and  June,  1897. 


498  Diseases  and  Injuries  of  Bones  and  Joints 

administer  ether,  put  the  patient  upon  his  back,  bring  the  leg  over  the  end  of 
the  operating-table,  grasp  the  ankle  with  one  hand  and  the  lower  portion  of  the 
leg  with  the  other  hand,  and  make  strong,  steady  movements  of  flexion  and 
extension  until  the  limb  can  be  straightened.  The  adhesion  will  be  felt  to  break, 
the  snapping  often  being  audible.  At  once  apply  a  plaster-of-Paris  dressing  to 
the  extended  extremity,  and  keep  the  Hmb  immobile  for  two  weeks.  At  the  end 
of  this  period  remove  the  plaster  and  begin  massage  and  passive  movements, 
and,  if  reaction  is  not  great,  soon  advise  active  movements.  This  procedure  is 
not  free  from  danger.  Vessels  may  be  ruptured,  nerves  may  be  torn,  skin  and 
fascia  mav  be  lacerated,  suppuration  may  ensue  from  the  admission  into  the 
joint  of  encapsuled  cocci,  or  of  bacteria  from  the  blood  or  lymph  which  find 
in  this  area  a  point  oj  least  resistance.  Because  of  the  danger  of  opening  up 
depots  of  encapsuled  bacilli  and  cocci,  do  not  forcibly  break  up  an  ankylosis 
that  results  from  tuberculous  or  septic  arthritis,  but  use  gradual  extension  by 
weights  or  by  screw-splints.  Ankylosis  of  the  knee  following  fracture  of  the 
patella  is  almost  sure  to  recur  after  forcible  breaking  up.  The  best  treatment 
for  knee-ankylosis  is  use  of  the  joint.  In  bony  ankylosis  of  any  joint  other  than 
the  elbow-joint  do  nothing  if  the  joint  is  in  a  useful  position.  If  the  joint  is 
firmly  fixed  in  an  unfortunate  position,  resort  to  excision  or  an  osteotomy.  In 
the  elbow  excision  should  be  performed,  no  matter  what  the  position,  in  the 
hope  of  obtaining  a  movable  joint.  In  ankylosis  of  the  jaw  surgeons  formerly 
endeavored  to  remedy  the  condition  by  wedging  the  jaws  apart  with  a  mouth - 
gag,  and  afterward  inserting  boxwood  plugs  at  frequent  intervals.  This 
method  is  invariably  a  failure.*  Esmarch's  operation  is  sometimes  curative 
(removal  of  a  wedge-shaped  piece  of  bone).  Some  operators  excise  the  con- 
dyle and  a  portion  of  the  neck.     Swain  advocates  sawing  the  bone  at  the  angle. 

False  or  Extra-articular  Ankylosis. — In  this  condition  the  joint  is  in- 
tact, but  the  contractures  are  in  surrounding  parts.  The  causes  are  muscular, 
fascial;  and  tendinous  contractures,  cicatrices  (especially  from  burns),  deposits 
of  bone,  muscular  paralyses,  tumors,  and  aneurysms.  Contractions  of  muscles 
or  tendons  may  be  due  to  gout,  rheumatism,  injury,  thecitis,  fractures,  and  dis- 
locations.    False  ankylosis  is  seen  in  club-foot  and  in  Dupuytren's  contraction. 

Treatment. — The  treatment  of  false  ankylosis  depends  upon  the  case.  Re- 
cently contracted  muscles  or  tendons  require  motion,  massage,  frictions  with 
stimulating  liniments,  hot  and  cold  douches,  and  the  use  of  the  hot-air  appara- 
tus. Old  contractions  require  division.  Whenever  possible,  excise  a  cicatrix 
that  causes  false  ankylosis,  and  fill  the  gap  with  sound  tissue.  Bony  deposits 
are  gouged  away  and  tumors  are  removed.  Contractures  in  cases  of  paralysis 
require  electricity,  passive  motion,  frictions  with  stimulating  liniments,  the 
hot-air  bath,  and  general  treatment. 

Loose  Bodies  in  Joints  (Floating  Cartilages).— The  knee  is  the 
joint  oftenest  affected.  These  bodies  may  be  free  or  each  may  have  a  stalk  or 
pedicle;  they  may  move  about  and  occasionally  block  the  joint,  or  may  lie 
quietly  in  a  joint-recess  or  diverticulum.  They  may  be  single  or  multiple,  flat 
or  ovoid,  smooth  or  irregular,  as  small  as  peas  or  as  large  as  plums,  and  may 
be  compo.sed  of  fibrous  tissue,  of  cartilage,  or  of  bone.  There  are  numerous 
different  modes  of  origin  of  these  bodies,  many  being  "detached  ecchondroses 
or  pieces  of  hyaline  cartilage  hanging  by  narrow  pedicles"  (J.  Bland  Sutton), 

*  Swain,  in  Lancet,  1894,  vol.  ii,  p.  187. 


Traumatic  Dislocations  499 

and  they  result  from  enlargement  and  chondrification  of  the  villi  of  the  synovial 
membrane.  Some  loose  bodies  are  broken-off  osteophytes;  some  arise  from 
blood-clots;  some  by  projection  or  herniation  of  the  synovial  membrane,  which 
protrusion  is  broken  off;  others  are  detached  fringes  of  tuberculous  synovial 
membrane.  Traumatism  is  the  usual  exciting  cause.  Loose  cartilages  are 
commonest  in  adult  men. 

Symptoms. — Many  small  bodies  give  rise  to  no  symptoms  other  than  those 
of  synovitis.  A  large  body  produces  pain  and  interferes  with  joint-function. 
The  joint  is  weak  and  a  little  swollen,  and  the  patient  can  feel  the  body  and 
often  can  push  it  into  a  superficial  area  of  the  joint,  where  it  may  be  felt  by  the 
surgeon.  From  time  to  time  the  body  may  get  caught,  thus  suddenly  locking 
the  joint  and  producing  intense  and  sickening  pain,  extension  and  fie.xion  being 
impossible  until  the  body  slips  out.  This  accident  is  followed  by  inflammation 
and  effusion. 

Treatment. — To  relieve  locking,  employ  forced  flexion  and  sudden  exten- 
sion. Cure  can  be  obtained  only  by  operation.  Asepticize  with  the  utmost 
care.  Let  the  patient  bring  the  foreign  body  to  a  point  where  it  can  be 
felt;  the  surgeon  then  fixes  it  with  a  pin  or  holds  it  with  the  fingers,  ether  being 
given  or  cocain  being  used.  The  joint  is  now  opened,  the  foreign  body  ex- 
tracted, and  an  exploration  made  to  see  that  no  other  bodies  are  present.  The 
wound  is  sutured  and  the  leg  is  placed  upon  a  splint.  Asepsis  must  be  most 
rigid.  The  operation  does  not  cure  the  causative  lesion,  and  these  bodies  are 
apt  to  form  again. 

4.   Luxations  or  Dislocations. 

A  dislocation  is  the  persistent  separation  from  each  other,  partially  or  com- 
pletely, of  two  articular  surfaces.  A  self-reduced  dislocation  is  called  a  sprain 
(Douglas  Graham).  There  are  three  forms  of  dislocations:  (i)  traumatic;  (2) 
spontaneous  or  pathological;  (3)  congenital. 

1.  Traumatic  dislocations  are  due  to  injury.  They  are  divided 
into — complete  dislocation,  in  which  the  two  articular  surfaces  are  entirely 
separated  and  the  ligaments  are  torn ;  incomplete  or  partial  dislocation,  in  which 
the  two  articular  surfaces  are  not  completely  separated  and  the  hgaments  are 
rarely  lacerated;  simple  dislocation,  in  which  there  is  no  wound  leading  from  the 
surface  to  the  articulation;  compound  dislocation,  in  which  a  wound  leads  from 
the  surface  to  the  joint;  complicated  dislocation,  in  which,  besides  the  disloca- 
tion, there  is  a  fracture,  extensive  damage  of  the  soft  parts,  an  opening  which 
makes  the  case  compound,  or  damage  of  a  nerve  or  blood-vessel;  primitive  or 
primary  dislocation,  in  which  the  bones  remain  as  originally  displaced ;  secon- 
dary dislocation,  in  which  the  dislocated  bone  assumes  a  new  position;  for  in- 
stance, a  subglenoid  luxation  of  the  humerus  is  primary,  and  it  may  become  sec- 
ondarily a  subcoracoid  luxation  because  of  muscular  contraction  or  attempts  at 
reduction;  recent  dislocation,  in  which  the  displaced  bone  is  not  tirmly  fastened 
by  tissue-changes  in  its  new  situation,  and  its  old  socket  is  not  obliterated;  old 
dislocation,  in  which  the  displaced  bone  is  firmly  fastened  by  tissue-changes 
in  its  new  habitat,  and  the  old  socket  is  to  a  great  extent  obliterated  (whether  a 
dislocation  is  old  or  new  depends  on  the  state  of  the  parts  rather  than  on  the 
time  which  has  elapsed  since  the  accident);  double  dislocation,  in  which  corre- 
sponding bones  on  each  side  are  dislocated ;  single  dislocation,  in  which  only  one 


500  Diseases  and  Injuries  of  Bones  and   Joints 

joint  is  dislocated;  unilateral  dislocation,  in  which  one  articulation  of  one  bone 
is  out  of  place;  bilateral  dislocation,  in  which  symmetrical  articulations  are  dis- 
located; and  relapsing  or  habitual  dislocation,  which  recurs  constantly  from 
slight  force  because  of  relaxed  ligaments  or  lack  of  complete  repair  after  the 
ligamentous  rupture  of  a  first  dislocation. 

2.  Spontaneous,  Pathological,  or  Consecutive  Dislocations. — 

Spontaneous  dislocation  arises  from  such  very  slight  force  that  the  cause  may 
not  be  identified,  and  it  acts  on  a  joint  rendered  lax  by  disease.  It  may  arise 
in  the  course  of  chronic  synovitis,  tuberculous  joint-disease,  or  rheumatoid 
arthritis.  In  typhoid  fever  spontaneous  dislocation  is  not  uncommon. 
The  hip-joint  is  most  often  the  one  attacked.  Dislocation  in  typhoid  jever 
generally  occurs  at  the  hip-joint,  follows  a  severe  joint-inflammation,  is 
usually  upon  the  dorsum  of  the  ilium,  and  is  frequently  not  noticed  until 
convalescence.  If  a  typhoid  dislocation  is  seen  early,  reduction  is  easily 
effected,  but  if  seen  late  is  impossible.  The  treatment  for  irreducible  typhoid 
dislocation  is  the  same  as  for  any  other  irreducible  dislocation.  In  Charcot's 
joint  a  spontaneous  dislocation  will  occur  sooner  or  later. 

3.  Congenital  Dislocations. — A  congenital  dislocation  is  due  to  a 
congenital  joint-malformation  which  renders  it  impossible  for  the  bone  to 
maintain  a  normal  position,  or  is  due  to  external  violence  during  the  period  of 
uterine  gestation.  Congenital  dislocations  should  not  be  confounded  with 
dislocations  produced  during  delivery.  The  hip  is  the  joint  most  often  in- 
volved. The  shoulder  suffers  occasionally.  Lannelongue  maintains  that  con- 
genital dislocation  of  the  hip  is  due  to  atrophy  of  the  muscles  and  of  the  aceta- 
bulum foUowing  spinal-cord  disease.  Verneuil  thinks  the  dislocation  is 
paralytic.  Broca  says  that  in  view  of  the  fact  that  the  head  of  the  bone 
is  larger  than  the  cavity  in  which  it  belongs,  it  is  useless  to  attempt  reduction 
by  manipulation  or  extension.  Lorenz  and  Hoffa  have  each  devised  an  opera- 
tion for  this  condition  (pages  551,  552).  Congenital  dislocation  of  the 
shoulder  requires  incision,  possibly  excision,  or  the  paring  down  of  the  head  to 
fit  the  glenoid  cavity  (Phelps). 

Traumatic  Dislocations. — In  the  succeeding  pages  the  traumatic 
form  of  dislocations  will  be  particularly  considered. 

The  causes  of  traumatic  dislocations  are  divided  into  predisposing  and 
exciting. 

Predisposing  causes  are:  (i)  age;  dislocations  are  commonest  in  middle  life, 
the  usual  lesion  of  the  young  being  green-stick  fracture,  and  that  of  the  old 
being  fracture;  dislocations  of  the  radius  are  not  uncommon  in  youth;  (2) 
muscular  development;  dislocations  being  commonest  in  those  with  powerful 
muscles;  (3)  sex,  males  being  more  predisposed  than  females,  because  of  their 
occupations  and  muscular  .strength;  (4)  occupation  predisposes  as  a  cause  ac- 
cording as  it  demands  the. employment  of  muscular  force,  as  in  the  carrying  of 
burdens;  (5)  nature  oj  the  joint,  ball-and-socket  joints  being  more  liable  to 
luxation  than  are  ginglymoid  joints,  because  of  their  wide  range  of  motion;  (6) 
joint-disease  predisposes  by  relaxing  the  hgaments;  (7)  situation  oj  the  joint, 
some  joints  being  more  exposed  to  injury  than  others. 

Exciting  causes  are  divided  into  (i)  external  violence  and  (2)  muscular 
action.  External  violence  may  be  direct,  as  when  a  blow  upon  one  of  the  bones 
forces  it  directly  away  from  the  other;  or  it  may  be  indirect,  as  when  a  blow  at  a 


Diagnosis  of  Traumatic  Dislocations  501 

distant  part  of  a  bone  transmits  force  to  its  end  and  drives  the  bone  out  of  its 
socket.  Muscular  action  is  a  cause  when  sudden  and  violent  muscular  con- 
traction occurs  during  the  maintenance  of  a  position  of  the  joint  which  gives  the 
muscles  full  sway,  and  throws  the  head  of  the  bone  against  the  weakest  part  of 
its  retaining  ligaments. 

Pathological  Conditions. — In  a  recent  complete  traumatic  dislocation 
the  ligaments  are  damaged,  and  may  perhaps  show  extensive  laceration,  or  may 
show  only  a  buttonhole  laceration  through  which  a  bone  projects.  External 
force  produces  much  laceration  and  Httle  stretching  of  the  ligaments;  muscular 
■  action  produces  httle  laceration  and  much  stretching  of  the  ligaments.  In 
some  cases  of  dislocation  due  to  external  violence  the  structures  about  the  joint 
are  bruised  or  otherwise  damaged;  the  old  socket  is  filled  with  blood,  and  the 
bone  in  its  new  situation  lies  in  a  bloody  area.  Large  vessels  and  nerves  are 
rarely  torn,  though  they  may  be  compressed. 

If  a  dislocation  is  not  soon  reduced,  inflammation  arises  in  the  old  joint  and 
about  the  displaced  bone,  and  the  whole  area  is  glued  together,  first  by  coagu- 
lated exudate,  and  finally  by  fibrous  tissue.  After  a  time,  in  ball-and-socket 
joints,  the  old  socket  fills  with  fibrous  tissue,  contracts,  becomes  irregular,  and 
may  even  be  obliterated;  the  head  of  the  dislocated  bone  is  altered  in  shape,  its 
cartilage  is  destroyed  or  converted  into  fibrous  tissue,  and  the  pressure  of  the 
head  of  the  bone  forms  a  hollow  in  its  new  situation,  which  hollow  becomes 
surrounded  by  fibrous  tissue  or  even  by  bone.  A  new  joint  may  form,  the 
surrounding  tissue  becoming  a  compact  capsule,  and  a  bursa  forming  between 
the  head  of  the  bone  and  its  new  socket.  In  a  dislocated  hinge-joint  the  ends  of 
the  bone  alter  greatly  in  shape  and  their  cartilage  is  converted  into  fibrous  tis- 
sue. In  an  unreduced  dislocation  the  muscles  shorten  or  lengthen  or  undergo 
atrophy  or  fatty  degeneration,  as  the  case  may  be.  An  unreduced  dislocation 
of  a  ball-and-socket  joint  may  give  a  fairly  movable  new  joint,  but  an  unre- 
duced dislocation  of  a  hinge-joint  rarely  allows  of  much  motion. 

General  Symptoms  of  Traumatic  Dislocations. — In  general,  traumatic 
dislocations  are  indicated  (i)  by  pain  of  a  sickening,  nauseating  character;  (2) 
by  rigidity,  voluntary  motion  being  impossible  except  to  a  slight  extent  in  the 
direction  of  the  deformity.  (For  instance,  in  dislocation  of  the  inferior  maxil- 
lary the  jaw  can  be  opened  a  little  more,  but  it  cannot  be  closed.)  This  rigiditv 
brings  about  loss  of  function.  When  the  surgeon  attempts  to  move  the  joint  he 
finds  it  very  rigid;  (3)  by  change  in  the  shape  of  the  joint  (as  flattening  of  the 
shoulder  after  dislocation  of  the  humerus) ;  (4)  by  alteration  in  the  mutual  re- 
lations oj  bony  prominences  about  a  joint  (as  the  alteration  of  the  relation  be- 
tween the  olecranon  and  humeral  condyles  in  dislocation  of  the  elbow  back- 
ward) ;  (5)  by  feehng  the  displaced  bone  in  its  new  situation;  (6)  by  missing  the 
head  of  the  bone  from  its  proper  situation;  (7)  by  alteration  in  the  length  of  the 
limb  (in  dislocation  of  the  femur  into  the  thyroid  foramen  the  limb  is  length- 
ened, but  in  dislocation  onto  the  dorsum  of  the  ilium  it  is  shortened) ;  and  (8)  bv 
alteration  in  the  axis  of  the  bone  (in  dislocation  upon  the  dorsum  of  the  ilium 
the  axis  of  the  injured  thigh  would,  if  prolonged,  pass  through  the  lower  third 
of  the  sound  thigh) ;  (9)  by  seeing  the  dislocation  with  a  fluoroscope  or  looking 
at  a  skiagraph  of  it. 

Diagnosis  of  Traumatic  Dislocations. — .\  dislocation  may  be  mistaken 
for  a  fracture.     In  dislocation  there  is  rigidity,  in  fracture  there  is  preternatural 


502  Diseases  and  Injuries  of  Bones  and  Joints 

mobility;  in  dislocation  there  is  no  true  crepitus  (may  get  tendon-  or  joint- 
crepitus),  in  fracture  there  usually  is  crepitus;  in  dislocation  the  deformity  does 
not  tend  to  recur  after  reduction,  in  fracture  it  does  recur  after  extension  is  re- 
laxed. In  a  sprain  the  movements  of  the  joint  are  only  limited,  not  abolished, 
bv  the  almost  complete  rigidity  encountered  in  dislocation.  The  change 
which  a  sprain  may  cause  in  the  shape  of  a  joint  is  due  to  effusion  or 
to  bleeding;  there  is  no  alteration  in  the  relation  of  the  bony  prominences  to 
one  another;  there  is  no  notable  alteration  in  the  length  of  the  limb  (a  slight 
increase  in  length  may  arise  from  joint-effusion,  or  the  head  of  the  bone  may 
subsequently  be  absorbed,  and  thus  produce  shortening  after  some  weeks) ; 
there  is  no  alteration  in  the  axis  of  the  bone;  the  bony  head  is  not  felt  in  a 
new  position,  and  it  is  found  in  its  normal  place.  Always  remember  that  a 
fracture  may  exist  with  a  dislocation.  In  any  doubtful  case — in  fact,  in 
most  cases — give  ether,  for  a  dislocation  should  be  reduced  while  the  patient 
is  anesthetized  (except  in  dislocation  of  the  jaw,  of  the  fingers,  of  the  carpus, 
etc.).  In  some  cases  swelling  renders  the  diagnosis  difihcult  or  impossible. 
Always  compare  the  injured  joint  with  the  corresponding  joint  of  the  sound 
side.     The  .r-rays  constitute  a  valuable  aid  to  diagnosis. 

Treatment  of  Traumatic  Dislocations. — Recent  Simple  Dislocations. — 
Reduce  simple  dislocations  under  ether,  as  a  rule.  Try  manipulation,  a  pro- 
cedure which  seeks  to  make  the  bone  retrace  its  own  pathway.  If  this  pro- 
cedure fails,  employ  extension  and  counter-extension.  If  considerable  force  is 
needed,  an  assistant  makes  counter-extension,  and  the  surgeon  fastens  to  the 
extremity  a  clove-hitch,  which  he  ties  about  his  waist,  and  thus  secures  power- 
ful extension.  Counter-extension  may  be  obtained  by  bands,  or,  in  some  in- 
stances, by  the  foot  of  the  surgeon.  The  clove-hitch  is  used  because  it  will  not 
tighten  by  traction;  a  tightening  band  would  lacerate  the  soft  parts  (Fig.  240). 
If  great  power  is  needed,  compound  pulleys  may  be  employed,  such  as  the 
Jarvis  adjuster  or  some  similar  appliance,  but  at  the  present  day  pulleys  are 
rarely  used  (see  page  504) .  If  these  means  fail,  cut  down  upon  the  bone  and 
restore  it  to  position;  operation  is  much  safer  than  is  the  application  of  great 
force.  After  reducing  a  dislocation,  immobiUze  the  joint  for  a  time,  which 
varies  for  different  joints,  and  for  the  first  few  days  combat  swelling  and  inflam- 
mation by  rest  of  the  part  and  the  use  of  evaporating  lotions  or  an  ice-bag.  If 
there  exists  a  fracture  of  the  dislocated  bone,  apply  sphnts  and  then  try  to  re- 
duce by  manipulations,  grasping  the  Hmb  and  the  spHnts  with  one  hand  below 
and,  if  possible,  with  the  other  hand  above  the  seat  of  the  fracture.  AUis  be- 
lieves that  a  dislocation  can  be  reduced  even  when  a  fracture  exists.  It  is  pos- 
sible to  pull  the  dislocated  head  down  to  the  joint,  because  a  portion  of  perios- 
teum and  possibly  tendinous  material  and  muscle  still  hold  the  two  fragments 
as  a  strap  might  unite  two  sticks.  The  head  can  be  forced  into  place  by  the 
fingers  while  traction  is  being  made.  If  the  fracture  is  near  the  joint  and  the 
fragments  cannot  be  fixed,  try  to  reduce  the  dislocation,  first  striving  to  press 
the  bone  into  place.  This  attempt  can  be  greatly  aided  by  traction  upon  the 
lower  fragment.  In  some  cases  with  fracture  reduction  can  be  much  aided  by 
making  a  small  incision,  screwing  a  gimlet  into  the  head  of  the  bone,  and  using 
this  tool  as  a  handle.  McBurney  incises,  drills  a  hole  in  each  bone,  inserts 
hooks  into  them,  and  pulls  the  dislocated  bone  into  position  (Figs.  159,  160). 
When  the  dislocation  has  been  reduced,  the  bone  fragments  should  be  wired. 


Special  Traumatic  Dislocations  503 

Compound  Traumatic  Dislocations. — The  opening  in  the  soft  parts  may  be 
due  to  external  violence  or  to  projection  of  a  bone.  Compound  dislocations  are 
very  serious.  Hinge-joints  are  more  liable  to  these  injuries  than  are  ball-and- 
socket  joints.  Many  cases  require  excision-,  some  amputation;  one  that  does 
not  demand  excision  or  amputation  should  be  treated  by  sterilizing  the  parts, 
restoring  the  dislocated  bone,  making  a  counter-opening,  draining,  dressing 
antiseptically,  and  immobihzing.  Considerable  ankylosis  generally  ensues, 
except  sometimes  in  the  small  joints.  It  is  scarcely  ever  necessary  to  cut  away 
any  portion  of  the  protruding  bone  to  effect  reduction.  If  a  joint  is  badly 
splintered,  or  if  the  soft  parts  are  extensively  damaged,  it  may  be  necessary 
to  excise  or  amputate;  if  the  main  vessels  or  the  nerves  are  seriously  injured, 
or  if  the  patient  is  so  old  or  so  feeble  that  it  is  perilous  to  force  him  to  combat 
a  long  illness,  amputate. 

Old-  Traumatic  Dislocations. — The  problem  always  presented  in  an  old 
dislocation  is.  Shall  reduction  be  tried,  or  shall  the  bones  be  let  alone?  Sir 
Astley  Cooper  laid  down  this  rule:  "Do  not  attempt  to  reduce  a  shoulder- 
dislocation  after  three  months,  nor  a  hip-dislocation  after  two  months";  but 
this  rule  was  put  forth  before  the  days  of  ether.  Do  not  select  any  fixed  period 
of  time  to  determine  what  action  is  advisable.  In  dislocation  of  a  ball-and- 
socket  joint  considerable  motion  may  become  possible  and  a  new  joint  may 
form.  If  movement  does  not  produce  pain,  a  useful  new  joint  may  be  obtained 
by  the  persistent  employment  of  active  and  passive  movements;  if  movement 
of  the  limb  does  produce  pain,  enough  motion  will  not  be  attempted  by  the 
patient  to  produce  a  useful  joint.  In  the  former  case  try  to  obtain  a  useful  new 
joint,  and  in  the  latter  case  try  to  reduce  the  old  dislocation.  Always  remem- 
ber that  dislocations  of  a  hinge-joint,  if  left  unreduced,  will  never  eventuate 
in  a  useful  new  joint. 

In  trying  to  reduce  an  old  dislocation,  give  ether,  make  movement  to  break 
up  adhesions,  and  persist  in  making  these  motions  until  the  head  of  the  bone 
is  felt  to  move;  then  try  at  once  to  reduce  by  manipulation  or  extension,  and 
counter-extension,  not  waiting  for  two  days,  as  some  suggest.  If  the  head  of 
the  bone  cannot  be  made  to  move,  the  Dieffenbach  plan  may  be  followed, 
which  is  to  cut  the  tense  restraining  bands  with  a  tenotome.  Lord  Lister, 
being  much  impressed  with  the  danger  inevitably  linked  with  forcibly  drag- 
ging old  dislocations  into  place,  prefers  to  cut  down  and  restore  the  bone, 
employing,  of  course,  the  strictest  asepsis,  and  surgeons  in  general  have 
adopted  this  view.  In  some  old  dislocations  excision  of  the  head  of  the  bone 
is  the  proper  operation. 

Special  Traumatic  Dislocations.— Lower  Jaw,— A  dislocation  of 
the  lower  jaw,  when  there  is  no  fracture,  is  almost  in\ariably  forward.  Back- 
ward dislocation  without  fracture  is  extremely  rare,  and  some  have  maintained 
that  it  cannot  occur.  Croker  King  reported  a  case  in  185S.  Theim  has  ob- 
served it  seven  times  in  five  women.  The  condyle  passes  under  the  lower  sur- 
face of  the  auditory  canal.*  The  common  dislocation  is  forward,  and  this  is 
the  form  meant  when  we  simply  speak  of  dislocation  of  the  jaw.  There  are 
two  forms  of  forward  dislocation — the  unilateral,  which  is  rare,  and  the  bi- 
lateral, which  is  common.  Dislocations  of  the  jaw  are  commonest  in  women 
and  during  middle  life.  When  the  mouth  is  open,  contraction  of  the  external 
pterygoid  muscle  may  pull  the  condyle  over  the  articular  eminence;  this  con- 
*  Tlieim,  in  Rev.  de  Chir.,  vol.  viii,  1888. 


504  Diseases  and  Injuries  of  Bones  and  Joints 

traction  may  be  brought  about  by  yawning,  vomiting,  scolding,  etc.  When 
the  mouth  is  open,  dislocation  of  the  lower  jaw  may  be  caused  by  a  blow  upon 
the  chin;  it  may  also  be  caused  by  forcing  the  mouth  more  widely  open  by 
pushing  a  bulky  body  between  the  teeth. 

Symptoms  of  Lower-jaw  Dislocations. — In  the  bilateral  form  the  mouth  is 
open  and  fixed,  and  it  cannot  be  closed,  though  it  can  be  opened  a  httle  more. 
The  condyles  are  in  front  of  the  articular  eminences,  and  are  fixed  by  the  action 
of  the  masseters  and  internal  pterygoids,  the  coronoid  processes  being  wedged 
against  the  malar  bones.  The  lower  jaw  is  advanced  in  front  of  the  upper  jaw 
and  the  face  looks  longer  than  natural.  The  lips  cannot  close,  the  sahva 
dribbles,  swallowing  and  speech  are  difficult,  there  is  a  depression  in  front  of 
each  ear,  the  condyles  are  recognizable  in  their  new  abodes,  the  coronoid  pro- 
cesses are  detected  by  a  finger  in  the  mouth,  and  the  masseters  and  temporals 
stand  out  in  a  state  of  rigidity.  Pain  may  be  severe,  may  be  moderate,  or 
mav  be  absent.  In  the  unilateral  form  the  chin  goes  toward  the  sound  side, 
and  the  mouth  is  not  so  widely  open  as  in  the  bilateral  form,  neither  is  the 
jaw  so  fixed.  The  symptoms  are  similar  to  those  of  a  bilateral  luxation,  but 
are  not  so  pronounced.  The  hollow  in  front  of  the  ear  and  the  abnormal 
situation  of  the  condyle  are  detected  upon  one  side  only.  In  an  unreduced 
dislocation  the  patient  may  after  a  time  establish  some  movement  of  the  jaw, 
but  the  power  of  mastication  will  always  be  seriously  impaired. 

Treatment  0}  Lower-jaw  Dislocations. — In  reducing  a  dislocation  of  the 
lower  jaw  the  patient  is  placed  with  his  head  against  the  back  of  a  chair  or 
against  the  body  of  an  assistant.  The  surgeon,  after  wrapping  up  his  thumbs  to 
protect  them  from  being  bitten,  stands  in  front  of  the  patient,  puts  his  thumbs 
upon  the  last  molar  teeth,  and  grasps  the  chin  with  his  free  fingers.  He  now 
presses  downward  and  backward  on  the  jaw,  and  as  soon  as  the  condyle  is  loos- 
ened closes  the  jaw  over  the  thumbs  by  pushing  up  the  chin,  using  his  thumbs 
as  levers.  If  this  prpcedure  fails,  wedges  should  be  put  between  the  molar  teeth 
and  the  chin  should  be  pushed  up  either  by  the  hands  or  by  a  tourniquet  whose 
band  is  round  the  head  and  chin.  In  a  unilateral  dislocation  the  wedge  should 
only  be  used  on  the  injured  side.  In  difficult  cases  vSir  Astley  Cooper  pushed 
a  round  wooden  ruler  between  the  molar  teeth,  used  the  upper  teeth  as  a  ful- 
crum, and  raised  the  end  of  the  ruler  as  the  handle  of  a  lever.  The  forceps 
used  by  an  anesthetizer  may  depress  the  condyle  from  its  point  of  fixation, 
whereupon  the  chin  may  be  pushed  up  and  back.  Nekton's  plan  was  to  put 
the  thumbs  in  the  mouth  and  push  the  coronoid  processes  backward.  After 
reduction  a  Barton  bandage  is  applied  and  worn  for  over  two  weeks.  The 
dressing  is  renewed  once  a  day,  and  passive  motion  is  begun  in  the  second 
week..  The  bandage  is  discarded  in  the  third  week.  Liquid  diet  is  advisable 
for  three  weeks  after  the  accident.  In  an  old  dislocation  reduction  is  always 
attempted,  at  least  up  to  a  period  of  six  or  seven  months  after  the  accident. 
An  unreducible  dislocation  requires  osteotomy  of  the  neck  of  the  bone,  if  the 
part  cannot  be  restored  after  incision. 

Dislocation  of  the  Clavicle.— Sternal  End. — There  are  three  forms  of 
dislocation  of  the  sternal  end  of  the  clavicle,  namely:  (i)  forward;  (2)  back- 
ward; and  (3)  upward. 

Forward  Dislocation  of  the  Sternal  End  of  the  Clavicle.— The  causes 
of  forward  dislocation  of  the  clavicle  are  blows,  falls,  or  pulls  which  drive  or 
draw  the  shoulder  backward. 


Dislocation  of  the  Clavicle 


505 


Symptoms  and  Treatment  0/  Forward  Dislocation  0/  the  Sternal  End  oj 
the  Clavicle. — The  symptoms  manifest  in  dislocation  of  the  clavicle  are: 
prominence  in  front  of  the  sternum;  the  acromion  is  nearer  to  the  sternum 
on  the  injured  than  on  the  sound  side;  the  clavicular  origin  of  the  sterno- 
cleidomastoid muscle  is  rigid ;  movement  is  difficult  and  painful.  To  reduce 
a  dislocation  of  the  clavicle,  pull  the  shoulders  back  against  the  knee  of  the 
surgeon,  which  is  placed  between  the  scapula;.  Dress  with  a  posterior  figure- 
of-eight  bandage  (Fig.  532),  or  a  Velpeau  bandage  (Fig.  534),  the  dressing 
to  be  worn  for  three  weeks.  After  removal  of  the  dressing  apply  a  truss,  the 
pad  of  which  is  put  over  the  head  of  the  clavicle,  and  which  instrument  is 
to  be  worn  for  a  month.  Dislocation  of  the  clavicle  is  difficult  to  keep  re- 
duced, but  even  if  it  becomes  fixed  in  deformity  the  motions  of  the  arm  will 
not  be  impaired  permanently.  It  can  be  reduced  and  fixed  by  incision  and 
wiring. 

Backward  dislocation  of  the  sternal  end  of  the  clavicle  is  very  rare. 


Fig.  236. — Rhoads's  apparatus  for  treating  dislocation  upward  of  the  acromial  end  of  the  clavicle. 


The  causes  are  direct  violence  and  indirect  force,  such  as  falls  or  blows  which 
drive  the  shoulder  forward  and  inward. 

Symptoms  and  Treatment  oj  Backward  Dislocation  of  the  Sternal  End  oj 
the  Clavicle. — The  symptoms  are:  pain;  loss  of  function  in  the  arm;  inchnation 
of  head  toward  the  injured  side;  stiffness  of  the  neck;  the  shoulder  passes  for- 
ward and  inward,  and  often  falls  downward;  a  depression  exists  over  the  sterno- 
clavicular joint;  the  head  of  the  clavicle  cannot  be  felt,  or  is  found  back  of  the 
sternum.  The  displaced  clavicle  may  press  upon  the  trachea,  the  esophagus, 
or  the  great  vessels,  inducing  dyspnea,  dysphagia,  obliteration  of  pulse  in  the 
arm  of  the  injured  side,  or  great  venous  congestion  of  the  head  (see  Pick). 
To  treat  a  backward  dislocation,  pull  the  shoulders  backward  and  apply  a 
]")osterior  figure-of-eight  bandage  (Fig.  532),  which  must  be  worn  for  three 
weeks.  If  pressure-symptoms  are  urgent,  incise,  restore  the  bone  to  place 
and  wire  it,  or  resect  the  displaced  head. 

Upward  dislocation  of  a  clavicle  is  very  rare.  The  cause  is  indirect  force 
which  carries  the  shoulder  downward,  inward,  and  backward  (Smith). 


5o6  Diseases  and  Injuries  of  Bones  and  Joints 

Symptoms  and  Treatment  of  Upward  Dislocation  of  the  Sternal  End  of  the 
Clavicle. — The  chief  symptom  is  impaired  function  of  the  arm;  the  shoulder 
passes  downward  and  inward,  the  clavicular  axis  is  altered,  and  the  displaced 
head  is  felt.  Dyspnea  may  or  may  not  exist.  To  treat  this  dislocation,  put  a 
pad  in  the  axilla  and  press  the  elbow  to  the  side  in  order  to  throw  the  bone  out- 
ward, and  try  to  push  the  head  into  place.  Apply  a  Desault  bandage  (Fig. 
536)  and  place  a  firm  pad  over  the  sternoclavicular  joint.  The  deformity  is 
apt  to  recur,  but  a  useful  Hmb  will  nevertheless  be  obtained.  It  may  be  de- 
sirable to  wire  the  bones  in  place. 

Dislocation  of  the  acromial  end  of  the  clavicle  is  almost  always  upward, 
but  it  may  be  below  the  acromion.  The  cause  is  violent  force,  which,  if  so 
applied  to  the  scapula  as  to  drive  the  shoulder  forward,  may  produce  a  dis- 
location upward.  A  dislocation  downw^ard  is  due  to  blows  upon  the  upper 
surface  of  the  outer  end  of  the  clavicle. 

Symptoms  and  Treatment. — The  symptoms  of  dislocation  of  the  acromial 
end  of  the  clavicle  are:  prominence  of  the  clavicle  upon  the  top  of  the  acromion; 
impaired  function  of  the  arm  (it  cannot  be  lifted  over  the  head) ;  the  shoulder 
falls  downward  and  passes  inward ;  there  is  apparent  lengthening  of  the  arm ; 
the  head  is  bent  toward  the  injured  side,  and  the  clavicular  origin  of  the 
trapezius  is  strong!}-  outlined  (Pick).  In  dislocation  downward  both  the 
acromion  and  the  coracoid  are  very  prominent,  the  clavicular  axis  is  altered, 
and  there  is  depression  over  the  sternoclavicular  joint.  A  dislocation  upward 
is  reduced  by  pulling  the  shoulder  back  and  pushing  the  bone  into  place. 
The  old  method  was  to  apply  a  Desault  bandage,  which  was  kept  on  for 
three  weeks,  and  more  or  less  deformity  was  looked  for  as  inevitable.  Stimson 
dresses  with  adhesive  plaster.  The  author  has  recently  seen  a  case  treated 
by  the  apparatus  of  Thomas  Leidy  Rhoads.  The  apparatus  completely 
corrected  the  deformity,  and  the  patient  made  a  most  satisfactory  recovery. 
The  essential  element  of  Rhoads's  apparatus  is  a  trunk  strap  applied  as  is 
shown  in  Fig.  236.  Dislocation  downward  is  reduced  and  treated  in  the 
same  manner  as  dislocation  upward. 

Simultaneous  dislocation  of  both  ends  of  the  clavicle  is  a  very  rare  injury. 
It  is  treated  as  is  single  dislocation. 

The  so-called  dislocation  of  the  lower  angle  of  the  scapula  is  not, 
as  it  was  long  thought  to  be,  a  dislocation  at  all.  The  lower  angle  and  verte- 
bral border  deviate  from  the  chest.  This  condition  was  thought  to  be  due 
to  the  bone  slipping  from  under  the  latissimus  dorsi  muscle,  but  it  is  now 
known  to  be  due  to  paralysis  of  the  serratus  magnus  muscle,  the  bone  being 
acted  upon  by  the  trapezius,  pectoralis  minor,  levator  anguli  scapulae,  and 
rhomboid  muscles.  Examination  shows  that  the  scapula  will  not  rotate 
normally  forward.  This  is  demonstrated  by  extending  the  arms  in  front 
to  a  right  angle,  the  gliding  forward  of  the  scapula  upon  the  sound  side  being 
marked  and  upon  the  diseased  side  being  slight  or  absent. 

Treatment  of  paralysis  of  the  serratus  magnus  muscle  comprises  mas- 
sage, electricity,  passive  motion,  and  deep  injections  of  strychnin. 

Dislocations  of  the  Humerus  (Shoulder-joint). — These  injuries  are 
quite  frequent  because  of  the  free  mobility  of  the  shoulder-joint,  its  anatomical 
insecurity,  and  its  exposed  .situation;  they  rarely  occur  in  the  very  young 
and  in  the  aged,  and  are  oftenest  encountered  in  muscular  young  adults. 


Dislocations  of  the  Humerus 


507 


Four  chief  forms  of  shoulder- joint  dislocation  exist,  namely:  (i)  forward, 
inward,  and  downward,  under  the  coracoid  process — subcoracoid;  (2)  down- 
ward, forward,  and  inward,  beneath  the  glenoid  cavity — subglenoid;  (3) 
backward,  inward,  and  downward,  under  the  spine  of  the  scapula — sub- 
spinous; and  (4)  forward,  inward,  and  upward,  under  the  clavicle — sub- 
clavicular. 

A  very  rare  form  of  shoulder-joint  dislocation  has  been  described,  which 
is  known  as  the  supracoracoid.     Another  rare  form  is  the  luxatio  erecta. 

Subcoracoid  Luxation. — The  subcoracoid  variety  of  dislocation  embraces 
three-fourths  of  all  the  shoulder-joint  luxations.  It  may  be  caused  by  direct 
force  driving  the  head  of  the  humerus  forward  and  inward,  or  bv  indirect 


Fig.  237. — Subcoracoid  dislucaliua 


jt  ihc  hunic-rus  (St.  Joseph's  Hospiuil 
Dr.  Nassau). 


: ;  photographed  by 


force,  such  as  falls  upon  the  hand  or  the  elbow.  In  this  dislocation  the 
anatomical  neck  of  the  humerus  lies  upon  the  anterior  margin  of  the  glenoid 
cavity,  just  beneath  the  coracoid  process,  and  is  above  the  tendon  of  the 
subscapularis  muscle. 

Subclavicular  luxation  is  very  rare.  It  is  caused  by  the  same  sort  of 
violence  which  produces  subcoracoid  luxation.  The  head  of  the  bt)ne  rests 
upon  the  thorax,  below  the  clavicle  and  underneath  the  })ectoralis  major 
muscle. 

Subg/enoid  or  axillary  luxation  may  be  produced  by  contraction  of  the 
great  pectoral  and  latissimus  dorsi  muscles  when  the  arm  is  at  a  right  angle 
to  the  body,  but  it  is  usually  due  to  falls  upon  the  hand  or  the  elbow  when 
the  arm  is  raised  and  the  head  of  the  bone  is  against  the  lower  pcrtion  of 


5o8  Diseases  and  Injuries  of  Bones  and  Joints 

the  capsule.  In  this  dislocation  the  head  of  the  bone  rests  upon  the  border 
of  the  scapula,  below  the  tendon  of  the  subscapularis,  in  front  of  the  long 
head  of  the  triceps,  and  above  the  teres  muscles.  Some  observers  hold  that 
most  dislocations  of  the  shoulder  are  primarily  subglenoid,  the  position 
having  been  altered  by  muscular  action.  Lnxatio  erecta  is  an  unusual  form 
of  subglenoid  dislocation.  The  arm  is  upright  and  the  forearm  rests  behind 
the  occiput  or  on  the  top  of  the  head,  and  the  patient  holds  it  there  to  avoid 
pain.     Judd,  Hulke,  and  Cleland  have  related  cases. 

Subspinous  luxation  is  a  rare  injury.  Pick  met  with  this  accident  in  a 
man  who,  while  having  his  hands  in  his  pockets,  fell  upon  the  front  of  the 
point  of  the  shoulder.  The  head  of  the  bone  reposes  beneath  the  scapular 
spine,  between  the  infraspinatus  and  teres  minor  muscles. 

Supracoracoid  luxation  is  seldom  encountered.  The  head  of  the  humerus 
rests  upon  the  coraco-acromial  ligament  or  upon  the  acromion  process  and 
the  acromion  or  the  coracoid  is  always  fractured. 

Symptoms  of  Dislocation  of  the  Shoulder-joint. — Dislocation  is  diagnos- 
ticated by  (i)  pain  of  a  sickening  character;  (2)  flattening  of  the  shoulder, 
the  head  of  the  bone  having  ceased  to  bulge  out  the  deltoid  muscle;  (3)  ap- 
parent projection  of  the  acromion  through  sinking  in  of  the  deltoid;  (4) 
hollow  beneath  the  acromion,  over  the  empty  glenoid  cavity,  and  the  bone 
missed  from  its  normal  habitat.  This  hollow  may  be  easily  appreciated 
by  the  finger,  especially  when  the  extremity  is  somewhat  abducted;  (5)  rigidity 
(some  movement  is  possible,  in  the  direction  especially  of  an  existing  de- 
formity, but  mobility  is  strictly  limited  and  attempts  at  motion  produce 
great  pain);  (6)  Dugas's  .sign:  the  elbow  cannot  touch  the  side  when  the 
hand  is  placed  upon  the  sound  shoulder,  and  the  hand  cannot  be  placed 
upon  the  sound  shoulder  if  the  elbow  is  to  the  side  (this  is  due  to  the  rotundity 
of  the  chest.  In  a  dislocation  the  head  of  the  bone  is  already  touching  the 
chest,  and  the  bone,  being  approximately  straight,  cannot  touch  it  in  two 
places  at  the  same  time.  If  the  elbow  can  be  placed  against  the  chest  with 
the  hand  on  the  sound  shoulder,  there  cannot  be  dislocation;  if  it  cannot 
be  so  placed,  there  must  be  dislocation) ;  (7)  finding  the  head  of  the  bone 
in  a  new  situation;  (8)  examining  by  means  of  the  .T-rays.  Symptoms  i  to 
5  inclusive  may  be  grouped  as  Erichsen's  list  of  signs.  The  form  of  dis- 
location is  made  out  by  a  study  of  the  direction  of  the  axis  of  the  limlj,  the 
existence  and  extent  of  lengthening  or  of  shortening,  and  the  situation  of  the 
head  of  the  bone. 

In  a  shoulder-joint  dislocation  the  head  of  the  bone  may  press  u])on  the 
brachial  plexus  and  produce  pain  and  numbness,  and  occasionally  a  traumatic 
neuritis  or  pjaralysis;  sometimes  pressure  upon  the  axillary  vein  causes  intense 
edema,  and  pressure  upon  the  axillary  artery  diminishes  or  obliterates  the 
pulse.  The  axillary  vessels  may  be  torn  and  the  muscles  may  be  lacerated 
badly.  The  capsule  is  torn  and  considerable  blood  is  usually  effused.  Swell- 
ing is  due  first  to  hemorrhage,  and  secondly  to  inflammation.  Partial  dis- 
locations sometimes,  though  rarely,  occur.  What  is  usually  spoken  of  as 
"partial  dislocation"  or  "subluxation"  is  a  condition  in  which  the  head  of 
the  humerus  passes  forward  under  the  coracoid  because  of  rupture  of  the 
long  head  of  the  biceps  or  because  this  tendon  slips  out  of  its  groove,  the 
ligaments  of  the  shoulder-joint  being  intact. 


*  Dislocations  of  the  Humerus 


509 


The  following  table  from  T.  Pickering  Pick's  work  on  "Fractures  and 
Dislocations"  makes  the  above  points  clear: 


Presence  of  the  He.\d 

Direction  of  the  Axis 

Alteration  in  the 

OF  the  Bone  in  New 

OF  THE  Limb. 

Length  ok  the  Limb. 

Situation. 

Subcoracoid. 

Tlie  elbow  is  carried 

Very  slight  lengthen- 

The head  of  the  bone 

backward    and    slightly 

ing. 

cannot  easily  be  felt ;  it  is 

away  from  the  side. 

found    at    the    upper  and 
inner  part  of  the  axilla. 

Subglenoid. 

The  elbow  is  carried 

Very       considerable 

The  head  of  the   bone 

away    from    the    trunk 

lengthening. 

can  easily  be    felt   in  the 

and  slightly  backward 

axilla. 

Subspinous. 

The   elbow  is  raised 

Lengthening  interme- 

The head   of   the  bone 

from  the  side  and  car- 

diate in  degree  between 

can  be  felt  and  be  grasped 

ried  forward. 

the  subglenoid  and  the 

beneath   the   spine  of    the 

subcoracoid. 

scapula. 

Subclavicular. 

The  elbow  is  carried 

Shortening. 

The  head  of   the   bone 

outward  and  backward. 

can  readily  be  seen  and  he 

felt  beneath  the  clavicle. 

Diagnosis  oj  Shoulder-joint  Dislocation. — In  fracture  of  the  neck  of  the 
scapula  there  is  prominence  of  the  acromion  and  a  hollow  below  it,  a  hard 
body  being  felt  in  the  axilla;  but  the  coracoid  process  descends  with  the 
head  of  the  humerus,  which  it  does  not  do  in  dislocation.  Furthermore,  in 
fracture  there  is  mobility;  in  dislocation,  rigidity.  In  fracture  crepitus  is 
present ;  in  dislocation  it  is  absent.  In  fracture  the  deformity  is  easily  reduced, 
but  it  at  once  recurs;  in  dislocation  the  deformity  is  with  difficulty  reduced, 
but  does  not  recur.  In  fracture  the  elbow  can  be  made  to  touch  the  side 
when  the  hand  is  upon  the  sound  shoulder;  in  dislocation  it  cannot  be  so 
manipulated.  In  fracture  of  the  anatomical  neck  of  the  humerus  deformity 
is  slight;  the  head  of  the  humerus  is  found  in  place,  does  not  move  when 
the  shaft  is  rotated,  and  is  not  in  line  with  the  axis  of  the  bone.  Crepitus 
exists  in  the  fracture  if  impaction  is  absent.  In  paralysis  of  the  deltoid  mus- 
cle there  is  distinct  flattening,  but  the  bone  is  felt  in  place  and  there  is  no 
rigidity.     The  .v-rays  are  a  great  aid  to  diagnosis. 

Treatment  oj  Shoulder-joint  Dislocation. — Reduction  b}"  manipulation  is 
usually  readily  obtained  in  recent  cases  of  shoulder-joint  dislocation.  If  a 
simple  trial  without  ether  fails,  an  anesthetic  should  be  administered.  For- 
ward dislocations  (subcoracoid,  subclavicular,  and  axillary)  are  reduced' 
by  Kocher's  method  (Fig.  238).  Reduction  by  this  method  can  frequently 
be  effected  without  the  aid  of  ether.  Put  the  arm  against  the  side,  flex  the 
forearm  to  a  right  angle  with  the  arm,  perform  external  rotation  of  the  arm 
until  resistance  becomes  decided,  raise  the  elbow,  make  internal  rotation, 
bring  the  arm  across  the  front  of  the  chest  and  lower  the  elbow.  The  for- 
mula is,  flexion  of  the  forearm,  external  rotation,  lifting  the  elbow  forward, 
internal  rotation  of  the  arm,  and  lowering  the  elbow.  The  motions  to  unlock 
the  bone  and  start  it  to  retrace  the  steps  it  took  when  emerging  should  be 
gentle,  not  forcible;  slow,  not  sudden;  and  rigid  muscles  should  be  tired  out 
and  made  to  relax  by  steady  traction  upon  then-i.  Sudden  and  violent 
motions  increase  rigidity.  If  in  trying  Kocher's  plan  external  rotation  of 
the  humerus  does  not  take  place,  abandon  the  method,  as  persistence  will 


10 


Diseases  and  Injuries  of  Bones  and  joints 


fracture  the  humerus.  Another  method  of  manipulation  is  as  follows:  if 
the  right  shoulder  is  dislocated,  the  surgeon  stands  behind  the  patient  (who 
is  sitting  erect) ;  if  the  lejt  shoulder  is  dislocated,  he  stands  in  front  of  the 
patient.  The  surgeon  holds  the  forearm  flexed  upon  the  arm  with  his  right 
hand  and  makes  external  traction  and  rotation,  and  with  the  fingers  of  his 
left  hand  he  tries  to  force  the  bone  into  place. 

In  Henry  H.  Smith's  method  for  forward  dislocations  the  surgeon  stands 
in  front  of  the  patient.  If  the  lejt  shoulder  is  dislocated,  the  surgeon  grasps 
it  with  his  left  hand;  if  the  right  shoulder  is  dislocated,  he  grasps  it  with  his 
right  hand,  the  thumb  resting  on  the  head  of  the  bone.  With  his  disengaged 
hand  the  surgeon  grasps  the  elbow,  abducts  it,  makes  traction  and  external 
rotation,  and  suddenly  sweeps  the  elbow  inward,  aiming  it  at  the  sternum, 
and  tries  with  his  thumb  to  push  the  bone  into  place.  In  subspinous  luxa- 
tions reduction  may  be  eft'ected  if  the  surgeon  stands  behind  the  patient, 
makes  abduction,  traction,  and  internal  rotation,  sweeps  the  elbow  inward 
toward  the  spine,  and  wath  the  thumb  aids  the  bone  in  its  return  into  position. 
Raising  the  elbow  far  above  the  head  and  sweeping  it  inward  will  reduce 
some  dislocations.     As  the  head  of  the  bone  slips  back  a  distinct  jar  is  felt 


Fig.  238.— Kocher's  method  of  reduction  by  manipulation  :  a,  First  movement,  outward  rotation; 
b,  second  movement,  elevation  of  elbow  ;  c,  third  movement,  inward  rotation  and  lowering  of  the 
elbow  (Ceppi). 

and  a  snap  is  heard,  the  motions  of  the  joint  are  again  obtainable,  and  with 
the  hand  on  the  opposite  shoulder  the  elbow  may  be  made  to  touch  the  side. 

Reduction  by  Extension.— Beiore  attempting  the  reduction  of  a  dis- 
location of  the  shoulder-joint  by  extension,  the  patient  should  be  anes- 
thetized and  placed  upon  a  low  bed  or  upon  the  floor.  The  surgeon 
then  places  his  foot,  covered  only  by  a  stocking,  in  the  axilla.  Place 
the  sole  of  the  foot,  not  the  heel,  against  the  chest  high  up,  the  instep 
being  made  to  touch  the  humerus  and  the  heel  the  border  of  the  shoulder- 
blade,  a  towel  being  first  put  into  the  axiUa  to  rest  the  foot  against 
(Fig.  239).  If  the  left  arm  is  dislocated,  use  the  left  foot,  and  vice  versa. 
The  elder  Gross  approved  of  making  extension  while  sitting  between  the 
patient's  limbs.  Make  steady  extension,  which  will  in  many  cases  bring 
about  the  reduction.  If  it  fails  to  cause  reduction,  bring  the  patient's  arm 
across  the  chest  and  use  the  foot  as  the  fulcrum  of  a  lever.  If  the  humerus 
is  pretty  firmly  fixed  in  its  abnormal  position,  make  counter-extension  with 
a  foot  in  the  axilla  and  make  extension  by  fixing  a  clove-hitch  (Fig.  240) 
above  the  elbow  and  fastening  to  it  bands  which  go  over  one  shoulder  and 
under  the  other  shoulder  of  the  surgeon.     The  back  may  be  used  for  extension, 


Dislocations  of  the  Humerus 


511 


the  hands  being  left  free  for  manipulation  (AUis's  and  Pick's  plan).  Lateral 
extension  is  used  by  some  surgeons.  The  patient  lies  down,  a  large  piece  of 
canvas  is  split,  the  arm  is  passed  through  the  split  and  the  body  is  thus  fixed. 
The  arm  is  pulled  to  a  right  angle  with  the  body  and  traction  is  applied. 

The  late  Prof.  Joseph  Pancoast  favored  Sir  Astley  Cooper's  method  of 
placing  the  unanesthetized  patient  in  a  chair  and  using  the  knee  as  a  fulcrum, 

pushing  the  elbow  to  the  side  (Fig.  241). 
Brunus,  in  the  thirteenth  century,  de- 
\ised  the  method  of  upward  exten- 
sion.    In    applying    this    method    the 


Fig.  239. — Reduction  of  shoulder-joint  disloca- 
tion by  the  foot  in  the  axilla  (Cooper). 


Fig.  240. — Clove-hitch  knot  applied  above 
the  wrist.  In  dislocation  of  the  shoulder  this 
knot  is  put  above  the  elbow  (after  Erichsen). 


surgeon  takes  his  place  behind  the  patient,  steadies  the  scapula  with  his 
hand,  and  carries  the  patient's  arm  upward  and  backward  above  his  head, 
making  extension  and  external  rotation  (Fig.  242).  La  Mothe's  method  is 
applied  with  the  patient  supine  upon  the  floor.  The  surgeon  places  his  foot 
upon  the  shoulder  to  make  counter-extension,  and  makes  extension  as  in 
Brunus's  method.     It  is  a  useful  expedient,  when  either  of  these  plans  is 

applied,  to  have  an  assistant  make  the  trac- 
tion while  the  surgeon  manipulates  the  head 
of  the  bone.  Cock  advises,  when  reduction 
fails,  that  an  air-pad  be  placed  in  the  axilla 


Fig.  241. — Reduction  of  shoulder- 
joint  dislocation  by  the  knee  in  the 
axilla  (Cooper). 


Fig.  242 


-Reduction  of  shoulder-joint   dislocation  by 
upward  extension  (Cooper). 


and  the  arm  be  bound  to  the  side — a  method  by  which  reduction  will  often 
take  place  after  two  or  three  days. 

Pulleys  should  not  be  used  to  pull  the  bone  into  place,  as  they  develop  a 
dangerous  force.  In  a  dislocation  irreducible  by  ordinary  force,  antiseptic 
incision  is  safer  and  better  than  the  pulleys.  After  incision  try  to  restore  the 
bone  to  place.  In  an  old  dislocation  it  may  be  necessary  to  resect  the  head 
of  the  bone. 


12 


Diseases  and  Injuries  of  Bones  and  Joints 


Fig.  243. — Dislocation  of  both  bones  of  the  forearm  backward. 


In  reducing  a  dislocation  the  axillary  artery  or  \ein  ma}"  be  ruptured, 
fracture  of  the  neck  of  the  humerus  may  take  place,  injury  to  the  brachial 
plexus  may  occur,  or  the  soft  parts  may  be  badh"  damaged.  After  reducing 
a  dislocation  apply  a  Velpeau  bandage,  keep  the  shoulder  immobile  for  one 
week,  then  make  passive  motion  daih-,  reapplying  the  dressing  after  each 
seance.     The  patient  may  wear  a  sling  alone  during  the  third  week,  after 

which  period  he  may  use 
the  arm.  (For  old  disloca- 
tions and  compound  dislo- 
cations see  page  503.)  Re- 
duction of  old  dislocations 
may  sometimes  be  effected 
by  manipulation.  Extension 
may  have  to  be  used,  and 
ether  will  be  required.  In 
old  dislocations  try  to  re- 
duce, after  breaking  up  ad- 
hesions, by  forced  flexion 
and  strong  extension.  After 
reduction  immobilize  for 
three  weeks,  and  begin  pas- 
sive motion  after  seven 
days. 

If  a  dislocation  is  com- 
plicated by  a  fracture  of  the 
humerus,  try  to  pull  the  head  of  the  bone  opposite  the  joint.  This  may  be 
possible  if  the  two  fragments  are  held  partly  together  by  a  fair  amount  of 
periosteum  and"  muscle.  Traction  is  exerted  upon  the  arm,  and  an  attempt 
is  made  to  manipulate  the  head  into  the  socket  (AUis's  plan  in  the  hip). 
McBurney  incises,  fixes  a  hook  in  the  scapula  and  a  hook  in  the  head  of 
the  humerus,  pulls  the  head  into  place,  and  wires  the  fragments  (Figs.  158, 
159,  160).  In  an  emergency  gimlets 
may  be  used  instead  of  the  hooks.  In 
some  cases  it  is  necessary  to  excise  the 
head  of  the  bone. 

Dislocations  of  the  Elbow-joint. 
Dislocations  of  the  elbow-joint  are 
not  infrequent,  and  they  are  common- 
est in  children.  Both  bones  or  only 
one  bone  of  the  forearm  may  be  dis- 
located, and  the  dislocation  may  be 
partial  or  complete. 

Dislocation  of  Both  Bones  Back- 
ward.— The  anises  (;f  backward  fJislo- 

cation  of  both  bones  of  the  forearm  are  falls  upon  the  extended  hand  or  twists 
inward  of  the  ulna  (Malgaigne).  The  cornnoid  y)rocess  lodges  in  the  olec- 
ranon fo.ssa  of  the  humerus. 

Symptoms  oj  Backward  Dislocation. — In  complete  dislocation  of  both 
bones  of  the  forearm  the  olecranon  is  very  prominent  (Fig.  243).    The  dis- 


Fig.  244. — Reduction  of  elbow-joint  dislocation. 


Dislocation   of  Both   Bones  of  the  Forearm  513 

tance  between  the  point  of  the  olecranon  and  the  apex  of  the  inner  condyle  is 
notably  greater  than  on  the  sound  side;  the  forearm  is  flexed,  supinated,  and 
shortened ;  the  lower  end  of  the  humerus  projects  in  front  of  the  joint,  below 
the  skin-crease;  the  head  of  the  radius  is  found  back  of  the  outer  condyle; 
and  there  are  the  general  symptoms  of  dislocation.  Fracture  of  the  coronoid 
rarely  occurs  with  backward  dislocation,  but  if  it  does  occur  there  will  be  crepi- 
tus and  mobility.  Fracture  at  the  base  of  the  condyles  is  distinguished  from 
dislocation  of  both  bones  of  the  forearm  backward  by  the  following  points: 
in  fracture  there  are  found  the  ordinary  symptoms;  measurement  from  the 
condyles  to  the  styloid  processes  does  not  show  shortening;  there  is  no  altera- 
tion of  the  normal  relation  between  the  olecranon  process  and  the  condyles; 
and  the  projection  in  front  of  the  joint  is  above  the  crease  of  the  bend  of 
the  elbow. 

Treatment  0}  Backward  Dislocation. — Reduction  must  be  effected  early 
in  dislocation  of  both  bones  of  the  forearm,  because  it  will  soon  become  im- 
possible, and  an  unreduced  dislocation  means  a  limb  without  the  powers  of 
flexion,  pronation,  and  supination.  The  surgeon  places  his  knee  in  front  of  the 
elbow-joint,  grasps  the  patient's  wrist,  presses  upon  the  radius  and  ulna 
with  his  knee,  and  bends  the  forearm  with  considerable  force,  the  muscles 
pulling  the  bones  into  place  (Sir  Astley  Cooper's  plan).  Forced  flexion, 
traction,  and  extension  may  be  tried  (Fig.  244).  Put  the  arm  in  Jones's  posi- 
tion for  two  weeks,  and  make  passive  motion  daily  after  the  first  few  days. 

Dislocation  of  Both  Bones  Forward. — The  cause  of  forward  disloca- 
tion of  both  bones  of  the  forearm  is  a  blow  on  the  olecranon  when  the  arm 
is  flexed.     It  is  an  unusual  accident. 

Symptoms  and  Treatment. — The  symptoms  of  forward  dislocation  of  both 
bones  of  the  forearm  are — the  forearm  is  flexed  and  lengthened ;  some  shght 
motion  is  possible;  the  olecranon  is  on  a  level  with  the  condyles  if  unfractured, 
hence  its  prominence  is  gone;  the  humeral  condyles  are  felt  posteriorly,  and 
the  radius  and  ulna  are  felt  anteriorly.  The  treatment  of  this  injury  consists 
in  early  reduction,  which  is  accomplished  by  means  of  forced  flexion  and 
pressure,  placing  the  part  in  Jones's  position  for  two  weeks,  and  making 
passive   motion  daily  after  the  first  few  days. 

Lateral  dislocation  of  both  bones  of  the  forearm  is  usually  in- 
complete. 

Symptoms  and  Treatment  oj  Outward  Dislocation. — The  symptoms  of 
outward  dislocation  of  both  bones  of  the  forearm  are — the  forearm  is  fle.xed, 
fixed,  and  pronated ;  the  joint  is  widened ;  .the  head  of  the  radius  projects  ex- 
ternally and  has  a  depression  above  it;  the  inner  condyle  projects  internally 
and  has  a  depression  below  it;  the  olecranon  is  nearer  than  normal  to  the 
external  condyle  and  further  than  normal  from  the  internal  condvle.  Reduc- 
tion is  effected  by  extension  of  the  forearm  and  pressure  inward  upon  the 
head  of  the  radius.  Apply  an  ascending  spiral  reverse  bandage  of  the  fore- 
arm, a  figure-of-eight  bandage  of  the  elbow-joint,  and  a  sling.  Make  passive 
motion  after  a  few  days.     The  bandages  must  be  worn  for  two  weeks. 

Symptoms  and  Treatment  oj  Inward  Dislocation. — In  dislocation  inward 
of  both  bones  of  the  forearm  the  position  of  the  forearm  is  the  same  as  that 
in  dislocation  outward;  the  sigmoid  cavity  of  the  ulna  projects  internally,  and 
the  external  condyle  projects  externallw     Reduction  is  effected  by  extension 


514  Diseases  and  Injuries  of  Bones  and  Joints 

of  the  forearm   and   pressure  outward   on   the   ulna,   subsequent   treatment 
being  the  same  as  that  employed  in  the  preceding  form. 

Dislocation  of  the  ulna  alone  is  very  rare,  and  can  only  take  place 
backward. 

Symptoms  and  Treatment. — Dislocation  of  the  ulna  alone  is  indicated 
by  the  forearm  being  flexed  and  pronated.  The  head  of  the  radius  is  found 
in  place,  and  the  olecranon  projects  posteriorly.  The  treatment  of  this  injury 
is  the  same  as  that  for  dislocation  of  both  bones. 

Dislocation  of  the  Radius  Forward. — Dislocation  of  the  radius  forward 
is  the  commonest  form  of  dislocation  of  the  elbow.  This  injury  is  caused 
by  a  fall  upon  the  hand  with  the  forearm  in  pronation  and  extension,  or  is 
produced  by  blows  on  the  back  of  the  joint;  forced  pronation  alone  will  not 
cause  it. 

Symptoms  and  Treatment. — The  symptoms  in  dislocation  of  the  radius 
forward  are — the  forearm  is  midway  between  pronation  and  supination,  and 
is  semiflexed ;  attempts  to  increase  flexion  cause  the  radius  to  strike  against 
the  humerus  with  a  distinct  blow;  the  head  of  the  radius  is  felt  in  front  of 
the  outer  condyle  and  is  missed  from  its  proper  abode.  Reduction  is  effected 
bv  flexion  over  the  knee,  extension,  and  manipulation.  The  subsequent  treat- 
ment is  Jones's  position  and  passive  motion.  Deformity  is  apt  to  recur 
after  reduction,  because  of  rupture  of  the  orbicular  ligament. 

Dislocation  of  the  radius  backward  is  caused  by  falls  on  the  hand 
or  by  blows  on  the  front  of  the  joint. 

Symptoms  and  Treatment. — Backward  dislocation  of  the  radius  is  indicated 
by  the  forearm  being  slightly  flexed  and  fixed  in  pronation,  by  some  impair- 
ment of  flexion  and  extension,  and  by  the  radius  being  feh  behind  the  outer 
condyle.  Reduction  is  effected  by  flexion  over  the  knee,  extension,  and 
manipulation,  and  the  subsequent  treatment  is  the  same  as  that  given  for 
the  preceding  dislocation. 

Dislocation  of  the  radius  outward  is  very  rare.  In  this  injury  the 
head  of  the  radius  is  distinctly  felt.  Reduction  is  effected  by  extension  and 
pressure;  the  subsequent  treatment  is  the  same  as  that  for  the  above-mentioned 
dislocations. 

Subluxation  of  the  Head  of  the  Radius.— This  name  is  given  to  an 
injury  which  is  very  frequent  in  children  between  two  and  four  years  of  age. 
It  resuhs  from  traction  upon  the  hand  or  the  forearm,  and  often  arises  when 
the  nurse  or  the  mother  pulls  upon  a  child's  arm  to  save  it  from  a  fall  or  to 
lift  it  over  a  gutter.  Some  writers  hold  that  pronation  is  required,  as  well 
as  extension,  to  produce  the  injury;  many  surgeons  claim  that  extension 
and  adduction  are  the  causative  forces.  Hutchinson  asserts  that  supination 
may  cause  subluxation.     Bardenheuer  assigned  falls  as  causes. 

The  symptoms  are  very  characteristic.  The  history  points  to  the  injury. 
Pain,  and  often  a  click,  may  be  feU  in  the  wrist  at  the  time  of  the  accident. 
The  arm  hangs  by  the  side,  with  the  elbow-joint  slightly  flexed  and  the  forearm 
midway  between  pronation  and  supination.  Flexion  to  a  less  angle  than  60^ 
and  complete  extension  are  resisted  and  are  very  painful,  but  movement" 
between  60°  and  130°  are  free  and  painless.*     The  movements  of  the  wrist- 

•*See  the  instructive  article  by  W.  W.  Van  Arsdale,  in  the  Annals  of  Surgery,  vol.  ix, 
1889. 


Dislocations  of  the   Wrist 


515 


joint  are  free  and  painless.  The  elbow-joint  presents  no  deformity.  Pressure 
over  the  head  of  the  radius  causes  pain.  Strong  pronation  is  painful;  strong 
supination  is  very  painful,  and  there  seems  to  be  a  mechanical  obstacle  to  its 
performance.  Forced  supination  develops  a  distinct  click  at  the  head  of 
the  radius,  and  causes  pronation  and  supination  to  become  natural  and  free 
from  pain.  The  condition  will  be  reproduced  if  a  splint  is  not  used.  The 
nature  of  the  lesion  is  not  understood,  and  various  conditions  have  been 
thought  to  exist  by  ditYerent  observers.  Among  them  may  be  mentioned 
the  following:  a  slight  anterior  displacement  of  the  head  of  the  radius;  a 
slight  posterior  displacement;  locking  of  the  tuberosity  of  the  radius  behind 
the  inner  edge  of  the  ulna;  dislocation  of  the  triangular  cartilage  of  the  wrist; 
intracapsular  fracture  of  the  radial  head;  painful  paralysis  from  nerve-injury; 
displacement  by  elongation,  the  return  of  the  bone  being  prevented  by  collapse 
of  the  capsule;  and  the  slipping  up  of  the  margin  of  the  orbicular  ligament 
over  the  rim  of  the  head  of  the  radius. 

Treatment. — Place  the  forearm  at  a  right  angle  to  the  arm  and  make 
forcible  supination;  apply  an  anterior  angular  sphnt,  and  have  it  worn  for 
four  or  five  days,  or  put  the  part  in  Jones's  position  for  an  equal  period. 

Dislocations  of  the  wrist  are  very  uncommon  and  are  caused  bv  falls 
upon  the  hand. 


Fig.  245. — Deformity  in  dislocation  of  the  wrist  backward  (a)  and  in  Colles's  fracture  (b)  (Stimson). 


Backward  Dislocation  of  the  Wrist. — Symptoms. — The  deformity  in 
backward  dislocation  of  the  wrist  (Fig.  245,  a)  resembles  that  of  CoUes's 
fracture  (Fig.  245,  b).  The  fingers  are  fle.xed,  the  wrist  is  bent  backward. 
the  radius  projects  on  the  front  of  the  wrist,  the  carpus  projects  on  the  dorsal 
surface  of  the  forearm,  the  relation  of  the  styloid  process  of  the  radius  to  the 
styloid  process  of  the  ulna  is  unaltered  (it  is  altered  in  Colles's  fracture), 
there  is  rigidity,  and  crepitus  is  absent  (Fig.  245). 

Forward  dislocation  of  the  wrist,  which  is  very  unusual,  is  causefl  bv 
a  fall  upon  the  back  of  the  hand. 

Symptoms  and  Treatment. — In  forward  dislocation  of  the  wrist  the  radius 
and  ulna  project  posteriorly  and  the  carpus  projects  in  front.  The  treatment 
in  both  of  these  dislocations  is  reduction  by  extension  and  manipulation,  the 
use  of  a  Bond  splint  for  ten  days,  and  the  emplcnment  of  passive  motion 
after  five  or  six  days. 

Dislocation  at  the  inferior  radio-ulnar  articulation,  which  is  also 
\erv  uncommon,  is  caused  by  twists. 

Symptoms  and  Treatment. — In  joncard  dislocation  at  the  inferior  radio- 
ulnar articulation  the  forearm  is  pronated,  the  space  between  the  styloid 
processes  is  diminished,  and  the  ulna  forms  a  projection  posteriorly.  In 
backward  dislocation  the  forearm  is  supinated,  the  space  between  the  styloid 


5i6 


Diseases  and   Injuries  of  Bones  and  Joints 


processes  is  diminished,  and  the  ulna  projects  in  front.  Reduction  is  accom- 
pHshed  by  extension  and  manipulation.  Two  straight  splints  (as  in  fracture 
of  both  bones)  are  to  be  applied  for  four  weeks,  and  passive  motion  is  to 
be  made  in  the  third  week. 

Dislocation  of  Individual  Carpal  Bones. — Pick  says  there  is  one  weak 
spot,  which  is  "  between  the  head  of  the  os  magnum  and  the  scaphoid  and 
semilunar  bones,"  and  the  os  magnum  may  be  forced  up.  The  os  magnum 
is  the  only  bone  dislocated  with  any  frequency,  and  the  injury  is  caused  by 
forced  flexion  of  the  wrist. 

Symptom  and  Treatment. — The  symptom  of  dislocation  of  the  carpal 
bones  is  a  firm  projection  which  becomes  more  prominent  during  flexion 
of  the  wrist.  The  treatment  is  extension  and  manipulation,  a  Bond  splint 
being  worn  for  three  weeks. 

Dislocations  of  metacarpal  bones  are  uncommon.  The  first  metacarpal 
bone  is  most  liable  to  dislocation. 

Symptoms   and    Treatment. — Dislocations   of   the   metacarpal   bones   are 


Fig.  246. — Levis's  splint  for  reducing  dislocation  of  phalanges. 


Fig.  247. — Levis's  splint  applied. 


obvious  because  of  projection.  The  dislocations  are  reduced  by  extension 
and  manipulation,  a  straight  splint  and  large  pad  for  the  palm  are  applied 
(as  in  fracture  of  the  metacarpus),  and  the  splint  is  worn  for  three  weeks. 

Dislocations  at  the  metacarpophalangeal  articulations  are  uncom- 
mon. Backward  dislocation  is  the  most  common.  The  cause  is  a  fall 
upon  the  hand. 

Symptoms  and  Treatment. — Dislocated  metacarpophalangeal  articulations 
are  obvious.  Reduction  is  easily  effected  by  extension  and  manipulation, 
except  in  the  case  of  the  thumb.     A  splint  must  be  worn  for  three  weeks. 

Dislocation  of  the  Metacarpophalangeal  Joint  of  the  Thumb. — 
In  this  dislocation  the  y)halanx  usually  passes  backward. 

Symptoms. — The  symptoms  of  backward  dislocation  are  as  follows  :  The 
base  of  the  first  phalanx  rests  upon  the  metacarpal  bone;  the  head  of  the 
metacarpal  bone  projects  forward  and  buttonholes  the  muscles  of  the  thumb; 
the  first  phalanx  of  the  thumb  is  strongly  extended,  and  the  terminal  phalanx 
is  semiflexed.     The  symptoms  of  forward  dislocation   are   as  follows  :  The 


Pelvic   Dislocations  517 

base  of  the  first  phalanx  is  felt  in  the  palm,  and  the  head  of  the  metacarpal 
bone  is  felt  posteriorly. 

Treatment. — In  treating  backward  dislocation  of  the  metacarpophalangeal 
joint  of  the  thumb,  reduction  is  difficult  because  the  head  of  the  bone 
is  caught  in  the  perforation  of  the  flexor  muscle.  Always  give  ether. 
Keetley's  directions  are  to  adduct  the  metacarpal  bone  into  the  palm  (this 
relaxes  the  muscles)  and  to  have  an  assistant  hold  it;  bend  the  thumb  strongly 
back,  extend,  pull  the  thumb  toward  the  fingers,  and  suddenly  flex.  To 
get  a  firm  enough  grasp  for  these  manipulations  use  the  apparatus  of  Char- 
riere  or  of  Levis  (Figs.  246,  247).  If  the  above  maneuvers  fail,  perform 
tenotomy  or  incise  freely  and  reduce.  After  reduction  of  this  dislocation  a 
splint  must  be  worn  for  three  weeks.  In  forward  dislocation  reduction  is 
easily  effected  by  strong  extension  and  forced  flexion.  A  splint  is  to  be 
worn  for  three  weeks. 

Dislocations  of  the  phalanges  may  be  complete  or  may  be  partial. 
They  are  commonest  between  the  first  and  second  phalanges. 

Symptoms  and  Treatment. — Dislocations  of  the  phalanges  are  obvious. 
In  reducing  such  dislocations  employ  extension  and  manipulation.  Use  a 
splint  for  one  week. 

Dislocations  of  the  Ribs  and  Costal  Cartilages. — The  ribs  may  be 
dislocated  from  the  vertebrae.  This  accident  is  seldom  uncomplicated,  and 
cannot  be  differentiated  from  fracture.  The  diagnosis  is  rarely  made,  and 
the  injury  is  treated  as  a  fracture.  The  ribs  may  be  dislocated  from  their 
cartilages,  one  or  more  ribs  being  displaced.  The  end  of  the  rib  forms  an 
anterior  projection,  there  is  a  depression  over  the  cartilage,  and  crepitus  is 
absent.  Treatment  is  the  same  as  that  employed  for  fractured  ribs.  The 
costal  cartilages  may  be  displaced  from  the  sternum,  forming  an  anterior 
projection  upon  this  bone.  Reduction  is  brought  about  by  placing  the 
patient  upon  a  table,  with  a  sand  pillow  between  the  scapulae,  pushing  back 
the  shoulders  and  chest,  and  forcing  the  cartilage  into  place.  The  dressings 
are  the  same  as  those  used  in  fractured  sternum.  The  cartilages  of  the 
lower  ribs  (sixth,  seventh,  eighth,  ninth,  and  tenth)  may  be  separated.  The 
inferior  cartilage  goes  forward  and  can  be  felt.  Pick  states  that  reduction 
is  brought  about  by  causing  the  patient  to  hold  the  chest  full  of  air  while 
efforts  are  made  to  push  the  cartilage  into  place.  The  injury  is  dressed  as 
are  fractured  ribs. 

Dislocations  of  the  Sternum. — In  dislocations  of  the  sternum  the 
manubrium  may  be  separated  from  the  gladiolus  in  young  subjects.  The 
symptoms  and  treatment  are  the  same  as  those  in  fracture  (page  407). 

Pelvic  dislocations  are  almost  always  complicated  with  fracture.  A 
pubic  bone  can  be  dislocated  by  falls  from  a  height  or  by  applying  violent 
force  to  the  acetabula.  The  dislocation  may  be  up  or  down,  front  or  back, 
and  it  may  damage  the  urethra  or  the  bladder.  The  patient  cannot  stand; 
there  are  great  pain  and  recognizable  deformity.  Treat  by  moulding  the 
bones  into  place,  by  applying  a  pelvic  belt,  and  by  rest  in  bed  for  four  weeks. 
Dislocations  of  the  sacro-iliac  joint  are  produced  by  falls.  Movement  on  the 
part  of  the  patient  is  difficult  or  impossible;  there  is  violent  pain,  and  often 
paralysis  (from  pressure  u])on  nerves).  In  dislocation  Ijackward  there  is  an 
apparent  shortening  of  the  leg,  eversion  of  the  foot  exists,  and  the  ilium 


5i8  Diseases  and   Injuries  of  Bones  and  Joints 

moves  posteriorly  and  upward.  In  dislocation  forward  the  anterior  superior 
iliac  spine  projects  and  the  pelvis  is  broadened.  Sacro-iliac  dislocations 
are  reduced  by  holding  the  pelvis  firm  and  making  extension  with  a  pulley. 
The  patient  stays  in  bed  for  four  weeks  and  wears  a  pelvic  belt  as  in  fracture. 

Dislocations  of  the  Femur  (Hip-joint). — These  injuries  are  not  often 
encountered,  as  the  hip-joint  is  very  strong.  They  occur  in  young  adults.  In 
forcible  extension  the  head  of  the  femur  presses  against  the  capsule  of  the  joint, 
but  the  capsule  here  is  very  thick,  and  certain  muscles,  the  rectus,  psoas,  and 
iliacus,  are  pulled  tight  and  serve  to  strengthen  it.  The  head  of  the  bone 
cannot  go  directly  upward,  because  of  the  acetabulum  (Edmund  Owen).  The 
weak  point  of  the  acetabular  rim  is  below;  the  weak  part  of  the  capsule  is 
also  below;  hence  forced  abduction  is  apt  to  push  the  head  of  the  bone  through 
the  lower  part  of  the  capsule,  a  dislocation  occurring  primarily  into  the 
thyroid  foramen.  The  signs  of  the  dislocation  depend  upon  the  untorn 
portion  of  the  capsule.  The  Y-ligament  and  more  than  the  Y-ligament 
usually  escape  laceration.  Vessels  are  rarely  injured.  Muscles  are  often 
torn.  In  some  cases  the  sciatic  nerve  is  lacerated,  bruised,  or  caught  up  on 
the  neck  of  the  bone.  Four  forms  of  hip-joint  dislocation  are  usually 
described:  (i)  upward  and  backward,  on  the  dorsum  of  the  ilium;  (2)  back- 
ward, into  the  sciatic  notch;  (3)  downward,  into  the  obturator  foramen; 
and  (4)  inward,  on  the  pubes. 

All  dislocations  are  primarily  inward  or  outward.  From  these  initial 
positions  the  head  may  be  shifted  to  any  region  about  the  socket  within  reach 
of  the  remnant  of  untorn  capsule  (Oscar  H.  AlUs).  Allis  rejects  the  old 
classification  and    suggests  the  following: 


Low  thyroid,  ^ 

Mid-       "        VaU  present  abduction  and  outward  rotation. 
High       "       j 
Reversed  thyroid: 

Low  dorsal,  ^ 

Mid-      "       VaU  present  adduction  and  inward  rotation. 

High      "      J 

Dislocations  upon  the  dorsum  of  the  ilium  comprise  one-half  of  all 
hip-dislocations.  They  are  caused  by  a  fall  or  a  blow  when  the  limb  is  flexed 
and  abducted  (as  in  carrying  a  weight  upon  the  shoulder),  by  a  fall  upon 
the  knees  or  feet,  by  a  weight  striking  the  back  while  bending,  etc.  AUis  says 
rotation  inward  is  the  chief  element  in  their  production.  In  these  dislocations 
the  head  of  the  femur  goes  upward  and  backward,  rests  upon  the  ilium,  and 
is  always  above  the  tendon  of  the  obturator  internus  muscle.  These  disloca- 
tions are  secondary  to  thyroid  dislocation,  muscular  action  shifting  the  bone 
from  its  initial  seat  of  displacement. 

Signs. — Dislocation  on  to  the  dorsum  of  the  ilium  is  indicated  by  the 
following  symptoms:  the  buttock  appears  fiat  and  broad;  the  great  trochanter 
is  above  Nekton's  line  and  is  deeply  placed;  the  head  of  the  bone  can  be 
detected  in  its  new  situation ;  deep  pressure  in  front  of  the  joints  finds  a  hollow; 
the  leg  is  shortened  by  about  two  or  three  inches,  as  a  rule;  the  fascia  lata  is 
relaxed;  in  some  thin  people  the  socket  can  be  outlined;  when  the  patient  is 


Dislocation  upon  the  Dorsum  of  the  Ilium 


519 


recumbent  the  injured  extremity  can  be  brought  to  the  perpendicular  without 
flexing  the  leg  (Allis) ;  the  knee  is  somewhat  flexed ;  the  thigh  is  slightly  flexed, 
inwardly  rotated,  and  adducted  (Fig.  248)  (this  is  shown  by  the  fact  that 
the  axis  of  the  thigh  of  the  injured  side,  if  prolonged,  would  pass  through 
the  lower  third  of  the  sound  thigh) ;  when  the  capsule  is  extensively  lacerated 
there  may  be  no  adduction  and  may  be  eversion  (Allis) ;  the  heel  is  raised, 
and  the  great  toe  of  the  foot  of  the  injured  side  rests  upon  the  front  of  the 
instep  or  the  ankle  of  the  sound  side;  rigidity  exists;  voluntary  movement  is 
impossible,  though  some  passive  motion  is  possible  in  the  direction  of  the 
deformity  (the  deformity  can  be  made  more  marked).  If  a  patient  is  re- 
cumbent and  the  knees  vertical,  the  foot  of  the  sound  extremity  is  free  of 
the  bed,  but  the  foot  of  the  injured  extremity  touches  the  bed  (Alhs's  sign). 

Diagnosis. — Examine  first  without  anesthesia,  and  then  again  while  the 
patient  is  anesthetized.  The  .r-rays  are  valuable  in  diagnosis.  Dislocation  is 
distinguished  from  intracapsular  fracture  by  noting  the 
inversion,  the  great  shortening,  the  absence  of  crepitus, 
the  age  of  the  subject,  and  the  nature  of  the  force.  The 
nature  of  the  force,  the  inversion,  and  the  absence  of 
crepitus  mark  the  diagnosis  from  extracapsular  fracture. 

Treatment. — The  chief  obstacle  to  reduction  in  dis- 
location on  to  the  dorsum  of  the  ilium,  Bigelow  states, 
is  the  untorn  portion  of  the  capsule,  especially  the 
Y-ligament.  The  ilio-femoral,  Y.  or  Bigelow's  ligament 
resembles  an  inverted  Y,  arises  from,  the  anterior  inferior 
spine  of  the  ilium,  is  inserted  into  the  anterior  intertro- 
chanteric line,  and  is  incorporated  into  the  front  of  the 
capsule.  To  reduce  a  dislocation  this  ligament  must  be 
relaxed  by  manipulation  or  be  torn  by  extension.  Man- 
ipulation makes  the  head  of  the  bone  retrace  its  steps 
over  the  same  route  it  took  in  emerging.  Give  ether; 
place  the  patient  supine  upon  a  mattress  on  the  floor;  flex 
the  leg  on  the  thigh  (to  relax  the  hamstrings),  flex  the  thigh  on  the  pelvis;  in- 
crease the  adduction  over  the  middle  line;  strongly  abduct;  perform  external 
rotation  and  extension.  This  treatment  may  be  summed  up  as  flexion,  adduc- 
tion, external  circumduction,  and  extension;  or,  as  Pick  puts  it,  "bend  up,  roll 
out,  turn  out,  and  extend."  Allis's  advice  is  to  fix  the  pelvis  to  the  floor,  lift  the 
head  of  the  bone  to  the  level  of  the  socket,  rotate  outward  by  carrying  the 
leg  toward  the  pubis,  and  extend  the  femur.  If  e.xtension  and  counter- 
extension  are  employed,  make  extension  in  the  axis  of  the  dislocated  limb 
and  obtain  counter-extension  by  a  perineal  band.  The  extension  band  is 
fastened  to  the  thigh  by  a  clove-hitch.  After  reduction  put  the  patient  to 
bed  and  use  sand-bags  (as  in  fracture  of  the  hip)  for  four  weeks.  We  may 
tie  the  knees  together  instead  of  using  the  sand-bags.  Passive  motion  is 
made  in  the  third  week.  The  pulleys  must  not  be  used  in  reduction.  They 
may  inflict  great  or  even  fatal  injury.  If  the  surgeon  fails  to  reduce  the 
deformity,  there  are  two  courses  open  to  him.  He  may  let  it  alone.  He 
may  operate.  If  he  lets  it  alone,  the  limb  will  become  ankylosed.  though 
probably  useful.  Allis  thinks  the  dorsal  region  will  be  the  best  place  to 
leave  it.     If  he  determines  to  operate,  he  must  recognize  that  tenotomy  is 


Fig.  248. — Hip-joint 
dislocation  on  to  the 
dorsum  of  the  ilium 
(Cooper). 


520 


Diseases  and   Injuries  of  Bones  and  Joints 


useless.     It  is   necessary  to   make   a  free  incision   in  order  to  restore  the 
bone. 

Dislocation  into  the  Sciatic  Notch. — In  this  dislocation  the  head  of 
of  the  bone  passes  backward  and  a  Httle  upward,  and  rests  upon  the  ischium 
at  the  margin  of  the  sciatic  notch  (not  in  the  notch),  below  the  tendon  of 
the  obturator  internus  muscle.  The  causes  are  the  same  as  those  given 
for  the  previous  dislocation. 

Signs. — The  signs  in  dislocation  into  the  sciatic  notch  are  like  those  of 
dislocation  upon  the  dorsum  of  the  ilium,  but  they  are  not  so  marked.  There 
are  flattening  and  broadening  of  the  hip;  ascent  of  the  trochanter  above 
Nelaton's  line;  shortening  to  the  extent  of  an  inch;  relaxation  of  the  fascia 
lata.  If  the  knee  of  the  injured  side  is  vertical,  the  sole  of  the  foot  touches 
the  bed.  Flexion,  inward  rotation,  and  adduction  exist,  but  the  axis  of  the 
femur  of  the  injured  side  passes  through  the  knee  of  the  sound  side,  and  the 
ball  of  the  great  toe  of  the  injured  side  rests  upon  the  great  toe  of  the  sound 
side  (Fig.  249).  Other  symptoms  are  identical  with  those  of  dislocation 
upon  the  dorsum  of  the  ilium,  but  are  less  pronounced. 
AUis's  signs  of  this  dislocation  are  of  value:  if,  with  the 
patient  recumbent,  the  thighs  are  brought  to  a  right  angle 
with  the  body,  shortening  on  the  affected  side  is  materi- 
ally increased;  if  the  dislocated  thigh  is  extended,  the 
back  arches  as  in  hip  disease. 

Diagnosis  and  Treatment. — The  signs  of  dislocation 
into  the  sciatic  notch  are  similar  to,  but  are  less  marked 
than,  those  of  dorsal  dislocation,  and,  being  a  backward 
dislocation,  the  reduction  and  treatment  are  the  same 
as  for  dislocation  backward  upon  the  dorsum  of  the 
ilium. 

Dislocation  Downward  into  the  Obturator  Fora- 
men.— Downward  dislocation  is  the  primary  position  of 
most  dislocations  of  the  hip,  the  bone  rarely  remaining  in 
the  thyroid  foramen,  but  usually  mounting  up  as  a  result 
of  muscular  action  or  of  the  initial  violence.  The  cause  is  violent  abduction 
by  falls  or  by  stepping  from  a  moving  car. 

Signs. — Dislocation  downward  into  the  obturator  foramen  is  indicated 
by  flattening  of  the  hip;  the  head  of  the  bone  is  felt  in  its  new  position  and 
is  missed  from  the  acetabulum;  rigidity  exists;  passive  motion  is  only  possible 
in  the  direction  of  deformity,  and  that  to  a  slight  extent;  a  hollow  is  noted 
over  the  great  trochanter,  which  process  is  well  below  Nelaton's  line  and 
nearer  than  normal  to  the  middle  line.  The  gluteal  crease  is  lower  than  is 
the  crease  of  the  opposite  side;  there  is  lengthening  to  the  extent  of  one  to 
two  inches;  the  body  is  bent  forward  by  the  traction  upon  the  psoas  and 
iliacus  muscles,  and  is  also  deviated  to  the  side,  thus  causing  great  apparent 
lengthening;  the  limb  is  advanced  partially  flexed  and  abducted,  and  the 
foot  is  pointed  straight  ahead  or  is  a  little  everted  (Fig.  250);  when  the 
patient  is  recumbent,  extension  is  impossible,  the  knees  cannot  be  pushed 
together  without  great  pain,  and  the  abductor  muscles  are  hard  and  rigid. 
Allis's  sign  is  absent.  Unreduced  dislocations  do  well,  the  patient  obtain- 
ing a  very  useful  hifj-joint  (Sedillot). 


Fig.  249. — Hip-joiiit 
dislocation  into  the 
sciatic  notch  (Cooper). 


Dislocation   with   Catching   up   of  Sciatic   Nerve 


521 


Fig.  250. — Hip-joint 
dislocation  into  the  ob- 
turator or  thyroid  fora- 
men (Cooper). 


Treatment. — In  treating  dislocation  downward  into  the  obturator  foramen 
give  ether  and  effect  reduction,  if  possible,  by  manipulation,  and,  if  this 
fails,  by  extension.  To  reduce  by  manipulation,  flex  the  leg  on  the  thigh 
and  the  thigh  on  the  pelvis,  and  then  perform,  in  the  following  order,  abduc- 
tion, internal  circumduction,  and  extension.  Allis's  rule  of  reduction  is  as 
follows:  fix  the  pelvis  to  the  floor;  pull  the  head  of  the 
femur  outward  and  above  the  socket;  fix  the  head;  push 
the  knee  toward  sound  knee  and  extend  the  femur.  If 
extension  is  made,  make  traction  in  the  axis  of  the  limb 
by  means  of  muslin  fastened  around  the  thigh  by  a  clove- 
hitch.  Do  not  use  pulleys;  incise  rather  than  use  them. 
Dislocation  upon  the  pubis  is  a  very  uncommon 
accident.  The  head  of  the  bone  usually  rests  just  internal 
to  the  anterior  inferior  spine  of  the  ilium.  The  primary 
position  of  the  bone  is  in  the  thyroid  foramen;  the 
pubic  dislocation,  when  it  occurs,  is  always  secondary, 
and  is  due  to  the  initial  force  and  to  muscular  action. 

Symptoms. — In  pubic  dislocation  the  head  of  the  bone 
can  be  felt  and  seen  in  its  new  position;  the  hip  is  flat- 
tened; there  is  a  hollow  over  the  great  trochanter,  this 
process  being  found  below  the  anterior  superior  spine  of 
the  ilium;  there  is  shortening  to  the  extent  of  an  inch;  the  limb  is  in  abduction 
with  eversion  (Fig.  251),  and  the  knees  cannot  be  approximated  without 
great  pain. 

Treatment. — In  the  treatment  of  pubic  dislocation  give  ether  and  employ 
manipulation  as  for  thyroid  dislocation.  If  this  fails,  employ  extension. 
The  limb  is  well  abducted,  extension  made  downward  and  backward,  and  the 
head  of  the  femur  pulled  outward  "by  a  towel  around 
the  thigh,  just  beneath  the  groin"  (Keetley).  The  after- 
treatment  is  the  same  as  that  for  the  previous  forms. 

Anomalous  Dislocations  of  the  Hip. — In  supra- 
spinous dislocation  the  dislocation  of  the  hip  is  backward, 
the  head  of  the  femur  resting  upon  the  ilium  above  or 
even  anterior  to  the  anterior  superior  spine.  In  ischial 
dislocation  the  dislocation  is  downward  and  backward, 
the  head  of  the  femur  resting  on  the  ischial  tuberosity 
or  in  the  lesser  sciatic  notch.  Monteggia's  dislocation  is 
a  supraspinous  dislocation  with  eversion  of  the  limb.  In 
perineal  dislocation  the  head  of  the  femur  is  in  the  peri- 
neum. In  suprapubic  dislocation  the  head  of  the  femur 
passes  above  the  pubes.  In  subspinous  dislocation  the 
femoral  head  rests  on  the  horizontal  ramus  of  the  pubes. 
Dislocation  with  Catching  up  of  the  Sciatic  Nerve  during  Reduction. 
— This  accident  causes  severe  pain.  The  leg  is  fle.xed  on  the  thigh  and  the 
thigh  is  fle.xed  on  the  pelvis.  Allis  tells  us  that  the  task  of  reduction  is  very 
unpromising.  We  must  strive  to  put  the  neck  of  the  femur  in  such  a  position 
that  the  nerve  will  "drop  off,"  and  yet  often  the  nerve  cannot  drop  off  because 
it  is  held  by  adhesion  to  the  injured  muscles.  Allis  attempts  reduction  by 
the  following  plan: 


Fig.    251. — Dislocation 
on  pubis  (Cooper). 


522  Diseases  and   Injuries  of  Bones  and  Joints 

1.  Place  the  patient  upon  his  back  and  redislocate  the  femur. 

2.  Extend  the  thigh. 

3.  Fle.x  the  leg  on  the  thigh. 

4.  Turn  the  ankle  out  until  the  leg  is  horizontal  (this  causes  the  head 
of  the  bone  to  look  downward) . 

5.  "Shake,  shock,  jar,  adduct,  and  abduct,"  to  disengage  the  nerve. 

6.  Rotate  into  socket  without  flexing  the  leg  (without  making  the  nerve 
tense) . 

7.  If  this  fails,  make  an  incision  above  the  popliteal  space,  and  draw  the 
nerve  out  of  the  wound.  Detach  the  head  of  the  bone  from  its  entangle- 
ment and  rotate  it  into  the  socket.* 

Dislocation  of  the  Head  of  the  Femur  with  Fracture  of  the  Shaft 
of  the  Bone. — We  may  incise  and  replace  and  wire  the  fragments.  We 
may  use  McBurney's  hooks  as  in  the  shoulder.  We  may  be  forced  to  do  a 
resection  of  the  head. 

Allis  maintains  that  it  is  possible  to  reduce  it  by  manipulation.  He 
states  that  the  upper  fragment  is  the  entire  lever,  and  the  lower  fragment 
''is  only  the  agent  through  which  we  apply  our  force."  The  fragments  are 
not  completely  separated,  but  are  connected  at  one  side  by  material  which 
is  "partly  periosteal,  partly  tendinous,  and  partly  muscular."  This  con- 
necting material  enables  us  to  make  traction  upon  the  upper  fragment,  but 
does  not  allow  "rotation,  circumduction,  and  leverage  through  the  agency 
of  the  lower  fragment."  Hence  "the  only  agency  at  our  command  is  trac- 
tion." If  the  dislocation  is  inward  (forward),  draw  the  head  outward  and 
have  an  assistant  make  direct  pressure  upon  the  head  of  the  bone.  If 
this  fails,  the  assistant  holds  the  head  of  the  bone  to  prevent  its  slipping 
into  the  thyroid  depression,  and  the  surgeon  makes  traction  inward  or 
inward  and  downward.  If  the  dislocation  is  outward  (backward),  make 
traction  directly  upward  to  lift  the  head  of  the  bone  to  the  level  of  the 
socket,  and  try  to  place  the  head  over  the  socket  by  traction  obliquely 
upward  and  inward.  During  all  these  manipulations  an  assistant  presses 
upon  the  trochanter  to  prevent  the  head  of  the  bone  slipping  back.  Trac- 
tion is  now  made  downward  and  inward,  and  the  tightened  ligament  drags 
the  head  of  the  bone  into  place. 

Dislocations  of  the  Knee. — These  dislocations  are  rare.  There  are  four 
forms — forward,  backward,  inward,  and  outward.  They  may  be  complete 
or  incomplete;  the  commonest  dislocations  are  lateral.  The  cause  is  violent 
force,  such  as  a  fall,  or  in  jumping  from  a  moving  train,  or  in  being  caught 
by  the  foot  and  dragged. 

Dislocation  Forward  of  the  Knee-joint. — In  the  complete  form  of 
forward  dislocation  the  deformity  is  obvious.  The  limb  is  usually  extended, 
but  it  may  be  flexed.  Much  shortening  exists;  the  condyles  are  felt  posterior 
and  below;  the  head  of  the  tibia  is  felt  anterior  and  above;  the  patella  is 
movable  and  the  quadriceps  is  lax;  pressure  of  the  condyles  upon  the  con- 
tents of  the  popliteal  space  arrests  the  tibial  j)ulse  and  causes  edema  and 

*  AUis'.s  views  will  be  found  in  "An  Inquiry  into  the  Difficulties  Encountered  in  the 
Reduction  of  Dislocations  of  the  Hip."  By  Oscar  H.  Allis,  M.D.  This  highly  original  and 
valuable  treatise  received  the  Samuel  D.  Gross  [irize  of  the  I'hiladelphia  Academy  of  Surgery 
in  1895. 


Dislocations  of  the  Patella 


523 


intense  pain.  In  incomplete  dislocation  the  symptoms  are  identical  in  kind, 
but  are  less  pronounced. 

Treatment. — Compound  dislocation  of  the  knee-joint  often  demands  e.x- 
cision  or  amputation.  In  simple  dislocation  give  ether,  have  one  assistant 
extend  the  leg  while  another  makes  counter-extension  on  the  thigh,  and  the 
surgeon  pushes  the  bone  into  place.  Reduction  is  easy  because  of  liga- 
mentous laceration.  Place  the  limb  on  a  double  inclined  plane,  and  combat 
inflammation  by  the  usual  methods  (see  Synovitis,  page  469).  Begin  passive 
motion  in  the  third  week.  The  patient  must  wear  a  knee-support  for  months. 
If  the  popliteal  vessels  are  much  damaged,  gangrene  will  supervene  and 
amputation  will  be  demanded. 

Dislocation  Backward  of  the  Knee-joint. — In  the  complete  form  of 
knee-joint  dislocation  backward,  displacement  is  not  so  great  as  in  dislocation 
forward.  The  head  of  the  tibia  projects  posteriorly  and  above,  the  femoral 
condyles  anteriorly  and  below;  the  leg  is,  as  a  rule,  partly  fle.xed,  but  it  may  be 
extended,  and  there  is  moderate  shortening.  In  incomplete  dislocation  the 
symptoms    are  less  marked. 

Treatment. — The  treatment 
of  backward  dislocation  of  the 
knee-joint  is  the  same  as  for  for- 
ward dislocation. 

Dislocation  Outward  of  the 
Knee-joint. — Is  usually  incom- 
plete. The  inner  tuberosity  of 
the  tibia  in  outward  dislocation 
lies  upon  the  outer  condyle  of  the 
femur  (Pick);  the  inner  condyle 
of  the  femur  projects  internally; 
the  outer  tibial  tuberosity  and 
fibular  head  project  externally, 
the  former  having  a  depression 
below  it,  and  the  latter  above  it; 
the  leg  is  semiflexed,  but  shorten- 
ing is  absent. 

Dislocation  Inward  of  the 
Knee-joint. — Is  usually  incom- 
plete. The  outer  tuberosity  of 
the  tibia  in  inward  dislocation 
lies  upon  the  inner  condyle  of  the 

femur;  the  outer  condyle  of  the  femur  forms  an  external  prominence,  and  the 
inner  tuberosity  of  the  tibia  forms  an  internal  prominence.  Pick  cautions  us  not 
to  mistake  a  separation  of  the  lower  femoral  epiphysis  for  lateral  dislocation 
(the  former  is  reduced  easily,  the  deformity  tends  to  recur,  and  there  is  soft 
crepitus). 

Treatment. — In  treating  lateral  dislocation  of  the  knee-joint,  effect  ex- 
tension and  counter-extension  as  in  anteroposterior  dislocations.  The  leg 
is  moved  from  side  to  side  and  attempts  are  made  at  rotation.  The  after- 
treatment  is  the  same  as  that  for  anteroposterior  luxations. 

Dislocations  of  the  Patella. — .\re  usually  acquired.  There  are  thirty- 
five  congenital  cases  on  record  (Bajardi).     There  are  three  forms:  outward. 


Fig.  232. — Old  diskicalidii  of  tlic  patella  outward. 


524  Diseases  and   Injuries  of  Bones  and  Joints 

inward,  and  edgewise.  The  so-called  dislocation  upward  is  in  reality  rupture 
of  the  ligamentum  patellae  (page  557). 

Dislocation  outward  (Fig.  252)  may  be  due  to  muscular  action  or  to 
direct  force,  and  occurs  during  extension  of  the  leg.  It  occasionally  happens 
in  a  person  with  knock-knees.  If  dislocation  is  complete,  the  bone  lies  upon 
the  external  surface  of  the  external  condyle;  if  incomplete,  the  patella  rests 
upon  the  anterior  surface  of  the  external  condyle.  The  leg  is  extended,  flexion 
is  impossible,  and  attempts  at  flexion  produce  great  agony.  In  the  patient 
shown  in  Fig.  252,  flexion  became  possible  in  an  unreduced  dislocation,  but 
not  until  months  after  the  accident.  The  knee  is  wider  than  normal.  There 
is  a  hollow  in  front  of  the  joint.     The  bone  is  felt  in  its  new  position. 

Dislocation  inward  is  very  rare.  The  signs  are  like  those  of  disloca- 
tion outward,  except  that  the  patella  rests  upon  the  inner  condyle. 

Treatment. — Give  ether.  Raise  the  body  upon  a  bed-rest,  and  flex  the 
thigh.  Grasp  the  patella,  depress  the  margin  of  the  patella  which  is  farthest 
from  the  center  of  the  joint  (Pick).  The  muscles  pull  the  bone  into  place. 
Immobilize  for  three  weeks,  and  then  begin  passive  motion.  Incision  may 
be  necessary  in  order  to  effect  reduction. 

Dislocation  of  the  Patella  Edgewise. — The  patella  rotates  vertically, 
one  edge  resting  between  the  condyles.  As  a  rule,  the  outer  border  is  in  the 
intercondyloid  notch  (Pick).  This  condition  is  produced  by  direct  force 
when  the  extremity  is  partly  flexed.  Twisting  and  muscular  action  have 
been  assigned  as  causes.     The  condition  is  obvious  at  a  glance. 

Treatment. — Give  ether.  Pick  recommends  "sudden  and  forcible  bend- 
ing of  the  knee."  In  some  cases  the  bone  can  be  pushed  into  place,  the 
limb  being  extended  and  flexed  as  in  the  reduction  of  a  lateral  dislocation. 
In  some  cases  incision  will  be  necessary. 

Dislocation  of  the  Semilunar  Cartilages  of  the  Knee-joint  (the 
Internal  Derangement  of  Hey;  Subluxation  of  the  Knee-joint). — The  inter- 
articular  cartilages  of  the  knee-joint  are  attached  in  front  of  and  behind 
the  tibial  spine,  and  the  convexity  of  each  cartilage  is  attached  to  the  edge 
of  the  corresponding  tibial  tuberosity  by  means  of  the  coronary  ligament. 
The  internal  cartilage  is  fastened  to  the  internal  lateral  ligament  and  has  a 
moderate  freedom  of  movement.  The  outer  cartilage  is  not  connected  with 
the  internal  lateral  ligament  and  is  not  freely  movable.  It  has  been  stated 
that  the  outer  cartilage  is  more  frequently  dislocated  than  the  inner,  but 
modern  experience  indicates  that  this  is  not  true,  and  that  the  internal  car- 
tilage is  the  one  most  apt  to  suffer.  In  17  ca.ses  operated  upon  by  Barker, 
the  internal  cartilage  was  involved  in  every  case  ("Lancet,"  Jan.  4,  1902). 
Those  persons  whose  occupations  force  them  to  pass  considerable  time  upon 
their  knees  are  predisposed  to  this  accident  (Annandale).  The  derangement 
of  the  cartilage  is  usually  caused  by  a  sudden  external  rotation  of  the  tibia, 
while  the  knee-joint  is  in  partial  flexion;  for  instance,  when  the  patient  stumbles 
over  an  obstacle,  the  knee-joint  being  partially  flexed,  the  tibia  is  twisted 
outward.  When  the  joint  is  flexed,  a  normal  cartilage  moves  backward, 
and  when  it  is  extended,  moves  forward  again.  When  the  cartilage  is  thrown 
out  by  the  .sudden  eversion  and  flexion  of  the  tibia,  it  is  caught  and  does 
not  move  into  place  readily  when  the  leg  is  extended.  The  tear  takes  place 
in  the  direction  of  the  fibers  of  the  cartilage. 


Dislocations  of  the   Fibula  525 

Symptoms. — The  indications  of  interarticular  cartilage  displacement  are 
a  sudden,  violent,  sickening  pain  in  the  knee,  which  may  be  so  severe  as  to 
cause  the  patient  to  fall  to  the  ground.  The  knee  is  in  a  position  of  fixed 
semiflexion.  Further  flexion  is  possible,  but  extension  is  impossible.  In 
some  cases  the  patient  can  voluntarily  make  further  flexion;  in  others,  the 
pain  is  so  severe  that  he  either  cannot  or  will  not  do  it;  but  increase  of  flexion 
can  be  obtained  by  passive  motion.  The  joint  is,  however,  blocked  both  to 
passive  and  to  voluntary  extension.  Attempts  at  passive  motion  are  pro- 
ductive of  fierce  pain.  If  either  cartilage  is  displaced  away  from  the  tibial 
spine,  a  prominence  may  be  found  on  one  or  the  other  side  of  the  knee-joint. 
If  the  displacement  takes  place  toward  the  tibial  spine,  a  prominence  may 
be  found  on  one  side  of  the  ligament  of  the  patella.  Subluxation  is  rapidly 
followed  by  inflammation  of  the  synovial  membrane  of  the  joint  and  of  the 
cartilages  themselves;  and  swelling  quickly  masks  the  projection  of  the 
cartilage.  This  accident  is  frequently  mistaken  for  the  blocking  of  the  joint 
by  a  floating  cartilage;  but  a  dislocated  cartilage  always  remains  in  the  same 
position,  and  a  loose  cartilage  changes  its  position  from  time  to  time  (Turner). 
Loose  bodies  in  a  joint  produce  pain  of  a  shifting  character,  and  interference 
with  both  flexion  and  extension,  or  with  either  flexion  or  extension  in 
an  irregular  way  (Cotterill).  In  regard  to  the  diagnosis,  Cotterill  points 
out  that  in  a  sprain  of  the  joint  extension  is  not  painful,  but  flexion  is  inter- 
fered with;  whereas,  in  the  dislocation  of  a  cartilage  of  the  joint,  flexion  is 
still  possible,  but  extension  cannot  be  carried  out  ("Lancet,"  Feb.  22,  1902). 

Treatment. — In  treating  dislocation  of  a  semilunar  cartilage  of  the 
knee  give  ether  and  reduce  by  forced  flexion  and  external  rotation.  Exten- 
sion becomes  possible  if  the  cartilage  is  freed.  During  these  maneuvers  an 
assistant  endeavors  to  push  any  projection  of  cartilage  into  place.  After 
reduction  apply  a  splint  for  two  weeks  and  combat  inflammation  bv 
proper  remedies  (see  Synovitis);  then  begin  passive  motion.  At  the  end  of 
two  weeks  apply  a  firm  knee-cap  made  of  leather  and  let  the  patient  get  about 
on  crutches.  After  a  couple  of  weeks  the  crutches  can  be  laid  aside.  As 
recurrence  of  the  displacement  is  usual,  the  patient  should  wear  a  knee-cap 
during  the  day  for  many  months.  A  partial  tear  may  entirely  heal  when 
thus  treated  by  rest  and  support;  an  extensive  tear  will  not,  although  even 
in  such  cases  a  useful  but  somewhat  stiff  joint  may  be  obtained.  If  it  is 
found  impossible  to  unlock  the  blocked  joint,  or  if  the  tear  is  extensive 
and  redislocation  is  prone  to  occur,  an  operation  is  advisable.  The  joint 
is  opened  and  the  loose  cartilage  is  pushed  into  place  and  held  by  stitches  or 
the  loosened  portion  is  excised. 

Dislocations  of  the  Fibula :  Dislocation  at  the  Superior  Tibio- 
fibular Articulation. — This  injury  is  rare.  The  head  of  the  fibula  ma\-  go 
forward  or  backward.  The  causes  are  direct  force  and  violent  adduction  of 
the  foot  with  abduction  of  the  knee  (Bryant). 

Symptoms. — After  dislocation  of  the  fibula  the  position  is  one  of  semiflexion 
of  the  knee,  voluntary  extension  and  flexion  being  impaired  or  lost.  A 
distinct  movable  projection  is  readily  noticed  in  front  or  behind,  which  is 
found  to  be  continuous  with  the  fibula.  There  is  a  depression  over  the 
normal  position  of  the  head  of  the  fibula. 

Treatment. — In  treating  dislocation  of  the  fibula  bend  the  knee  to  relax 


526  Diseases  and   Injuries  of  Bones  and  Joints 

the  biceps,  and  proceed  to  push  the  bone  into  place.  Put  a  compress  over 
the  head  of  the  fibula,  apply  a  bandage,  and  put  the  limb  on  a  double  in- 
clined plane  for  three  weeks.  At  the  end  of  this  time  put  a  lacing  knee- 
support  upon  the  knee  and  let  the  patient  up.  Displacement  being  liable 
to  recur,  a  knee-cap  must  be  worn  for  a  year. 

Dislocations  of  the  Ankle-joint. — These  injuries  are  not  unusual. 
Fracture  is  a  frequent  complication.  There  are  five  forms  of  ankle-joint 
dislocation — outward,  inward,  forward,  backward,  and  upward. 

Lateral  dislocations  of  the  ankle-joint  are  either  outward  or  inward, 
and  may  be  complete  or  incomplete.  In  these  dislocations  the  astragalus 
rotates.  In  incomplete  dislocations  ''there  is  no  great  separation  of  the 
trochlear  surface  of  the  astragalus  from  the  under  surface  of  the  tibia,  but 
the  outer  or  inner  margin  of  this  surface  is  brought  into  contact  with  the 
articular  surface  of  the  tibia,  and  the  whole  foot  presents  a  lateral  twist" 
(Pick).     The  causes  of  these  dislocations  are  twists  of  the  joint. 

Symptoms. — Incomplete  outward  dislocation  of  the  ankle-joint  is  known 
as  Pott's  fracture  (see  page  465).  Complete  outward  dislocation,  in  which 
the  articular  surface  of  the  astragalus  is  completely  displaced  outward  from 
the  articular  surface  of  the  tibia,  and  which  condition  is  associated  with  a 
fracture  of  the  fibula  and  separation  of  the  inferior  tibiofibular  articulation, 
is  known  as  Dnpuytren's  fracture.  In  incomplete  dislocation  the  foot  goes 
outward  and  upward,  the  fibula  is  fractured,  and  the  tibiofibular  ligaments 
are  torn  off.  In  Dupuytren's  fracture  the  ankle  is  broad,  the  inner  malleolus 
projects  and  looks  lower  than  natural,  the  outer  malleolus  ascends  with  the 
foot,  the  foot  rotates  outward,  and  crepitus  can  be  detected.  In  inward  dis- 
location which  is  associated  with  fracture  of  the  inner  malleolus  there  is 
inversion,  the  outer  malleolus  projects,  and  crepitus  can  be  detected.  In 
incomplete  separation  the  symptoms  are  similar,  but  are  not  so  marked. 

Treatment. — In  treating  a  case  of  dislocation  of  the  ankle-joint  the  de- 
formity is  reduced  by  flexing  the  leg  on  the  thigh  and  the  thigh  on  the  pelvis; 
an  assistant  makes  counter-extension  from  the  knee;  the  surgeon  makes 
extension  from  the  foot,  and  at  the  same  time  rocks  the  astragalus  into  place. 
Dupuytren's  fracture  is  treated  in  the  same  manner  as  Pott's  fracture  (page 
466).  Dislocation  inward  is  treated  in  a  fracture-box  for  the  same  period  as 
Pott's  fracture. 

Anteroposterior  dislocations  of  the  ankle-joint  are  rare.  The  catise 
is  the  catching  of  the  foot  in  jumping  or  falling — direct  violence.  In  disloca- 
tion forward  the  foot  is  lengthened,  the  heel  is  not  conspicuous,  the  tibia  and 
fibula  project  against  the  tendo  Achillis,  and  the  relation  of  the  malleoli  to 
the  tarsus  is  altered.  In  incomplete  dislocation  the  symptoms  are  similar, 
but  less  pronounced.  In  dislocation  backward  the  foot  is  shortened,  the 
tibia  and  fibula  project  in  front,  the  heel  is  prominent,  and  the  relation  be- 
tween the  malleoli  and  the  tarsus  is  altered.  In  incomplete  dislocation  the 
symptoms  are  similar,  but  less  marked. 

Treatment. — In  antcro[)Osterior  dislocation  of  the  ankle-joint,  reduce  as 
in  lateral  dislocations.  Sometimes  the  tendo  Achillis  must  be  cut.  Apply 
a  plaster-of- Paris  dressing,  and  let  it  be  worn  for  two  weeks;  then  begin 
passive  mrjtion,  and  let  the  patient  wear  side-splints  for  a  week  longer. 

Dislocation  upward  of  the  ankle-joint,  or  Nelaton's  dislocation,   is 


Subastragaloid   Dislocation  527 

a  very  rare  injury.  The  astragalus  is  wedged  between  the  widely  separated 
tibia  and  fibula.  This  dislocation  is  usually  associated  with  fracture.  The 
cause  is  a  fall  upon  the  feet  from  a  great  height. 

Symptoms. — Upward  dislocation  of  the  ankle-joint  is  indicated  by  the 
widening  of  the  ankle  and  by  the  flattening  of  the  foot.  The  malleoli  are 
nearly  on  a  level  with  the  plantar  surface  of  the  foot,  and  there  is  absolute 
rigidity. 

Treatment. — In  treating  upward  dislocation  of  the  ankle-joint  give  ether, 
and  try. to  reduce  by  powerful  extension  and  counter-extension.  Treat  the 
injury  afterward  in  the  same  manner  as  an  anteroposterior  luxation. 

Dislocation  of  the  Astragalus. — The  astragalus  may  be  displaced  from 
the  bones  of  the  leg  and  at  the  same  time  be  separated  from  the  rest  of  the 
tarsus.  The  displacement  may  be  forward,  backward,  outward,  inward,  or 
rotary. 

Dislocation  of  the  astragalus  forward  or  backward  is  caused  by  falls 
or  twists. 

Symptoms. — In  forward  dislocation  the  astragalus  projects  strongly;  there 
is  shortening  of  the  foot,  and  the  malleoli  approach  the  plantar  aspect  of  the 
foot;  the  foot  is  deviated  to  one  side  or  to  the  other,  and  there  is  absolute 
rigidity  of  the  ankle-joint.  In  incomplete  luxations  the  symptoms  are  similar, 
but  less  marked.  This  dislocation  may  be  obliquely  forward.  In  backward 
dislocation  of  the  astragalus  the  foot  is  not  deviated  to  either  side;  the  astragalus 
projects  between  the  malleoli  and  above  the  os  calcis,  and  the  tendo  Achillis 
is  stretched  over  the  projection.  Rigidity  is  absolute.  This  dislocation  may 
be  obliquely  backward. 

Lateral  and  Rotary  Dislocations  of  the  Astragalus. — Lateral  dis- 
locations of  the  astragalus  are  rare,  are  always  compound,  and  are  always 
associated  with  fracture.  In  rotary  dislocation  the  astragalus  remains  in 
its  normal  habitat  after  rotating  on  its  own  axis,  either  horizontal  or  vertical. 
The  causes  of  rotary  dislocation  are  twists  of  the  foot  when  it  is  at  a  right 
angle  to  the  leg  (Barwell).  The  symptoms  of  rotary  dislocations  are  obscure. 
There  is  rigidity,  but  sometimes  portions  of  the  astragalus  may  be  made  out. 

Treatment  of  Dislocations  oj  the  Astragalus. — In  treating  astragalus  dis- 
location reduce  under  ether  by  flexing  the  knee  to  relax  the  gastrocnemius, 
extending  the  foot,  and  pushing  the  bone  into  place.  It  may  be  necessary 
to  cut  the  tendo  Achillis.  After  reduction  put  up  the  foot  and  leg  in  a  plaster- 
of-Paris  dressing  for  two  weeks,  and  then  begin  passive  motion  and  apply 
side-splints,  which  are  to  be  worn  for  one  week  more.  If  reduction  fails, 
support  the  limb  on  splints,  combat  inflammation,  and  endeavor  to  bring 
about  union  between  the  dislocated  bone  and  the  tissues.  Often,  in  un- 
reduced dislocation,  the  skin  sloughs  o\er  the  projecting  bone.  Excision 
is  demanded  the  moment  sloughing  is  seen  to  be  inevitable.  Cases  of  com- 
pound dislocation  of  the  astragalus  require  immediate  excision. 

Subastragaloid  Dislocation. — This  condition  is  a  separation  of  the 
astragalus  from  the  os  calcis  and  scaphoid,  without  separation  from  the  bones 
of  the  leg.  Pick  states  that  the  usual  classification  for  these  dislocations 
is  forward,  backward,  inward,  and  outward,  but  that  the  displacement  is, 
as  a  rule,  oblique,  the  foot  passing  backward  and  outward  or  backward  and 
inward.     The  cause  is  twistintr. 


528  Diseases  and   Injuries  of  Bones  and  Joints 

Sy)npto)>is. — In  subastragaloid  dislocation  the  astragalus  projects  on  the 
dorsum;  the  foot  is  everted  in  outward  dislocation  and  inverted  in  inward 
dislocation;  the  relation  of  the  malleoli  to  the  astragalus  is  unaltered;  the 
ankle-joint  is  not  absolutely  rigid;  the  foot  ''is  shortened  in  front  and  is 
elongated  behind"  (Pick). 

Treatment. — To  treat  subastragaloid  dislocation  make  extension  in  the 
direction  opposite  to  that  of  the  displacement.  In  dislocation  of  the  tarsus 
backward  fix  a  bandage  around  the  foot,  on  a  level  with  the  heads  of  the 
metatarsal  bones,  which  bandage  the  surgeon  ties  around  his  shoulders. 
The  surgeon  puts  one  knee  in  front  of  the  ankle  and  thus  fixes  the  leg,  raises 
himself  up  to  make  extension  upon  the  tarsus,  and  moulds  the  bone  into 
position.  Tenotomy  may  be  necessary.  After  reduction  apply  a  plaster- 
of-Paris  dressing  and  have  it  worn  for  three  weeks.  The  ankle-joint,  fortu- 
nately, is  not  involved,  and  stiffness  of  this  articulation  need  not  be  appre- 
hended. If  reduction  is  impossible,  take  the  same  course  as  in  luxations  of 
the  astragalus. 

Dislocations  of  the  other  tarsal  bones  are  very  rare.  Single  bones 
may  be  dislocated,  or  the  luxation  may  occur  at  the  mediotarsal  articulation. 

Symptoms  and  Treatment. — Projection  is  an  obvious  symptom  in  disloca- 
tion of  the  other  tarsal  bones.  The  treatmejit  is  to  reduce  by  extension  and 
moulding,  the  part  being  put  up  in  plaster-of-Paris  dressing  for  two  weeks. 

Dislocations  of  the  metatarsal  bones  are  rare. 

Symptoms  and  Treatment. — Shortening  of  the  toes  and  projection  of  the 
dislocated  bone  are  symptoms  of  dislocation  of  the  metatarsal  bones.  To 
treat  these  dislocations  reduce  by  extension  under  ether  and  put  up  in  a 
plaster-of-Paris  dressing  for  two  weeks.  If  reduction  fails,  the  functions  of 
the  foot  will  not  be  much  impaired. 

Dislocations  of  the  phalanges  are  very  rare.  The  first  phalanx  of 
the  big  toe  is  the  one  most  liable  to  dislocation. 

Symptoms  and  Treatment. — Dislocations  of  the  phalanges  are  obvious. 
The  treatment  is  by  reduction  as  in  dislocations  of  the  thumb.  Immobilize 
for  two  weeks. 

5.   Operations  upon  Bones  and  Joints. 
Osteotomy. — By  the  term  osteotomy  the  modern  surgeon  means  literally 
the  sectioning  of  a  bone  for  the  purpose  of  straightening  a  limb  ankylosed 


F'g-  253. — Adams's  large  saw. 


in  a  bad  position,  correcting  a  bony  deformity,  or  amending  a  vicious  union 
of  a  fracture.  In  a  linear  osteotomy  the  bcjne  is  transversely  or  obliquely 
divided   at  one  spot;   in   a  cuneijorm   osteotomy  a  wedge-shaped   portion   of 


Osteotomy  for  Genu   Valgum,   or  Knock-knee 


529 


bone  is  removed.  The  operation  of  osteotomy  may  be  performed  with  a 
saw  (Fig.  253)  or  with  an  osteotome.  The  saw  creates  dust,  draws  much 
air  into  the  wound,  and  lacerates  the  tissues  to  a  considerable  degree. 
Most  surgeons  prefer  the  chisel  or  the  osteotome.  The  osteotome  slopes 
down  to  a  point  from  each  side  (Fig.  254);  the  chisel  is  straight  on  one 
side  and  on  the  other  is  bevelled  to  a  point. 


Fig.  254. — Osteotome. 


Fig.  255. — Rawhide  mallet. 


Osteotomy  for  Genu  Valgum,  or  Knock-knee  (Macewen's  Operation, 
Fig.  256). — In  this  operation  the  instruments  required  are  the  scalpel,  hemo- 
static forceps,  osteotomes  of  several  sizes,  a  mallet  (Fig.  255),  and  a  sand- 
bag wrapped  in  an  aseptic  towel. 

Operation. — The  patient  lies  upon  his  back,  being  rolled  a  little  toward 
the  diseased  .side.     The  leg  of  the  diseased  side  is  partly  tiexed  upon  the 
thigh  and  the  thigh  upon  the  pelvis,  and  the  extremity  is  laid  upon  its  outer 
surface,   the  sand-bag    being 
pushed  between  the  extremity 
and  the  bed,  opposite  to  the 
site  of  section.     The  flexion  of 
the  knee  relaxes  the  popliteal 


Fig.  256.— Osteotomy  of  the  right 
femur  in  a  case  of  knock-knee  :  a  b, 
Epiphyseal  line ;  c,  section  of  Mac- 
ewen  ;  D  e,  section  of  Ogston. 


Fig.  257.— Macewen's  operation  for  genu  valgum. 
The  chisel  is  held  in  the  line  for  striking  with  a  mal- 
let ;  the  arrow  shows  the  direction  in  which  the  chisel 
is  levered  up  and  down  so  as  to  make  a  wide  gap  in 
the  bone  (after  Barker). 


vessels  and  saves  them  from  injury.  The  surgeon,  if  operating  on  the  right 
leg,  stands  outside  of  that  extremity;  if  operating  on  the  left  leg,  he  stands 
opposite  the  left  hip  (Barker).  The  knife  is  inserted  into  the  tissues  and  car- 
ried to  the  bone  at  the  inner  side  of  the  knee,  just  in  front  of  the  adductor 
tubercle  of  the  inner  condyle  and  on  a  level  with  the  upper  border  of  "the 
patellar  articular  surface  of  the  femur"  (Barker).  An  incision  is  made 
upward  one  inch  in  length,  in  the  direction  of  the  axis  of  the  femur.  At 
the  lower  angle  of  this  wound  an  osteotome  is  inserted  and  the  blade  after 
34 


530  Diseases  and   Injuries   of  Bones  and  Joints 

insertion  is  turned  to  a  right  angle  with  the  shaft  of  the  femur,  half  an 
ineh  above  the  epiphysis  (Fig.  256).  The  osteotome  is  struck  several  times 
with  a  mallet;  the  handle  is  moved  several  times  toward  and  from  the  body, 
so  as  to  widen  the  cut  in  the  bone  (Fig.  257);  the  osteotome  is  again  struck 
with  the  mallet  several  times  ;  it  is  again  moved  toward  and  from  the  body, 
and  this  process  is  continued  until  the  bone  is  cut  one-third  through.  If 
the  osteotome  becomes  tightly  fixed,  it  should  be  withdrawn  and  a  smaller 
one  introduced.  In  the  soft  bone  of  a  young  child  this  to-and-fro  movement 
of  the  chisel,  if  carefully  executed,  is  not  liable  to  break  the  instrument.  In 
dense  bone  it  may  break  the  instrument;  hence,  when  doing  an  osteotomy 
in  dense  bone,  the  osteotome  is  moved  to  and  fro  across  the  limb  and  slight 
downward  pressure  upon  the  handle  will  to  a  great  extent  prevent  binding. 
When  the  bone  is  cut  two-thirds  through,  the  osteotome  is  withdrawn,  a  piece 
of  w-et  antiseptic  gauze  is  held  over  the  wound,  and  the  surgeon  fractures 
the  femur  by  strong  adduction.  The  wound  is  neither  sutured  nor  drained, 
but  is  dressed  antiseptically,  the  entire  extremity  is  wrapped  in  cotton,  and  a 
plaster-of-Paris  dressing  is  applied  and  carried  up  to  the  groin.  The  dress- 
ing may  be  removed  in  two  weeks,  and  the  patient  may  subsequently  be 
treated  with  sand-bags,  as  for  an  ordinary  fracture  of  the  thigh,  but  with- 
out extension.     This  operation  is  scarcely  ever  fatal. 

Ogston's  Operation  (Fig.  256). — In  this  operation  the  internal  condyle  is 
sawed  off  obliquely  with  an  Adams  saw — a  proceeding  which  permits  the 
straightening  of  the  knee.  The  objection  to  the  procedure  is  that  it  opens 
the  knee-joint,  and  that  this  cavity  iills  up  more  or  less  with  a  mixture  of 
blood  and  bone-dust.     Macewen's  operation  is  decidedly  the  safer. 

Osteotomy  for  a  Bent  Tibia. — In  this  operation  the  instruments  required 
are  the  same  as  those  used  in  the  above  operation.  The  tibia  is  divided 
transversely  or  obliquely  (linear  osteotomy),  or  a  wedge-shaped  piece  is 
removed  (cuneiform  osteotomy).  The  oblique  incision  is  the  best.  If  the 
convexity  of  the  tibial  curve  is  inward,  cut  the  bone  from  above  downward 
and  from  in  front  backward;  if  the  curve  is  forward,  section  the  bone  from 
above  downward  and  from  within  outward.  The  fibula  need  rarely  be  inter- 
fered with.  After  the  osteotomy  the  limb  is  treated  just  as  it  would  be  for 
a  fracture. 

Osteotomy  for  Faulty  Ankylosis  of  the  Hip-joint. — This  operation  is 
performed  in  order  to  allow  straightening  of  a  limb  that  has  undergone  bony 
ankylosis  in  a  faulty  or  an  inconvenient  position.  In  some  cases  an  attempt 
is  made  to  obtain  a  movable  joint,  but  in  most  cases  the  surgeon  must  be 
satisfied  with  an  ankylosis  in  extension.  Osteotomy  may  be  performed 
through  the  neck  of  the  femur  or  through  the  shaft  of  the  femur  below  the 
trochanters. 

Osteotomy  through  the  neck  of  the  femur  is  performed  (i)  with  a 
saw  (Adams's  operation)  or  (2)  with  an  osteot(jme. 

I.  Adams\s  Operation  (Fig.  258). — In  this  operation  the  instruments  re- 
quired are  a  scalpel,  hemostatic  forceps,  a  long,  blunt  pointed  tenotome, 
and  an  Adams  saw. 

Operation. — The  patient  lies  upon  his  sound  hip;  the  surgeon  stands  upon 
the  side  to  be  operated  upon,  and  back  of  the  patient.  The  knife  is  entered 
a  finger's  breadth  above  the  great  trochanter,  is  pushed  in  until  it  strikes 


Osteotomy  for  Faulty  Anlcylosis  of  the  Knee-joint  531 

the  neck  of  the  bone,  is  then  carried  across  the  front  of  and  at  a  right  angle 
with  the  neck,  and  is  withdrawn,  enlarging  the  wound,  in  the  soft  parts 
as  it  emerges,  to  the  extent  of  an  inch.  The  saw  is  then  introduced  and 
the  neck  of  the  femur  is  entirely  divided.  After  the  osteotomy  dress  the 
wound  antiseptically  and  place  the  e.xtremity  straight.  To  straighten  the 
limb  it  may  be  found  necessary  to  cut  contracted  tendons  and  fascial  bands. 
After  securing  extension  and  applying  dressings  use  the  weight-extension 
apparatus  and  the  sand-bags.  Begin  passive  movements  from  the  start  if 
a  movable  joint  is  desired;  few  patients  can  tolerate  the  pain  necessary  to 
bring  this  about.  If  it  is  determined  to  aim  for  a  stiff  joint,  treat  the  case 
as  an  intracapsular  fracture  would  be  treated. 

2.  With  an  Osteotome. — The  instruments  required  in  this  operation  are 
the  same  as  those  used  for  genu  valgum.  A  sand-bag  is  not  needed.  The 
position  of  the  patient  is  the  same  as  that  in  Adams's  operation.  An  incision 
one  inch  long  is  made,  starting  just  above  the  great  trochanter,  ascending 
in  the  axis  of  the  femoral  neck,  and  reaching  to  the  bone.  An  osteotome 
is  introduced,  is  turned  to  a  right  angle  with  the  neck 
of  the  bone,  and  is  struck  with  a  mallet  until  the  bone  f^~~\ 

is  completely  divided.     (It  is  not  to  be  divided  partially  ^/XX     \  J 

and  then  broken.)     The  after-treatment  is  the  same  as  [  /^"^'^ 

that  for  Adams's  operation.     The  operation   with    the  I  \ 

osteotome  is  to  be  preferred  to  that  Ijy  the  saw.  \  / 

Osteotomy  of  the  Shaft  of  the  Femur  below  the 
Trochanters  (Gant's  Operation). — In  this  operation 
(Fig.  258)  the  saw  may  be  used,  but  the  osteotome  is  to 
be  preferred.  The  instruments  employed  are  the  same 
as  those  used  for  Adams's  operation,  plus  an  osteotome. 

Operation. — The  position  in  Gant's  is  like  that  in  Fig.  258.  —  osteot- 

Adams's  operation.     A  longitudinal    incision  one  inch      °'"-'  '''^"s''  '^^  "^^^^ 

,  .  ,  ,  ■"  r     ,        .  of       the      temur :       a, 

long  IS  made  upon  the  outer  aspect  of  the  femur  and  .Adams's  operation ;  b, 
on  a  level  with  the  lesser  trochanter.  The  osteotome  is  r.ant's  operation, 
inserted  and  the  bone  is  completely  divided  below  the 
lesser  trochanter.  The  after-treatment  is  the  same  as  that  for  Adams's  oper- 
ation. Gant's  operation  is  the  best  method  for  correcting  faulty  position  in 
bony  ankylosis,  and  Adams's  operation  can  only  be  employed  in  those  cases 
where  the  femur  still  has  a  neck  which  is  practically  unchanged. 

Osteotomy  for  Faulty  Ankylosis  of  the  Knee-joint. — This  operation 
is  performed  for  bony  ankylosis  of  a  knee  in  a  position  of  flexion.  The 
instruments  employed  are  the  same  as  those  used  for  genu  valgum. 

Operation. — The  patient  lies  upon  his  back  with  his  thighs  flat  upon  the 
bed,  the  legs  hanging  over  the  end  of  the  bed.  The  surgeon  stands  on  the 
patient's  right  side.  Just  above  the  patellar  articular  surface  upon  the  femur 
a  transverse  incision  is  made,  one  inch  in  length  and  reaching  to  the  bone. 
The  osteotome  is  introduced  and  the  bone  is  cut  nearly  through.  The  leg 
is  then  forcibly  extended.  It  must  not  be  extended  too  violentlv,  or  the 
popliteal  vessels  may  be  injured.  In  cases  where  the  structures  of  the  pop- 
liteal space  are  tense,  the  leg  must  not  be  brought  at  once  into  extension, 
but  this  position  should  be  attained  gradually  l^y  means  of  weights.     The 


532  Diseases  and   Injuries  of  Bones  and  Joints 

wound   is   dressed   aseptically.  and    the   extremity  is  placed  upon  a  double 
inclined  plane  and  is  treated  as  for  fracture  near  the  knee-joint. 

Osteotomy  for  vicious  union  of  a  fracture  is  performed  in  case  of 
angular  deformity,  and  is  carried  out  in  the  same  manner  as  are  the  above 
procedures.  It  is  best,  when  possible,  to  enter  the  osteotome  upon  the  con- 
cavity of  the  bent  bone,  so  that  the  periosteum  will  not  rupture  when  extension 
is  made,  and  the  patient  will  in  consequence  gain  a  longer  limb. 

Osteotomy  for  Hallux  Valgus. — In  this  operation  a  linear  osteotomy  is 
made  through  the  neck  of  the  metatarsal  bone  of  the  great  toe,  the  toe  is 
forcibly  adducted,  and  a  splint  is  applied  to  the  inside  of  the  foot  and  the 
toe. 

Osteotomy  for  Talipes  Equinovarus. —  The  instruments  required  in 
this  operation  are  a  scalpel,  hemostatic  forceps,  a  narrow,  blunt-pointed 
saw,  special  directors,  bone-cutting  forceps,  sequestrum  forceps,  and  scissors. 
Operation  (after  Barker). — The  patient  lies  upon  his  back,  the  thigh  is 
semiflexed,  the  knee  is  bent,  and  the  sole  of  the  foot  rests  upon  the  table. 
The  surgeon  stands  to  the  right  side  if  it  is  the  right  limb  which  is  to  be 
operated  upon,  or  to  the  left  side  if  it  is  the  left  limb.  The  surgeon  feels 
for  the  outer  surface  of  the  cuboid  bone,  and  cuts  away  from  over  the  latter 
a  piece  of  skin  corresponding  in  size  with  the  bone-wedge  intended  to  be 

removed  (this  piece  of  skin  must  include  the 
bursa  which  forms  in  these  cases).  The  foot 
is  then  turned  outward,  the  astragaloscaphoid 
articulation  is  located,  and  over  this  an  incision 
is  made  "from  the  lower  to  the  upper  dorsal 
Fig.  259.— Davy's  director  (Pye).  border  of  the  scaphoid  bone  "  (Barker),  reach- 
ing through  the  skin  only;  the  foot  is  placed 
again  in  the  first  position,  all  the  soft  parts  are  raised  from  off  the 
superior  surface  of  the  tarsus,  and  a  triangular  surface  corresponding 
with  the  base  of  the  wedge  to  be  removed  is  cleared;  a  "kite-shaped" 
director  (Fig.  259)  is  passed  into  the  external  wound  and  projected 
from  the  internal  wound;  the  saw  is  pushed  through  the  groove  of  the 
director  nearest  the  toes,  and  is  made  to  cut  through  the  tarsus,  from  the 
dorsum  to  the  sole,  at  right  angles  to  the  metatarsal  bones;  the  saw  is 
pushed  through  the  groove  of  the  director  nearest  the  ankle,  and  is  made  to 
cut  from  the  dorsum  to  the  sole,  at  right  angles  to  the  long  axis  of  the  cal- 
caneum;  the  wedge-shaped  piece  of  bone  is  grasped  with  sequestrum  forceps 
and  cut  out  with  scissors,  with  bone  forceps,  or  with  a  blunt  bistoury.  The 
wound  is  well  irrigated,  the  foot  is  straightened,  the  internal  wound  is  sewed 
up,  the  external  wound  is  sutured  except  at  its  lowest  portion,  where  a 
drainage-tube  is  to  be  retained  for  twenty-four  hours,  and  the  wound  is 
dressed  antisej)ti(ally.  The  foot  is  put  up  in  jjlaster  or  upon  a  Davy  splint. 
Osteotomy  for  Talipes  Equinus. —  This  operation  is  described  by  Mr. 
Davy,  who  devised  it,  as  follows:*  "Taking  the  line  of  the  transverse  tarsal 
joint  as  a  guide,  on  the  outer  and  inner  sides  of  the  foot,  and  immediately 
over  the  jf)int,  two  wedge-shaped  pieces  of  skin  are  removed,  equal  in  extent 
to  the  amount  of  bone  demanded.  The  soft  structures  are  freed  on  the 
dorsum  of  the  foot  in  the  way  yjrcviously  described ;  but,  as  the  base  of  the 
*])arker's  "  Manual  of  Surgical  O[)eration.s." 


Operative  Treatment  of  Recent  Fractures 


533 


osseous  wedge  for  equinus  cases  is  at  the  dorsum  and  its  apex  at  the  sole, 
the  parallel  wire  director,  instead  of  the  kite-shaped  varus  one,  is  used.  The 
saw  is  successively  inserted  in  its  grooves,  and  by  keeping  in  mind  the  idea 
of  a  keystone  a  clean  wedge  of  bone  is  cut  out  from  the  dorsum  to  the  sole 
of  the  foot."  The  wedge  is  extracted,  and  the  foot  is  straightened  and  is 
put  up  in  plaster-of-Paris  or  is  placed  on  a  Davy  splint. 

Operative  Treatment  of  Recent  Fractures. — In  recent  fractures  where 
reduction  is  impossible  or  where  displacement  recurs  in  spite  of  splints,  it 
may  be  advisable  to  operate.     In  doubtful  cases  a  skiagraph  should  always 


Fig.  260. — Bone  ferrules  (Senn). 


Fig.  261. — Bone  ring  and  ferrule  applied  (Senn). 


be  taken,  and  it  will  often  decide  whether  operation  is  or  is  not  indicated.  In 
most  instances  of  irreducible  fracture  reduction  of  the  fragments  is  impossible 
because  muscle  or  fascia  is  caught  between  them  or  because  the  periosteal 
soft  parts  have  hardened  and  shortened  as  a  result  of  hemorrhage  and  in- 
flammation. In  such  cases  it  may  be  necessary  to  make  a  tolerably  long 
incision;  loosen  the  ends  of  the  fragments  from  their  anchorage,  cut  the 
inflammatory  ties,  remove  tissue  from  between  the  fragments,  and,  if  the 
ends  are  very  irregular,  saw  them  off  evenly. 

The  fragments  are  bored  and  brought  together,  and  are  held  by  silver 
wire  or  kangaroo-tendon,  or  both  fragments  are  surrounded  by  Senn's  bone 
ferrule  or  bone  ring,  and  fixation  is  thus  secured  (Figs.  260,  261).     Drainage 


534 


Diseases  and   Injuries   of  Rones  and  Joints 


is  unnecessary,  the  soft  parts  are  sutured  and  dressed  with  sterile  gauze,  and 
the  extremity  is  put  up  in  plaster-of-Paris.  If  the  clavicle  is  operated  upon, 
after  sterile  dressings  are  applied  a  Velpeau  bandage  is  put  on,  and  the 
turns  of  this  bandage  are  overlaid  with  plaster-of-Paris,  a  trap-door  being 
cut  over  the  seat  of  operation.  In  an  operation  for  recent  fracture  the 
author  does  not  use  an  Esmarch  bandage,  as  he  believes  it  best  to  see  what 
is  cut  and  thoroughly  arrest  bleeding  at  the  time,  rather  than  run  the  danger 
of  oozing  and  infection. 

The  author  has  wired  recent  fractures  of  the  humerus,  tibia,  femur,  and 
clavicle.  Arbuthnot  Lane  believes  that  every  very  oblique  fracture  of  the 
tibia  and  fibula  low  down  should  be  treated  by  incision  and  fixation.*  It 
is  necessary  to  bear  in  mind  that  if  one  of  two  parallel  bones  is  broken  (as 
the  radius  alone  or  tibia  alone),  and  it  is  found  necessary  to  resect  a  con- 
siderable portion,  a  like  amount  should  be  resected  from  the  companion  bone 
in  order  to  prevent  great  deformity. 

Recent  Transverse  Fracture  of  the  Patella. — (See  page  458.) 
Bone=grafting,  or  Transplantation.— (Sec  page  371.) 
Operative  Treatment  of  Ununited  Fracture. — The  instruments 
required  in  this  operation  are  a  scalpel,  hemostatic  forceps,  dissecting  forceps, 


Fig.  263.  — Braiiiard's  drills  with  VVxeth's  adjustable  handles. 


retractors,  AUis's  dissector,  an  awl  or  special  drill  (Figs.  262,  263),  chisels, 
a  mallet,  a  fine  saw,  Hon-jaw  forceps,  and  silver  wire. 

In  operating,  incise  longitudinally  down  to  the  seat  of  fracture,  retract 
the  periosteum  from  the  bone,  drill  the  bones  before  cutting  them,  chisel 
away  the  material  of  imperfect  union,  .saw  through  each  bone  end  far  enough 
from  the  .seat  of  fracture  to  reach  sound  ti.ssue,  pass  large  silver  wires  through 
the  holes  (this  wire  should  be  one-tenth  inch  in  diameter  for  the  femur,  one- 
sixteenth  inch  for  the  y)atella,  etc.)  (Fig.  264),  twist  the  wires  a  fi.xed  number 
of  times  (two  complete  turns)  in  the  direction  that  the  hands  of  a  watch 
move  (this  is  Keen's  direction.  In  case  removal  of  the  wires  should  be 
demanded  later  we  know  how  to  untwist  them),  sever  the  ends  of  the 
wires,  and  hammer  their  stems  against  the  bones.  The  wires  may  never 
require  removal.  Dress  the  part  as  a  recent  fracture.  Various  plans 
besides  wiring  have  been   employed   in   ununited   fracture.     Gussenbauer's 

*  Brit.  Med.  Jour.,  April  20,  1895. 


Treves's   Operation   for  Vertebral   Caries 


535 


Fig.  264. — Wiring  of  bones  for  ununited 
fracture:  a  a,  Sawn  surfaces  approximated 
after  removal  of  old  material  which  was  inter- 
posed between  the  fragments  ;  b  b,  b  b.  perfor- 
ations drilled  completely  across  the  bone  ;  c  c, 
wires  readv  for  twisting. 


clamp  is  used  by  some.  Clayton  Parkhill's  bone-clamp  is  a  very  useful 
appliance,  and  holds  the  fragments  firmly  in  contact  (Fig.  396).  Menard 
and  Lannelongue  inject  a  i  :  10  solution  of  chlorid  of  zinc  between 
the  fragments  and  around  their  ends,  and  then  immobilize  the  parts. 
Some  surgeons  unite  the  fragments  with  kangaroo-tendon  instead  of  wire 
(suturing  of  bone) ;  others  use  nails  of 
bone  or  ivory;  others  use  screws.    Senn  c   c 

asserts  that  the  above  methods  will  not 
hold  fragments  in  contact  if  these  frag- 
rnents  have  a  tendency  to  become  dis- 
placed. Senn  fastens  the  bones  together 
by  hollow  cyhnders  of  decalcified  bone 
or  ivory,  the  cylinders  being  perforated 
in  many  places  (bone  ferrules)  (Fig. 
260).  The  soft  parts  are  sutured,  no 
drain  is  used,  and  the  limb  is  encased 
in  plaster-of-Paris. 

Ununited  Fracture  of  Patella. — 
An  incision  is  made  in  the  long  axis 
of  the  limb,  over  the  middle  of  the  space 

between  the  fragments,  from  well  above  the  upper  fragment  to  well  below  the 
lower  piece;  this  incision  divides  all  the  soft  parts.  The  soft  parts  are  retracted, 
but  the  periosteum  is  undisturbed;  each  fragment  is  bored  (Fig.  265,  i)  in  one 
or  two  places;  the  surfaces  of  the  fragments  are  cut  square  through  sound 

bone  with  a  saw;  all  old  reparative  material  is 
cut  away;  the  wires  are  passed  through  the  per- 
forations, twisted,  cut  off,  and  hammered  down 
(Fig.  265,  2).  If  the  bone  fragments  cannot  be 
approximated,  it  may  become  necessary  to  in- 
cise the  muscle  around  and  above  the  patella  or 
to  partially  separate  the  tuberosity  of  the  tibia 
and  bend  this  process  upward.  A  small  drain 
is  inserted  above  the  bone,  the  wound  is  su- 
tured, aseptic  dressings  are  applied,  and  the  limb 
is  put  upon  a  Macewen  splint. 

Treves's  Operation  for  Caries  of  the 
Lumbar  and  Last  Dorsal  Vertebrae.— In 

this  operation  the  right  loin  is  chosen  for  in- 
cision, as  a  rule.  The  instruments  required 
are  a  scalpel,  hemostatic  forceps,  grooved 
director,  an  Allis  dissector,  sequestrum  forceps, 
curet  spoons,  and  a  sand-bag. 

Operation. — The  patient  lies  upon  his  left 
side,  with  the  knees  drawn  up  and  a  sand-bag  under  him.  The  surgeon  stands 
behind  the  patient  (Barker).  An  incision  is  made  at  the  outer  border  of  the 
erector  spinae  mass,  reaching  from  the  last  rib  to  the  iliac  crest  and  going  down 
at  once  to  the  lumbar  fascia.  The  lumbar  aponeurosis  is  opened,  the  erector 
spina?  muscle  is  retracted  inward,  and  the  anterior  portion  of  the  erector  spinae 
sheath  is  incised.     The  quadratus  lumborum   muscle  is  next  cut,  and  then 


Fig.  265.— Wiring  of  the  patella; 
I,  Fragments  cut  and  cleaned  and 
the  wires  passed  ;  2.  wires  twisted 
and  hammered  down  upon  the  bone 
(after  Barker). 


536 


Diseases  and  Injuries  of  Bones  and  Joints 


the  anterior  leaflet  of  the  lumbar  aponeurosis  is  slit.  Loose  pieces  of  bone 
are  removed  with  forceps,  and  cavities  are  thoroughly  curetted.  The  wound  is 
irrigated  with  corrosive  sublimate  and  is  dusted  with  iodoform;  a  large  tube 
is  inserted;  the  wound  is  packed  with  iodoform  gauze,  is  partly  closed  by 
sutures  of  silkworm-gut,  and  is  dressed  antiseptically. 

Aspiration  of  Joints. — In  certain  cases  of  joint-effusion  from  inflam- 
mation, tuberculous  or  otherwise,  and  sometimes  in  hemorrhage  into  a  joint, 
it  is  desirable  to  remove  the  fluid  by  aspiration.  The  pneumatic  aspirator 
is  used  (Fig.  266).  The  trocar  and  cannula  are  thoroughly  asepticized  and 
the  joint  is  prepared  as  for  a  set  operation.  The  needle  is  entered  at  a  surface 
free  from  vessels.  The  directions  for  using  an  aspirator  are  as  follows: 
insert  the  stopper  firmly  into  a  strong  bottle  (preferably  a  clear  glass  one), 
then  attach  the  short  elastic  hose  to  the  stopcock  B  of  the  tube  projecting 
from  the  stopper,  and  attach  the  other  end  of  the  same  elastic  hose  to  the 
exhausting  or  inward-flowing  chamber  of  the  pump.  Next  attach  one  end 
of  the  longer  elastic  hose  to  the  stopcock  A  projecting  from  the  stopper, 
and  the  other  end  to  the  needle.     Care  should  be  taken  that  all  the  fittings 


Fig.  266. — Aspirator  and  injector. 


or  attachments  are  placed  firmly  into  their  respective  places.  Now  close  the 
stopcock  A  and  open  the  stopcock  B.  By  giving  from  thirty-five  to  fifty  strokes 
of  the  pump  a  sufficient  vacuum  can  be  produced  to  fill  with  the  fluid  from 
the  joint  a  bottle  holding  from  a  pint  to  a  quart.  After  having  formed 
the  vacuum,  close  the  stopcock  B,  and  insert  the  needle  in  the  joint. 
When  the  stopcock  A  is  opened,  suction  through  the  needle  draws  the 
fluid  from  the  joint.  The  trocar  may  also  be  used  to  inject  antiseptic 
agents.  After  the  completion  of  aspiration  the  part  is  dressed  antisepti- 
callv  and  the  extremity  is  put  at  rest  upon  a  splint. 

Excisions  of  Bones  and  Joints.— Excision  or  resection  of  a  joint 
is  the  removal  of  the  articular  portions  of  the  bones  of  the  joint,  and  also 
the  cartilage  and  synovial  membrane.  In  the  hip-joint  and  shoulder-joint 
the  head  of  the  long  bone  only  may  be  removed,  and  not  the  articular  sur- 
faces of  both  bones.  In  excision  enough  bone  is  known  to  have  been  re- 
moved only  when  the  remaining  bone  bleeds.     Excision  of  a  bone  is  the 


Erasion,   or  Arthrectomy  537 

removal  of  an  entire  bone  or  of  a  portion  of  it.  Excision  is  a  conservative 
operation  which  often  averts  amputation. 

Excision  may  be  performed  by  the  open  method,  in  which  the  periosteum 
is  not  preserved,  or  it  may  be  performed  by  the  subperiosteal  method,  in 
which  the  periosteum  is  carefully  separated  by  a  rugine  and  the  capsular 
ligament  is  preserved.  Arthrectomy,  or  erasion,  is  the  excision  of  the  dis- 
eased synovial  membrane  and  ligament,  and  also  small  foci  of  disease  of  bone 
and  cartilage. 

Excision  may  be  employed  for  compound  dislocation,  and  in  compound 
dislocations  of  the  elbow  and  the  shoulder  it  is  usuallv  performed.  Ex- 
cisions for  compound  dislocations  in  other  large  joints  are  very  dangerous; 
they  are  rarely  attempted  in  battle-field  practice,  and  are  to  be  avoided  even 
in  civil  practice  unless  the  patient  is  young  and  vigorous  and  every  advantage 
can  be  given  him  during  the  operation  and  convalescence.  Excision  for 
deformity  is  rarely  performed  except  upon  the  hip,  the  knee,  and  the  shoulder, 
and  these  excisions  must  not  be  employed  if  the  patient's  condition  leads 
one  to  fear  the  result  of  a  protracted  convalescence.  Excision  of  the  elbow, 
however,  is  usually  a  safe  operation.  In  excising  for  deformity  always  con- 
sider the  patient's  trade  and  the  demands  of  habitual  position  which  it  makes 
upon  him.* 

Excision  is  largely  employed  for  joint-disease,  especially  for  tuberculous 
joints.  Bell  states  that  attempts  to  preserve  the  limb  without  excision  are 
more  justifiable  in  the  lower  than  in  the  upper  limbs,  because  operation 
in  the  lower  extremity  is  more  dangerous  than  in  the  upper,  and  because 
a  cure  without  operation  in  the  lower  limbs,  if  this  cure  can  be  brought  about, 
gives  as  good  a  result  as  a  cure  by  excision.  In  the  upper  extremities  the 
danger  from  operation  is  less  than  is  the  danger  from  waiting.  In  a  young 
subject  an  excision  may  remove  the  epiphysis,  and  thus  lead  to  permanent 
shortening,  which  is  productive  of  less  inconvenience  and  deformitv  in  the 
arm  than  in  the  leg.  The  great  danger  of  excision  operations  is  that  the 
section  may  be  made  through  cancellous  bony  tis.sue;  hence  disastrous  sup- 
l^uration,  phlebitis,  myelitis,  septicemia,  or  pyemia  may  follow;  further,  in 
excision  the  cut  is  often  made  through  diseased  tissue,  and  a  protracted  con- 
valescence is  often  inevitable.  Amputation  is  effected  through  healthv  tissue, 
and  the  convalescence  is  short.  Excision,  however,  when  successful,  gives 
the  patient  a  very  useful  limb. 

Erasion,  or  Arthrectomy. — Erasion  is  the  complete  removal  of  diseased 
synovial  membrane,  ligaments,  etc.  This  operation  seeks  to  remove  a  depot 
of  infection  in  an  early  stage  of  tuberculous  synovitis,  and  it  possesses  the 
conspicuous  merit  of  not  interfering  with  the  epiphysis.  The  term  erasion 
is  also  used  to  designate  the  operation  of  removing  healthy  synovial  mem- 
brane, ligaments,  etc.,  for  the  purpose  of  producing  fixation  of  a  flail  joint 
due  to  infantile  paralysis.  Erasion  is  oftenest  practised  upon  the  knee- 
joint.  The  instruments  required  are  a  scalpel,  hemostatic  forceps,  dis- 
secting forceps,  toothed  forceps,  volsellum,  scissors,  bone-gouges,  curets,  and 
an  Esmarch  apparatus. 

Erasion  of  the  Knee-joint. — The  patient  lies  upon  his  back;  the  leg  is 
flexed  with  the  sole  of  the  foot  planted  upon  the  table,  and  an  Esmarch  ban- 

*  Joseph  Bell,  in  his  "  Manual  of  Surgical  Operations." 


538 


Diseases  and   Injuries  of  Bones  and  Joints 


dage  is  applied  at  a  point  well  up  on  the  thigh.  The  surgeon  stands  to  the 
right  of  the  patient.  The  incision  is  begun  in  the  mid-line  of  the  thigh  (on 
the  side  opposite  to  that  occupied  by  the  surgeon),  about  three  inches  above 
the  patella;  it  is  carried  down  across  the  ligament  of  the  patella  and  up  to 
a  corresponding  point  on  the  opposite  side  of  the  thigh.  This  incision 
goes  down  to  the  bone;  the  flap  is  turned  up  and  the  joint  exposed;  the 
knee-joint  is  strongly  flexed,  and  the  synovial  membrane  and  diseased  liga- 
ments are  dissected  away  with  scissors  and  forceps,  great  care  being  taken 
that  the  posterior  hgaments  (which,  fortunately,  are  rarely  implicated  early 


Fig.  267.  Fig.  268. 

Fig.  267. — i-io,  Amputations  (Joseph  Bell):  i,  of  lower  third  of  forearm  (Teale's)  ;  2,  at  shoulder- 
joint  by  large  postero-external  flap  (second  method)  ;  3,  at  shoulder-joint  by  triangular  flap  from  del- 
toid (third  method)  ;  4,  5,  through  tarsus  (Chopart's)  ;  6,  7,  at  knee-joint ;  8,  by  single  flap  (Garden's)  ; 
9,  10,  of  thigh  (Teale's).     a,  excision  of  hip;  b,  of  ankle-joint  (Hancock's  incision). 

Fig.  268. — 1-18,  Amputations  (Joseph  Bell)  :  i,  amputation  at  wrist-joint  (dorsal  incision) ;  2,  at 
wrist-joint  (palmar  incision)  ;  3,  at  forearm  (dorsal  incision)  ;  4,  at  forearm  (palmar  incision)  ;  5,  at 
elbow-joint  (anterior  flap)  ;  6,  at  arm  (Teale's)  ;  7,  at  shoulder-joint  (first  method) ;  8,  9,  of  metatarsus 
(Hey's);  10,  11,  at  ankle  (Syme's)  ;  12,  13,  of  leg,  posterior  flap  (Lee's)  ;  14,  at  knee-joint  (Garden's)  ; 
15,  of  thigh  (B.  Bell's)  ;  16,  of  thigh  (Spence's)  ;  17,  of  thigh  in  middle  third  ;  18,  at  hip-joint,  a,  ex- 
cision of  wrist  (radial  incision)  ;  b,  of  wrist  (ulnar  incision). 


in  the  case)  are  not  divided  and  that  the  contents  of  the  pophteal  space  remain 
intact.  After  removing  the  disea.sed  ligaments  and  synovial  membrane  the 
cartilage  is  examined  and  any  diseased  portion  is  removed.  The  bone  is 
then  examined  and  any  tuberculous  foci  are  gouged  away.  Any  exposed  ves- 
sels are  ligated.  The  wound  is  irrigated  with  salt  solution,  the  extremity  is 
straightened,  and  the  ends  of  the  ligamentum  patella'  are  sutured,  a  drain- 
age-tube is  inserted  at  each  angle  of  the  wound,  the  skin  is  sutured,  and  anti- 
septic or  sterile  dre.ssings  are  applied.  The  limb  is  placed  upon  a  po.sterior 
.splint  for  a  few  days,  then  the  drainage-tubes  are  removed,  the  dressings 
are  changed,  and  a  [>laster-of-Paris  cast  is  applied,  trap-doors  being  cut  on 


Excision   of  the  Shoulder-joint 


539 


each  side,  and  the  joint  is  kept  immobile  for  two  or  three  weeks.  This  oper- 
ation is  only  suited  to  early  cases  in  which  the  lesion  involves  chiefly  or  purely 
the  synovial  membrane  and  hgaments,  and  in  these  cases  it  frequently  gives 
a  good  result,  some  capacity  for  motion  being  not  unusually  preserved. 

Excision  of  the  Shoulder-joint. — In  the  shoulder-joint  partial  e.xcision 
is  often  performed,  the  head  of  the  humerus  being  removed  and  the  glenoid 
being  undisturbed;  but  some  patients  require  complete  excision,  the  entire 
glenoid  depression,  as  well  as  the  head  of  the  humerus,  being  removed  by 
the  surgeon.     Excision  of  the  shoulder-joint  is  made,  if  possible,  an  intra- 


Fig.  269.  Fig.  270. 

Fig.  269.— 1-9,  Amputations  (Joseph  Bell)  :  i,  of  arm  by  double  flaps  ;  2,  at  shoulder-joint;  3,  at 
ankle-joint  by  internal  flap  (Mackenzie's)  ;  4,  5,  of  leg  just  above  the  ankle-joint  (Syme's)  ;  6,  7,  below 
the  knee  (modified  circular)  ;  8,  through  condyles  of  femur  (Syme's)  ;  9,  at  lower  third  of  thigh 
(Syme's).     A,  excision  of  head  of  humerus;  b,  of  knee-joint  (semilunar  incision). 

Fig.  270. — i-S,  Amputations  (Joseph  Bell)  :  i,  at  elbow-joint  (posterior  flap)  ;  2,  at  shoulder-joint, 
posterior  incision  (first  method);  3,  at  ankle-joint  (Mackenzie's);  4.  through  condyles  of  femur 
(Syme's)  ;  5,  at  lower  third  of  thigh  (Syme's)  ;  6,  at  knee  (posterior  incision)  ;  7,  of  thigh  (Spence's); 
8,  at  hip-joint,  a-c,  Excisions  :  a,  excision  of  shoulder-joint  (deltoid  flap)  ;  b,  of  shoulder-joint  (pos- 
terior incision)  ;  c,  of  elbow-joint  (H-shaped  incision)  ;  d,  of  elbow-joint  (linear  incision)  ;  k.  of  hi()- 
joint  (Gross's)  ;  f,  of  os  calcis  ;  G,  of  scapula. 


capsular  operation,  the  capsule  being  opened,  but  the  capsular  attachment 
to  the  anatomical  neck  of  the  humerus  not  being  interfered  with.  In  ad- 
vanced cases,  however,  the  capsular  attachment  must  be  destroyed.  Ex- 
cision of  the  shoulder-joint  is  seldom  performed  in  civil,  but  is  a  common 
operation  in  military  practice;  it  is  performed  for  gunshot-wounds,  com- 
pound dislocations,  tuberculous  disease,  and  tumors  of  the  head  and 
upper  portion  of  the  humerus.  The  instruments  required  are  a  scalpel,  an 
Adams  saw  and  a  metacarpal  saw,  an  osteotome  or  chi.-^el,  a  mallet,  an  .\llis 
dissector,  a  periosteum-elevator,  hemostatic  forceps,  dissecting  forceps,  toothed 
forceps,  lion-jawed  forceps,  sequestrum  forceps,  metal  retractors,  curets,  and 
cutting  bone  forceps. 


540  Diseases  and   Injuries  of  Bones  and  Joints 

Operation  by  Anterior  Incision. — The  patient  lies  supine;  a  pillow  is  placed 
beneath  the  shoulders,  and  a  sand  pillow  is  put  beneath  the  shoulder  to  be 
operated  upon.  The  arm  is  held  to  the  side  with  the  outer  condyle  forward 
and  the  bicipital  groove  inward  (Barker's  directions).  The  surgeon  stands 
\)\  the  affected  side.  An  incision  three  or  four  inches  in  length  is  made  from 
just  external  to  the  coracoid  process  of  the  scapula,  running  straight  down  the 
humerus  (Fig.  269,  a).  This  incision  divides  the  border  of  the  deltoid  muscle 
and  brings  into  sight  the  long  head  of  the  biceps.  The  tendon  of  the  biceps 
is  retracted  inward,  unless  it  is  diseased,  in  which  case  it  is  resected.  The 
knife  is  carried  up  the  groove  and  opens  the  capsule  of  the  joint.  The  peri- 
osteum is  lifted  from  the  neck  of  the  bone  while  an  assistant  rotates  the 
elbow  to  make  the  muscles  tense.  In  some  places,  if  the  periosteum  tears, 
muscular  insertions  must  be  cut  with  a  knife.  The  head  of  the  bone  is 
sawn  off  while  the  bone  is  in  place,  or  the  elbow  is  strongly  pulled  back, 
and  the  head  of  the  bone  is  forced  out  of  the  wound,  and  is  then  sawn  off 
at  the  point  required.  In  ordinary  cases  only  the  articular  head  is  removed ;  in 
other  cases  the  section  is  made  just  above  the  surgical  neck;  in  yet  others 
a  portion  of  the  shaft  must  also  be  cut  away.  If  the  glenoid  cavity  is  found 
slightly  diseased,  the  dead  bone  must  be  removed  by  the  chisel  and  mallet  or 
by  the  cutting  forceps.  If  the  cavity  is  seriously  diseased,  the  entire  glenoid 
should  be  removed.  Scrape  away  all  damaged  tissue;  ligate  bleeding  points; 
irrigate  the  wound  with  corrosive  sublimate  solution;  swab  it  out  with  a  solution 
of  chlorid  of  zinc  (gr.  xx  to  '^]);  dust  with  iodoform;  close  the  upper  portion 
of  the  wound  and  insert  a  drainage-tube  in  the  lower  angle;  dress  the  wound 
antiseptically;  place  a  small  pad  in  the  axilla;  apply  the  second  roller  of 
Desault;  and  put  the  patient  in  bed  with  a  pillow  under  the  affected  shoul- 
der. In  seven  days  the  hand-sling  is  substituted  for  the  bandage,  and  with 
the  elbow  hanging  free  the  patient  is  permitted  to  get  up  and  is  advised  to 
move  his  arm  frequently.  Drainage  is  maintained  until  the  wound  is  well 
healed  from  the  bottom.  Great  limitation  of  movement  inevitably  follows 
a  shoulder-joint  resection. 

Excision  by  the  deltoid  flap  is  performed  when  the  head  of  the  bone  is 
much  enlarged  (as  by  a  tumor)  or  when  the  tissues  are  thick  and  indurated. 
The  deltoid  flap  is  in  the  shape  of  a  U  or  is  semilunar  (Fig.  270,  a).  Raising 
this  flap  exposes  the  head  of  the  bone  most  satisfactorily.  Bell  states  that 
when  the  glenoid  cavity  is  chiefly  involved  the  incision  should  be  posterior 
(Fig.  270.,  B). 

Senn's  Method. — -Senn  has  recently  described  *  an  incision  which  does 
not  damage  any  important  vessels,  muscles,  tendons,  or  nerves,  and  which 
is  followed  by  good  functional  results.  A  semilunar  skin-flap  is  formed, 
the  incision  running  from  the  coracoid  process  to  the  posterior  border  of 
the  axillary  space.  The  flap  is  turned  up,  exposing  the  upper  half  of  the 
deltoid  muscle.  The  acromion  is  sawn  off  and  turned  down  with  the  attached 
deltoid.  The  capsule  is  now  freely  exposed;  it  is  opened,  and  either  arthrec- 
tomy  or  excision  is  performed,  according  to  conditions.  In  closing  the 
wound  it  is  not  necessary  to  bore  the  acromion  and  pass  silver  wires  to  join 
the  fragments;  it  is  enough  to  suture  the  periosteum  with  catgut. 

Excision  of  the  Elbow- joint. — This  operation  is  performed  for  wounds, 

*  Phila.  Med.  Jour.,  Jan.   I,  1898. 


Excision   of  the   Wrist-joint 


541 


faulty  ankylosis,  and  chronic  articular  disease.  Excision  must  be  complete. 
Endeavor  to  make  a  subperiosteal  resection;  this  maintains  the  shape  of  the 
articulation  and  gives  the  best  chance  for  a  movable  joint.  The  instruments 
used  are  the  same  as  tho.se  for  the  shoulder,  plus  a  Butcher  saw. 

Operation. — The  patient  is  "supine,  but  inclining  to  the  sound  .side,  the 
affected  arm  being  held  almost  vertical,  with  the  forearm  flexed  and  nearly 
horizontal"  (Barker).  The  incision  is  made  on  the  posterior  surface  of  the 
joint.  A  single  posterior  incision  is  usually  employed  (Fig.  270,  d).  An 
incision  is  made  a  little  internal  to  the  long  axis  of  the  olecranon,  beginning  two 
inches  above  and  terminating  two  inches  below  the  tip  of  the  olecranon.  This 
incision  goes  down  to  the  bone,  and  throughout  the  entire  operation  the  surgeon 
must  guard  and  shield  the  ulnar  nerve.  The  periosteum  and  soft  parts  are 
well  separated;  the  olecranon  is  sawn  off;  forced  flexion  exposes  the  joint- 
cavity  freely,  and  enables  the  surgeon  to  lift  the  periosteum  and  soft  parts 
from  the  humerus;  the  humerus  is  sawn  through  at  the  beginning  of  its 
condyloid  proces.ses;  the  radius  and  ulna  are  cleared  and  are  sawn  at  a  level 
below  that  of  the  base  of  the  coronoid  process  of  the  ulna.  Diseased  tissues 
are  cut  and  scraped  away;  the  wound  is  irrigated,  sutured,  drained,  and 
dressed.  In  some  cases  an  H-shaped  incision  is  employed  (Fig.  270,  c),  but 
the  cicatrix  of  a  transverse  cut  will  limit  flexion  of  the  limb. 

After  excision  of  the  elbow  the  patient  is  put  to  bed  and  the  arm  is  laid 
upon  a  pillow,  the  elbow  being  placed  midway  between  a  right  angle  and 
complete  extension,  the  forearm  being  placed  midway  between  pronation 
and  supination.  No  splint  is  used,  as  a  rule.  Esmarch  used  the  splint 
shown  in  Fig.   271.     The  aim  in  treatment  is  to  obtain  a  freely  movable 


Fig.  271. — Esmarch's  splint  tor  tlic  treatment  ot  a  limb  after  excision  of  the  elbow-joint. 


joint.  Passive  motion  is  begun  in  one  week,  at  which  time  the  patient  gets 
up.  The  hand  is  carried  in  a  sling  for  a  time  after  healing  of  the  wound  is 
complete. 

Excision  of  the  Wrist-joint. — Bell  states  that,  whatever  method  of 
excision  is  chosen,  three  cardinal  rules  must  be  borne  in  mind:  (i)  remove 
all  the  diseased  bone,  including  the  portions  of  the  radius,  ulna,  carpus, 
and  metacarpus  which  are  covered  with  cartilage;  (2)  interfere  with  the 
tendons  to  the  least  possible  degree;  and  (3)  begin  passive  motion  of  the 
fingers  very  early.  Many  surgeons  prefer  the  simple  gouging  away  of  dis- 
eased foci  and  the  scraping  of  sinuses  instead  of  a  formal  resection  of  the 
wrist,  amputation  being  employed  in   severe  cases  or  when  scraping  fails 


542  Diseases  and   Injuries  of  Bones  and  Joints 

after  several  trials.  Formal  excision  is  not  frequently  performed,  and  the 
results  cannot  be  regarded  as  very  favorable. 

Lister's  Open  Method  of  Excision. — The  instruments  required  in  this 
operation  are  the  same  as  those  used  for  any  resection.  Break  up  adhesions 
as  completely  as  possible  by  forcible  movements.  Apply  a  tourniquet  or  an 
fZsmarch  apparatus.  The  patient  lies  upon  his  back,  the  arm  and  the  fore- 
arm being  brought,  from  stage  to  stage,  into  the  most  desirable  positions. 
Begin  an  incision  over  the  middle  of  the  dorsum  of  the  radius,  on  a  level 
with  the  styloid  process:  carry  it  downward  in  the  direction  of  the  inner 
edge  of  the  articulation  of  the  thumb  with  its  metacarpal  bone,  and  when 
the  knife  reaches  the  radial  side  of  the  second  metacarpal  bone  alter  the 
direction  of  the  incision  and  carry  it  downward  in  the  long  axis  of  the  meta- 
carpal bone  to  about  its  middle  (Fig.  268,  a).  This  is  known  as  the  radial 
incision,  and  the  only  tendon  divided  is  that  of  the  extensor  carpi  radialis 
brevior  muscle.  The  tissues  upon  the  radial  aspect  of  the  incision  are  dis- 
sected up,  the  tendon  of  the  extensor  carpi  radialis  longior  muscle  is  divided 
at  its  point  of  insertion  (Bell),  and  all  the  soft  structures  are  retracted  out- 
ward, exposing  the  trapezium,  which  is  cut  off  from  the  rest  of  the  carpus, 
but  which  is  left  in  place,  as  its  removal  at  this  stage  endangers  the  radial 
artery  (Barker).  By  extending  the  hand  the  tendons  are  loosened  and  the 
carpus  is  cleared  in  the  direction  of  the  ulnar  border  of  the  hand. 

Another  incision  is  made,  starting  upon  the  inner  surface  of  the  wrist, 
two  inches  above  the  articular  surface  of  the  ulna,  and  midway  between 
the  ulna  and  the  flexor  carpi  ulnaris  tendon.  This  incision,  which  is  known 
as  the  ulnar  incision,  is  carried  down  until  it  is  opposite  the  middle  of  the 
fifth  metacarpal  bone  in  the  palm  (Fig.  268,  b).  "The  dorsal  lip  of  this 
incision  is  raised"  (Bell),  and  the  extensor  carpi  ulnaris  tendon  is  divided 
and  dissected  from  its  depression,  but  is  not  separated  from  the  integument. 
The  extensor  tendons  are  lifted ;  the  ligaments  upon  the  dorsum  and  sides  of 
the  wrist-joint  are  cut;  the  flexor  tendons  are  raised  from  the  carpal  bones; 
the  pisiform  bone  is  cut  from  the  carpus,  but  is  not  yet  removed;  and  the 
unciform  process  of  the  unciform  bone  is  cut  with  forceps.  The  anterior 
radiocarpal  ligament  is  divided,  the  carpometacarpal  articulations  are  cut 
through,  and  the  carpus  is  pulled  out  with  bone-forceps.  The  ends  of  the 
radius  and  ulna  are  forced  out  of  the  ulnar  incision.  All  that  portion  of 
the  ulna  which  is  crusted  with  cartilage  is  to  be  removed,  the  saw-cut  is  to 
be  oblique,  and  the  base  of  the  styloid  process  is  to  be  left  behind.  A  thin 
section  is  to  be  sawn  from  the  radius,  and  the  tendon-grooves  are  not  to  be 
impinged  upon.  The  articular  surface  of  the  ulna  is  cut  away  with  pliers 
(Bell).  If  foci  of  disease  are  discovered  beyond  these  points,  they  are  to 
be  gouged  out.  The  ends  of  the  metacarpal  bones  are  sawn  off,  and  their 
articular  facets  are  cut  away  by  means  of  pliers.  The  trapezium  is  dissected 
out,  the  end  of  the  first  metacarpal  bone  is  sawn  off  and  its  facet  is  cut  away 
with  pliers,  and  a  portion  of  the  pLsiform  bone  is  removed  (the  entire  bone 
being  removed  if  it  be  diseased).  The  wound  is  irrigated,  vessels  are  tied, 
the  radial  incision  is  closed,  the  ulnar  incision  is  partly  closed,  a  drainage- 
tube  is  inserted  by  way  of  the  ulnar  incision,  the  wounds  are  dressed  anti- 
s^ptically,  and  the  Esmarch  apparatus  is  taken  off.  The  forearm  and  hand 
are  placed  upon  a  splint  which  immoVjilizes  the  wrist  and  leaves  the  fingers 


Excision   of  the   Hip-joint 


543 


semiflexed.  Passive  motion  of  the  fingers  is  begun  after  thirty-six  hours. 
The  splint  is  worn  for  many  months,  until  the  wrist-joint  is  immobile  and 
solid.     Esmarch  uses  the  splint  shown  in  Fig.  272. 

Excision   of  Metacarpal   Bones   and   of  Phalanges. — Excision   of  a 
metacarpal   bone,   except   in    cases  of  necrosis   with   the   formation   of  large 


Fig.  272. — Esniarch's  interrupled  splint  applied. 


quantities  of  new  bone,  usually  leaves  a  useless  finger;  hence  amputation  is 
preferred  usually  to  excision.  This  rule  does  not  apply  to  the  metacarpal 
bone  of  the  thumb,  which  is  occasionally  resected.  The  incision  for  this 
operation  is  made  upon  the  dorsum,  and  is  straight.  Excision  of  the  proximal 
phalanx  of  the  thumb  is  sometimes  performed.  Excision  for  disease  is  rarely 
performed  upon  the  finger-joints,  amputation 
being  preferred,  though  the  operation  is  some- 
times undertaken  for  compound  dislocation.  In 
the  metacarpophalangeal  joint  of  the  thumb  ex- 
cision, if  it  can  be  performed,  is  preferred  to  am- 
putation. The  incision  for  resection  of  this  joint 
is  placed  upon  the  radial  aspect. 

Excision  of  the  Hip-joint. — Some  sur 
geons  advocate  this  operation ;  others,  notably 
Marsh,  are  emphatically  opposed  to  it.  E.xcision 
should  be  performed  in  the  early  stage  of  tuber- 
culous disease  //  less  radical  treatment  has  failed. 
In  this  stage  the  usual  position  of  the  limb 
is  one  of  flexion,  abduction,  and  eversion.  In 
cases  of  long  duration,  especially  where  dislo- 
cation exists,  excision  is  an  easy  and  a  compara- 
tively safe  operation;  in  recent  cases  it  is  diffi- 
cult and  carries  with  it  decided  dangers,  but  the 
peril  of  delay  may  be  greater  than  the  peril  of 
an  early  resection.  In  cases  of  hip  disease  with 
involvement  of  the  acetabulum  the  mortality  is 
50  per  cent.,  whether  operation  is  or  is  not  at- 
tempted. Excision  is  performed  especially  for  tuberculous  disease  and  for 
gunshot-injuries.     The  instruments  required  are  those  used  for  other  excisions. 

Operation  by  Anterior  Incision  (Fig.  273)  (Barker's  Operation). — In  this 
operation  the  patient  is  supine,  with  the  thighs  extended  as  thoroughly  as 
circumstances  permit.     The  surgeon  stands  to  the  right  of  the  patient.     An 


Fig,  273. — Excision  of  the  hip- 
joint  :  A,  Gluteus  muscle  ;  b,  tensor 
vagina-  femoiis  muscle;  c,  sai- 
lorius  muscle  ;  d,  anterior  incision. 


544  Diseases  and   Injuries  of  Bones  and  Joints 

incision  is  begun  half  an  inch  below  and  half  an  inch  external  to  the  anterior 
superior  iliac  spine,  and  it  is  carried  downward  and  a  little  inward  for  about 
three  inches  (Fig.  273,  d).  If  dislocation  exists,  the  incision  must  not  be 
so  long.  This  incision  is  carried  at  once  deeply  between  the  muscles,  and 
the  capsule  of  the  joint  is  opened.  The  neck  of  the  bone  is  divided  from 
its  upper  surface  downward  with  a  saw  or  an  osteotome,  and  without  dis- 
locating the  bone  through  the  wound  by  forcible  extension  and  eversion. 
The  head  of  the  bone  is  removed.  All  tuberculous  foci  must  be  scraped  away, 
and  the  flushing  gouge  is  used  upon  tuberculous  areas  of  the  acetabulum. 
All  sinuses  should  be  thoroughly  scraped.  Bleeding  is  arrested,  the  wound 
is  irrigated  with  normal  salt  solution,  mopped  out  with  chlorid  of  zinc 
solution,  and  dusted  with  iodoform.  A  drainage-tube  is  inserted  at  the 
lower  angle  of  the  incision,  and  the  upper  i)ortion  of  the  cut  is  closed. 
The  wound  is  dressed  antiseptically.  ICxtension  is  made  with  the  extension 
apparatus  until  healing  has  obtained  good  headway,  when  a  double  Thomas's 
splint  is  applied,  so  that  the  patient  can  be  taken  out  daily  in  the  air  and 
sunlight.  As  a  rule,  rigid  ankylosis  results  from  resection  of  the  hip,  but 
occasionally  a  joint  results  with  a  small  range  of  movement. 

Operation  by  Lateral  Incision  (Langenbeck's  Operation). — In  this  opera- 
tion a  straight  incision  two  inches  long  is  made  in  the  direction  of  the  axis 
of  the  femur,  and  passing  downward  from  the  apex  of  the  great  trochanter. 
From  the  beginning  of  this  incision  a  curved  incision  is  carried  toward  the 
head  of  the  bone,  the  convexity  of  the  curve  being  backward  (Fig.  267,  a). 
Bell  advises  the  use  of  the  saw  after  bringing  the  head  of  the  bone  into  the 
wound  by  abduction  and  eversion  of  the  thigh.  Barker  applies  the  saw  with 
the  bone  in  situ,  and  strongly  opposes  wrenching  the  bone  out  of  the  incision, 
because  of  the  danger  of  peeling  off  the  periosteum,  which  peeling,  if  it  takes 
place,  favors  necrosis. 

Incision  of  Gross. — In  Gross's  operation  a  semihmar  flap  is  made  with 
the  convexity  backward  (Fig.  270,  e). 

Excision  of  the  Knee-joint. — In  this  operation  a  complete  excision 
should  be  performed,  and  the  patella  ought  to  be  removed.  This  operation 
is  performed  for  tuberculous  disease,  some  compound  fractures  and  com- 
pound dislocations,  and  some  cases  of  angular  ankylosis,  but  it  is  rarely 
employed  for  gunshot-injuries,  amputation  being  usually  preferable.  The 
in.struments  required  are  the  same  as  those  for  the  shoulder,  plus  Butcher's 
saw. 

Operation  by  Anterior  Semilunar  Flap. — The  patient  lies  upon  his  back, 
and  the  joint,  if  not  ankylosed  in  extension,  should  be  semiflexed.  The 
surgeon  stands  to  the  right  side.  An  incision  is  made  which  at  once  opens 
the  joint.  The  incision  begins  at  one  condyle  and  reaches  the  other  con- 
dyle by  a  curve  which  passes  through  the  ligamentum  patellae  midway 
between  the  tuberosity  of  the  tibia  and  the  inferior  margin  of  the  patella 
(Fig.  269,  b).  The  flap  is  dissected  up,  the  knee  is  thrown  into  forced 
flexion,  the  lateral  ligaments  and  crucial  ligaments  are  cut,  and  the 
end  of  the  femur  is  well  cleared.  The  blade  of  Butcher's  saw  is 
passed  beneath  the  bone,  which  is  sawn  from  below  upward  (Ashhurst). 
The  end  of  the  tibia  is  cleared  and  a  portion  is  sawn  off.  If,  after 
sawing,   diseased  foci    are  discovered,   another  section  can  be  sawn  off  or 


Excision  of  the  Ankle-joint 


545 


the  foci  can  be  gouged  away.  Ashhurst,  who  has  had  a  vast  experience 
with  this  operation,  insists  that  in  sawing  through  the  femur  the  natural 
obUquity  of  the  bone  must  be  borne  in  mind  and  the  section  must  be  made 
in  "a  line  parallel  to  that  of  the  free  surface  of  the  condyles."  If  the  section 
is  made  transverse  to  the  axis  of  the  femur,  "the  limb,  after  adjustment, 
will  be  found  to  be  markedly  bowed  outward."  The  same  surgeon  says 
that  the  epiphyseal  line  is  somewhat  higher  on  the  front  than  it  is  on  the 
back  of  the  femur,  and  in  consequence  the  following  rule  is  formulated  for 
section  of  the  condyles:  the  section  of  the  condyles  should  be  "in  a  plane 
which,  as  regards  the  axis  of  the  femur,  is  oblique  from  behind  forward, 
from  below  upward,  and  from  within  outward. "  Ashhurst  advocates  section 
of  the  tibia  "in  a  plane  transverse  to  the  long  axis  of  the  bone,  with  a  slight 
anteroposterior  obliquity,  so  as  to  correspond  with  that  of  the  section  of 
the  condyles, "  and  he  further  says  that  the  patella  must  be  removed,  whether 
it  is  diseased  or  not,  and  quotes  Peniere's  observations  to  the  effect  that 
e-xcision  of  the  patella  diminishes  the  risk  of  death  one-third,  and  its  retention 
doubles  the  probability  of  an  amputation  becoming  necessary  in  the  future. 


Fig.  274. — Watson's  plaster-of-Paris  swing-splint. 


After  removing  the  patella  the  diseased  synovial  membrane  is  clipped 
away  with  scissors  and  all  sinuses  and  diseased  territories  are  well  curetted. 
The  posterior  ligament  of  the  joint  is  not  removed  unless  it  is  diseased;  its 
retention  prevents  displacement  and  guards  the  popliteal  space.  In  children 
the  fragments  should  be  wired  together;  in  adults  this  need  not  be  done. 
After  hemostasis,  irrigate,  dust  with  iodoform,  insert  a  drainage-tube,  suture, 
dress  antiseptically,  and  adjust  the  limb  upon  Price's  splint  or  Ashhurst's 
bracketed  wire  sphnt.  In  some  cases  tenotomy  is  required  to  permit  ex- 
tensioii.  Instead  of  the  bracketed  splint,  a  long  fracture-box  may  be  used. 
If  the  femur  tends  to  project  anteriorly,  use  an  anterior  splint.  If  there 
be  a  tendency  to  outward  bowing,  adopt  Ashhurst's  expedient  of  carrying 
a  strip  of  adhesive  plaster  around  the  outside  of  the  limb  and  fastening  it 
to  the  inner  side  of  the  splint.  The  splint  is  kept  on  until  bony  union  is 
complete,  as  in  this  operation  a  mo\able  joint  is  never  sought.  Manv  sur- 
geons use  a  plaster-of-Paris  splint,  which  is  em{)loyed  until  the  parts  have 
become  firm  and  solid  (Fig.  274). 

Excision  of  the  Ankle-joint. — This  operation  is  performed  chiefly  for 
gunshot-wounds,  compound  dislocations,  and  in  some  cases  of  tuberculous 
35 


546  Diseases  and  Injuries  of  Bones  and  Joints 

joint-disease.  Excision  of  the  ankle  is  an  operation  which  is  seldom  per- 
formed. The  instruments  used  are  the  same  as  those  employed  for  any 
resection. 

Operation  (Hancock's  Method). — In  this  operation  the  patient  lies  upon 
his  back,  the  foot  rests  upon  its  inner  side,  and  the  surgeon  stands  to  the 
outer  side  of  the  damaged  limb.  Begin  an  incision  just  behind  and  two 
inches  above  the  external  malleolus,  and  carry  it  across  the  front  of  the  joint 
to  a  corresponding  point  above  and  behind  the  internal  malleolus  (Fig.  267, 
b);  this  incision  goes  only  through  the  skin,  and  the  flap  thus  marked  out 
is  reflected.  "'  Cut  down  upon  the  external  malleolus,  carrying  the  knife 
close  to  the  edge  of  the  bone  both  behind  and  below  the  process,  dislodge 
the  peronei  tendons,  and  divide  the  external  lateral  ligaments"  (Joseph  Bell). 
Cut  the  fibula  one  inch  above  the  malleolus  by  means  of  phers;  divide  the 
tibiofibular  ligament;  turn  the  foot  upon  its  outer  side;  dissect  from  their 
habitat  back  of  the  inner  malleolus  the  tendons  of  the  posterior  tibial  and 
the  common  flexor  of  the  toes;  carry  the  knife  around  the  inner  malleolus, 
close  to  the  bonv  edge;  separate  the  internal  lateral  ligament,  and  dislocate 


Fig.  27.T. — Volkmanii's  dorsal  splint  for  excision  of  the  ankle. 

the  lower  end  of  the  tibia  through  the  wound  by  turning  the  sole  of  the  foot 
downward;  saw  off  the  lower  end  of  the  tibia  and  the  articular  process  of 
the  astragalus,  sawing  away  from  the  tendo  Achillis,  and  remove  the  frag- 
ments with  bone  forceps.  Cut  away  diseased  synovial  membrane,  and  curet 
all  sinuses  and  tuberculous  areas.  Arrest  bleeding,  irrigate,  and  drain.  Sew 
up  the  wound,  insert  a  tube  at  the  outer  angle,  and  cause  it  to  emerge  at  the 
inner  angle.  Apply  antiseptic  dressings,  and  put  up  the  foot  in  fixed  dress- 
ing or  in  splints  at  a  right  angle  to  the  leg  (Fig.  275).  In  Langenbeck's 
operation  the  excision  is  subperiosteal.  If,  in  an  excision  of  the  ankle-joint, 
the  astragalus  is  found  extensively  diseased,  remove  the  entire  bone. 

Excision  of  the  Os  Calcis. — In  caries  limited  to  the  os  calcis  most 
surgeons  prefer  to  gtmge  away  the  dead  l)one,  leaving  the  periosteum  and, 
if  possible,  a  shell  of  healthy  bone,  and  draining  thoroughly.  Others  advo- 
cate excision  in  some  cases.  Extensive  disease  limited  purely  to  the  os  calcis 
is  rare,  and  most  surgeons  advise  gouging  for  limited  caries,  and  Syme's 
amputation  in  the  event  of  the  disease  extending  beyond  the  periosteum  or 
reaching  adjacent  bones. 

Operation  by  Subperiosteal  Method. — In   this  operation   the  position   as- 


Excision   of  the  Scapula  547 

sumed  by  the  patient  is  supine  with  the  leg  extended  and  the  foot  resting 
on  its  inner  side.  The  incision,  which  cuts  the  tendo  Achillis  and  reaches 
the  bone  at  once,  is  begun  at  the  upper  border  of  the  os  calcis  and  the  inner 
margin  of  the  tendo  Achillis,  and  is  taken  outward  and  horizontally  forward 
to  a  point  in  front  of  the  calcaneocuboid  articulation  (Fig.  270,  f).  A  ver- 
tical incision  is  begun  near  the  forward  termination  of  the  initial  incision,  is 
carried  across  the  outer  edge  and  plantar  surface  of  the  foot,  and  terminates  at 
the  external  margin  of  the  inner  surface  of  the  os  calcis.  Some  surgeons  carry 
the  vertical  incision  a  little  upward,  toward  the  dorsum.  The  periosteum 
is  entirely  stripped  with  an  elevator,  the  os  calcis  is  removed,  the  cavitv  is 
packed  with  iodoform  gauze,  the  wound  is  stitched,  a  drain  is  inserted  pos- 
teriorly, and  the  foot  is  dressed  antiseptically,  is  placed  at  a  right  angle  to 
the  leg,  and  plaster-of-Paris  is  applied,  trap-doors  being  cut  for  drainage. 

Astragalectomy,  or  excision  of  the  astragalus,  is  seldom  performed. 
Astragalectom}-  is  employed  occasional!}'  for  relapsed  and  inveterate  cases 
of  club-foot.  The  indications  are  pointed  out  by  Willard  ("International 
Clinics,"  vol.  iii,  12th  series):  "(i)  Aduhs  with  great  bony  deformitv;  (2) 
neglected  children  of  five  to  fifteen  years,  who  have  markedly  distorted  their 
tarsi  by  locomotion ;  (3)  relapsed  cases  which  have  resisted  the  milder  forms 
of  operation,  or  which  ha\e  been  neglected  by  parents  after  pre\-ious  opera- 
tion; (4)  only  occasionally,  young  children  in  whom  from  infancy  the  bones 
of  the  foot  have  been  exceedingly  rigid  and  unyielding,  and  where  there  is 
practically  but  little  motion  either  at  the  ankle-joint  or  in  the  tarsus. " 

Operation  by  the  Subperiosteal  Plan. — Barker  advises  an  incision  going 
at  once  to  the  bone,  from  the  "tip  of  the  external  malleolus  forward  and 
a  little  inward,  curving  toward  the  dorsum  of  the  foot."  The  foot  is  ex- 
tended and  turned  inward,  the  periosteum  is  lifted,  the  astragalus  is  re- 
moved, and  the  wound  is  treated  and  the  foot  is  dressed  as  is  done  in 
excision  of  the  os  calcis. 

Excision  of  the  Metatarsophalangeal  Articulation  of  the  Great 
Toe. — In  this  operation  make  a  lateral  incision  and  cut  off  or  saw  off  the 
proximal  end  of  the  first  phalanx  and  the  distal  third  of  the  first  metatarsal 
bone. 

Excision  of  the  Metatarsal  Bone  of  the  Great  Toe  (Butcher's  Method). 
— In  this  operation  a  lateral  straight  incision  is  made,  the  periosteum  is 
elevated,  and  the  shaft  is  sawn  from  each  extremity  and  removed. 

Excision  of  the  clavicle  may  be  required  for  dislocation,  caries, 
necrosis,  gunshot-wound,  tumor  of  this  bone,  as  a  preliminarv  to  ligation 
of  the  artery  and  vein  in  certain  cases  of  amputation  at  the  shoulder- 
joint,  or  in  cases  of  removal  of  the  entire  upper  extremitv.  In  excision  of 
the  clavicle  the  position  of  the  patient  is  the  same  as  that  for  ligation  of  the 
third  part  of  the  subclavian  arter\'  (page  343)-  An  incision  is  made  down 
to  the  bone,  from  the  sternoclavicular  joint  to  the  acromioclavicular  articu- 
lation. If  the  case  is  suitable,  the  periosteum  is  stripped  and  the  bone  is 
sawn  and  removed;  if  not,  the  bone  is  sawn  and  each  half  is  separatelv  dis- 
articulated. The  wound  is  .sutured  and  dressed,  and  the  limb  is  put  up  in 
a  Velpeau  bandage. 

Excision  of  the  Scapula. — Complete  excision  of  the  scapula  is  usuallv 
l^erformed    for   tumors.     Partial    excision    requires    no   detailed    description. 


548  Diseases  and  Injuries  of  Bones  and  Joints 

In  excision  of  the  scapula  the  patient  lies  upon  his  sound  side.  Treves 
suggests  the  following  incisions:  one  outside  the  vertebral  border  of  the 
scapula,  from  its  superior  to  its  inferior  angle;  another  from  over  the 
acromioclavicular  joint,  along  the  acromion  process  and  spine  of  the  scapula, 
to  meet  the  first  incision.  Syme  used  an  incision  carried  transversely  inward 
from  the  acromion  process  to  the  vertebral  border  of  the  scapula,  and  another 
cut  directly  downward  from  the  center  of  the  first  incision  (Fig.  270,  g).  In 
the  method  of  Tre\es  *  the  upper  flap  is  reflected  and  the  trapezius  muscle 
is  divided;  the  lower  flap  is  reflected  and  the  deltoid  muscle  is  divided.  The 
patient's  hand  is  placed  on  the  sound  shoulder;  the  muscles  of  the  vertebral 
border  are  divided,  the  posterior  scapular  artery  is  tied,  and  while  the  vertebral 
border  of  the  scapula  is  pulled  toward  the  surgeon  the  serratus  magnus 
muscle  is  cut,  the  upper  border  of  the  shoulder-blade  is  cleared,  and  the 
suprascapular  artery  is  tied.  The  hand  is  now  brought  down  to  the  side;  the 
acromioclavicular  joint  is  disarticulated;  the  conoid  and  trapezoid  ligaments 
are  divided;  the  muscles  of  the  coracoid  process  are  cut;  the  capsule  is  incised, 
with  the  supraspinatus  and  infraspinatus,  the  subscapularis,  and  the  scap- 
ular origins  of  the  biceps  and  triceps  muscles;  and  finally  the  teres  major 
and  minor  muscles  are  divided,  the  subscapular  artery  is  tied,  and  the  bone 
is  removed.  The  wound  is  stitched,  a  drain  is  introduced,  and  antiseptic 
dressings  are  applied.  The  patient  lies  upon  his  back  until  healing  is  well 
under  way,  when  the  arm  is  placed  in  a  sling.  The  drainage-tube  may  be 
removed  in  twenty-four  hours. 

Excision  of  a  Rib. — In  caries  the  gouge  and  rongeur  may  remove  the 
disease.  In  other  cases  excision  is  performed.  In  this  operation  the  patient 
lies  upon  his  sound  side  unless  the  operation  is  performed  for  empyema,  in 
which  case  he  lies  on  his  back  or  only  partly  on  the  sound  side.  (See  Em- 
pyema, Operation  for.)  The  surgeon  faces  the  patient.  Make  an  incision 
down  to  the  bone,  in  the  long  axis  of  the  rib.  The  periosteum,  if  not  diseased, 
is  lifted  from  the  bone,  and  the  intercostal  artery  is  lifted  out  of  the  way  with 
the  periosteum  and  is  thus  saved  from  being  cut.  After  dividing  the  bone 
beyond  the  limits  of  disease,  remove  it.  During  the  sawing  a  metal  retractor 
is  held  beneath  the  rib,  between  the  rib  and  the  periosteum.  It  is  better  to 
saw  it  than  cut  it  with  ordinary  biting  forceps,  because  the  latter  splinter  the 
bone.  The  author  usually  uses  a  forceps  known  as  a  costotome,  which  cuts 
the  rib  without  splintering.  If  the  periosteum  is  diseased,  remove  it  after 
tying  the  intercostal  artery.  It  should  be  removed  in  a  case  of  empyema, 
otherwise  bone-formation  may  interfere  with  drainage.  In  empyema,  after 
removing  the  periosteum,  open  into  the  pleura  cavity,  allow  pus  to  flow  out 
slowly,  remove  fibrinous  masses,  employ  a  finger  to  feel  if  there  are  adhe- 
sions and  if  the  lung  will  probably  expand,  and  insert  a  drainage-tube.  In 
resection  for  rib  disease  curet  sinuses  and  i)ack  with  iodoform  gauze  for  some 
days.  Sew  up  the  wound  except  at  one  end.  Dress  antiseptically  and  apply 
a  binder.     (See  Operations  upon  the  Chest  and  Estlander's  Operation.) 

Complete  Excision  of  One-half  of  the  Upper  Jaw.— The  whole  upper 
jaw  has  been  removed,  but  in  what  follows  only  resection  of  one-half  the 
jaw  will  be  described.  This  operation  is  performed  for  malignant  tumors 
of  the  superior  maxillary  bone  or  its  antrum.     Up  to  1826,  at  which  time 

*Treves's  "  Manual  of  Operative  Surgery." 


Preliminary  Closure  of  the  External   Carotid  Artery         549 


Fig.  276. — A  E,  Excision  of  the 
upper  jaw ;  c  d  e,  excision  of  the 
lower  jaw. 


Lizars,  of  Edinburgh,  suggested  the  operation,  tumors  of  the  antrum  were 
treated  by  scraping  them  away  with  a  sharp  spoon.  Gensoul,  of  Lyons,  in 
1827  performed  the  first  operation  for  resection  of  the  upper  jaw.  This  ope- 
ration is  not  justifiable,  except  as  a  palliative  measure,  if  the  orbit  is  invaded, 
if  the  skin  and  subcutaneous  tissues  are  infil- 
trated, or  if  the  disease  extends  widely  beyond 
the  superior  maxillary  and  palate  bones.  The 
instruments  required  are  a  mouth-gag;  scal- 
pels; strong  scissors;  tracheotomy  tubes;  dis- 
secting, toothed, and  hemostatic  forceps;  bone- 
cutting,  lion-jaw,  sequestrum  and  tooth-ex- 
tracting forceps;  a  volsella;  a  narrow-bladed 
saw;  a  chisel  and  mallet;  a  periosteum-ele- 
vator; a  spatula  or  metal  retractor;  Paque- 
lin's  cautery;  sponges  which  are  tied  to  sticks; 
needles,  curved  and  straight;  silk  and  catgut 
ligatures;  silkworm  sutures;  large  curved 
needles;  and  Horsley's  antiseptic  bone-wax. 

Preliminary  Closure  of  the  External 
Carotid  Artery. — Some  surgeons  ligate  the 
external  carotid  artery  or  compress  it  tem- 
porarily. In  a  number  of  excisions  of  the  upper  jaw  I  have  always  found 
the  hemorrhage  readily  controllable  as  soon  as  the  bone  is  removed,  and  have 
never  felt  it  necessary  to  resort  to  preliminary  ligation  or  compression.  A 
number  of  surgeons  have  set  forth  contrary  views 
(Pirogoff,  Madelung,  Schlatter).  Crile  is  a  warm 
advocate  of  temporary  closure,  and  employs  a 
clamip  for  this  purpose. 

Operation  by  Median  Incision. — The  patient, 
whose  face  has  been  shaved,  is  placed  in  the  Tren- 
delenburg position,  thus  avoiding  the  possible  need 
of  instant  tracheotomy.  The  surgeon  stands  to  the 
right  side  of,  and  faces,  the  patient.  The  incisor 
tooth  on  the  diseased  side  is  pulled  out.  The  in- 
cision, which  is  known  as  Weber's  incision  (Fig. 
276,  line  A  b),  is  begun  half  an  inch  below  the 
inner  canthus  of  the  eye,  and  is  carried  along  the 
side  of  the  nose,  around  the  ala  of  the  nose,  by 
the  margin  of  the  nostril,  and  through  the  middle 
of  the  lip.  While  the  lip  is  being  incised  the 
assistant  arrests  hemorrhage  by  grasping  the  cor- 
ners of  the  mouth,  and  after  the  lip  is  divided 
the  coronary  arteries  are  at  once  ligated.  Some 
operators  approach  the  mucous  membrane  cau- 
tiously and  ligate  the  vessels  before  opening  the 
cavity  of  the  mouth.  The  upper  portion  of  the 
wound  having  been  compressed  by  another  assistant  during  these  manipula- 
tions, pressure  is  now  removed  and  bleeding  points  are  ligated.  Another 
incision  is  now  carried  outward  from  the  beginning  of  the  first  incisit)n,  along 


Fig.  277. —  I.  Excision  of  the 
upper  jaw  :  a  b,  section  of  the 
nasal  process ;  b  c,  section  of 
the  orbital  plate  ;  d,  section  of 
the  malar  bone  and  orbital 
plate ;  e,  section  of  the  alveo- 
lus and  hard  palate.  2.  Ex- 
cision of  the  lower  jaw  :  g,  sec- 
tion of  the  inferior  maxillary ; 
H,  section  of  the  ramus  in  par- 
tial resection. 


550  Diseases  and  Injuries  of  Bones  and  Joints 

the  orbital  margin  to  well  over  the  malar  bone.  The  flap  is  lifted  from  the 
periosteum,  and  the  bleeding  from  the  infraorbital  arter}-  and  the  small 
vessels  is  restrained  by  pressure.  The  nasal  cartilage  is  separated  from  the 
bone,  and  the  nasal  process  of  the  superior  maxillary  is  sawn  (line  A  b.  Fig. 
277).  The  orbital  periosteum  is  hfted  up,  and  the  orbital  plate  is  cut  with 
forceps  from  the  saw-cut  in  the  superior  maxillar\-  bone  to  the  sphenomaxillary 
fissure  (line  b  c,  Fig.  277).  The  malar  bone  is  sawn  or  is  bitten  through 
about  its  center,  the  cut  running  into  the  sphenomaxillary  fissure  and  taking 
a  downward  and  outward  direction  (line  c  d.  Fig.  277).  The  soft  parts 
covering  the  hard  palate  are  incised  in  the  median  line,  a  corresponding 
incision  is  made  along  the  floor  of  the  nose  near  the  septum,  and  the  soft 
palate  is  separated  from  the  hard  palate  by  a  transverse  cut.  The  saw  is 
introduced  through  the  nose,  and  the  palate  is  sawn  (fine  E,  Fig.  277).  The 
upper  jaw-bone  is  grasped  with  Fergusson's  lion-jaw  forceps  and  removed, 
the  removal  being  aided  by  the  use  of  the  scissors  and  bone-cutters;  the 
latter  are  used  to  separate  the  upper  jaw  from  the  pterygoid  process  (Treves). 
Every  vessel  that  can  be  seen  is  tied,  and  severe  bleeding  from  bone  is  arrested 
by  antiseptic  wax.  Oozing  is  controlled  by  hot  water  and  pressure  or  by 
Paquelin's  cautery.  E.xamine  carefully  to  see  if  all  the  diseased  area  is 
removed;  if  it  is  not,  use  the  gouge,  scissors,  chisel,  and  saw  until  healthy 
tissue  is  reached.  The  wound  is  packed  with  iodoform  gauze,  and  the  end 
of  the  strip  is  so  placed  as  to  be  accessible  through  the  mouth.  The  wound 
is  sutured  (the  mucous  membrane  of  the  lip  must  be  stitched,  as  well  as  the 
skin)  and  is  dressed  antiseptically  (the  eye  being  protected  by  aseptic  gauze), 
and  a  crossed  bandage  of  the  angle  of  the  jaw  is  applied. 

Excision  of  One-half  of  the  Lower  Jaw. — In  some  rare  instances 
the  entire  inferior  maxillary  bone  is  removed.  The  lesions  necessitating 
removal  of  the  lower  jaw  are  of  the  same  nature  as  cause  us  to  remove  the 
upper  jaw.  The  instruments  required  for  removal  of  the  lower  jaw  are 
those  used  for  excision  of  the  upper  jaw,  plus  a  metacarpal  saw  (having  a 
movable  back). 

In  this  operation  the  patient  is  placed  in  the  same  position  as  for  excision 
of  the  upper  jaw,  the  chin  having  been  previously  shaved.  A  vertical  cut 
is  made  through  the  chin-tissue,  starting  below  the  margin  of  the  lip  and 
reaching  to  below  the  border  of  the  jaw  (c  d.  Fig.  276).  From  the  point  d 
an  incision  is  carried  outward  below  the  border  of  the  jaw  and  then  back 
of  the  ramus,  as  shown  in  the  line  D  E  (Fig.  276).  Treves's  advice  is  to  carry 
this  incision  down  to  the  bone,  except  at  the  line  of  the  facial  artery,  at  which 
point  it  must  go  through  the  skin  only.  The  facial  artery  is  now  to  be  sought 
for,  tied  in  two  places,  and  divided.  The  periosteum  is  lifted  from  the 
external  surface  of  the  bone,  from  the  .symphysis  outward.  Hemorrhage  is 
arrested.  The  buccal  mucous  membrane  is  cut  from  the  alveolus.  A  lateral 
incisor  tooth  is  pulled,  and  the  bone  is  sawn  in  the  line  c,  (Fig.  277).  The 
bone  is  graspcfl  in  a  lion- jaw  forceps  and  is  drawn  outward.  The  mylo- 
hyoid insertion  is  cut;  the  internal  pterygoid  muscle  is  cut  or  the  periosteum 
at  this  spot  is  lifted ;  the  inferior  dental  artery  is  cut  and  tied ;  the  jaw  is  pulled 
down;  the  insertion  of  the  temporal  muscle  upon  the  coronoid  process  is 
cut  away;  and  the  external  pterygoid  muscle  is  divided.  The  capsule  of 
the  joint  is  ojjened,  and  the  l>one  is  separated  from  the  ligaments  which  still 


Operation   for   Congenital   Dislocation   of  Hip  551 

hold  it  in  place.  Bleeding  is  arrested,  the  wound  is  sutured,  a  tube  is  intro- 
duced in  the  posterior  portion  of  the  wound  and  retained  for  twenty-four 
hours,  and  antiseptic  dressings  and  a  Gibson  or  a  Barton  bandage  are  applied. 
Partial  excisions  of  the  alveolus  may  be  performed  through  the  mouth  by 
means  of  chisels  and  rongeur  forceps,  and  Wyeth  has  thus  removed  half  of 
the  jaw;  but  if  any  considerable  part  of  the  body  of  the  jaw  is  to  be  removed, 
it  is  usually  best  to  make  an  incision  below  the  inferior  maxillary. 

Barker's  Operation  for  Dislocation  of  the  Semilunar  Cartilages 
of  the  Knee-joint.* — Begin  the  incision  over  the  ligament  of  the  patella, 
half  an  inch  abo\e  the  articular  surface  of  the  tibia,  and  carry  it  in  a  curve 
downward  and  outward  to  the  anterior  edge  of  the  internal  lateral  ligament. 
The  periosteum  should  be  divided  by  the  cut.  This  incision  forms  a  flap 
the  lower  edge  of  which  is  half  an  inch  below  the  border  of  the  articular 
surface  of  the  tibia.  The  flap  is  lifted  until  the  cartilage  is  seen  ''  under 
the  attachment  of  the  meniscus,  which  if  partialh-  attached  will  rise  with 
the  flap  until  its  under  surface  is  seen."  If  partially  torn  anteriorly  it  is 
stitched  to  periosteum  by  a  few  silk  sutures.  The  periosteum  is  then  stitched 
in  place,  no  drain  is  used,  the  joint  is  immobilized,  and  for  one  week  ice  is 
kept  upon  the  part.  If  the  meniscus  is  found  completely  separated  and 
curled  up,  it  may,  if  the  injury  was  recent,  be  reduced.  If  the  injury  was  old 
and  if  the  cartilage  is  shrunken,  it  should  be  completely  cut  away  (Barker). 

Operation  for  Congenital  Dislocation  of  Hip. — Lorenz's  Bloodless 
Method  0}  Reduction. — The  method  of  reducing  by  manipulation  a  congenital 
dislocation  of  the  hip  was  devised  by  Paci  and  modified  and  improved  by 
Lorenz.  It  has  long  been  known  that  reduction  is  easy  at  birth,  because 
an  acetabulum,  though  probably  a  shallow  one,  exists  and  the  head  of  the 
•bone  is  not  firmly  held  in  its  new  situation.  In  an  older  child  the  problem 
is  far  more  difficult,  because,  even  if  reduction  is  effected,  the  acetabulum 
may  be  extremely  shallow  or  absent,  and  redislocation  may  readily  occur. 
Lorenz  aims  to  effect  thorough  reduction  and  then  fixes  the  limb  in  abduction 
for  months,  so  that  the  acetabulum  will  deepen  and  the  bone  will  become 
firm  in  its  proper  socket.  This  operation  is  rarely  successful  in  children 
over  six  years  of  age.  The  child  is  anesthetized  and  an  attempt  is  made  to 
draw  the  femoral  head  on  to  a  line  with  the  acetabulum.  If  the  child  has 
never  walked,  this  is  readily  accomplished.  If  it  has  walked,  the  procedure 
may  be  very  difficult,  and  it  ma\-  be  necessary  to  make  extension  with  a 
fillet  fastened  above  the  knee,  and  counter-extension  with  a  screw  and  a 
perineal  band.  The  drawing  down  of  the  head  is  made  easier  bv  stretch- 
ing and  massaging  the  adductor  muscles.  The  next  step  is  to  strongly  flex 
the  thigh,  rotate  it  a  trifle  internally,  and  then  abduct  it  while  flexion  is  main- 
tained. This  causes  the  head  of  the  femur  to  pass  around  the  posterior  mar- 
gin of  the  acetabulum  and  frequently  produces  reduction.  "  Full  abduction 
being  kept  up,  the  thigh  is  rotated  out,  thus  forcing  the  head  of  the  femur 
more  firmly  into  the  socket"  (see  the  description  of  the  Lorenz  method  in 
J.  Jackson  Clarke's  "  Orthopicdic  Surgery").  The  strongly  abducted  limb  i> 
put  up  in  plaster-of-Paris.  In  about  three  months  the  plaster  is  removed,  the 
abduction  is  diminished,  the  i)laster  is  reapplied  and  is  retained  for  another 
three  months.     During  the  continuance  of  immobilization  of  the  hi}),  the  child 

*"  Lancet,''  Taii.  4,  1902. 


552  Diseases  and   Injuries  of  Bones  and  Joints 

walks  about,  with  the  knees  bent.  When  the  plaster  is  finally  removed,  ma- 
nipulation, massage,  and  exercise  strengthen  the  muscles  and  give  freedom  to 
the  joint.  In  a  double  dislocation  one  joint  can  be  cured  before  the  other  is 
operated  upon,  or  both  may  be  operated  upon  at  the  same  seance.  In  double 
dislocation  plaster  must  be  worn  more  than  six  months.  The  Lorenz  opera- 
tion is  safe  when  applied  to  very  young  children,  but  has  elements  of  danger 
which  increase  with  the  years  of  the  subject.  A  patient  may  suffer  grave 
lacerations  of  muscles  and  ligaments,  and  even  vessels  and  nerves.  Death 
may  result  from  shock,  and  extensive  deep-seated  hemorrhage  may  occur. 
In  fact,  it  is  a  mistake  to  call  it  a  bloodless  method.  The  blood  flows,  though 
we  do  not  see  it.  An  untrained  man  may  do  fearful  mischief  by  this  opera- 
tion, and  it  should  only  be  attempted  by  a  very  skilful  manipulator  and  upon 
properly  selected  cases,  when  it  is  a  very  successful  procedure.  I  am  satisfied 
that,  except  in  the  case  of  a  very  young  child,  in  whom  reduction  is  easy,  one 
who  performs  the  Lorenz  operation  should  be  something  more  than  skilful 
and  experienced.  He  should  be  physically  strong,  so  that  traction  and  ab- 
duction will  be  powerful  and  steady.  A  weak  man  will  jerk,  will  throw  his 
weight  upon  the  part,  and  will  be  apt  to  tear  structures  instead  of  stretching 
them.     Sudden  forcible  movements  are  apt  to  break  the  bone. 

Hofja's  Operation. — The  instruments  used  are  the  same  as  for  a  resec- 
tion. Make  the  external  incision  of  Langenbeck  to  open  the  joint  (page  544). 
The  capsule  is  incised  at  its  insertion  into  the  neck,  and  the  periosteum  and 
muscles  are  lifted  from  the  great  trochanter.  Hoffa  claims  that  in  children 
less  than  five  years  of  age  the  head  of  the  bone  can  be  readily  replaced  into 
the  acetabulum  by  flexing  the  thigh  and  making  direct  pressure  upon  the 
head  of  the  bone.  After  replacing  the  femoral  head  it  is  held  in  place  while 
an  assistant  extends  the  leg  in  order  to  stretch  the  muscles.  In  children  over 
five  years  of  age  cut  the  muscles  which  spring  from  the  ischial  tuberosity  and 
also  the  adductors  with  a  tenotome;  cut  the  fascia  lata  and  muscles  which  arise 
from  the  anterior  superior  iliac  spine  by  incision ;  open  the  joint  and  liberate 
the  head  of  the  bone;  remove  the  ligamentum  teres;  scrape  out  the  acetabulum, 
removing  "cartilage,  fat,  and  considerable  spongy  tissue"  (Tubby);  and  re- 
place the  head  of  the  bone  in  the  acetabulum.  The  limb  is  maintained  in 
inversion,  abduction,  and  extension  for  several  weeks,  when  it  is  straight- 
ened. Massage  and  passive  motion  are  begun  in  the  fifth  week.  The  patient 
now  gets  about,  wearing  an  apparatus  for  many  weeks.  This  apparatus  per- 
mits the  head  of  the  bone  to  move  in  the  socket,  but  prevents  redislocation. 

Lorenz's  Operation. — This  is  a  modification  of  Hoffa's.  The  muscles 
inserted  into  the  greater  and  the  lesser  trochanter  are  not  cut;  the  sartorius, 
the  hamstrings,  and  the  external  portion  of  the  fascia  lata  are  cut  (Tubby). 

The  incision  of  Lorenz  is  longitudinally  from  the  anterior  superior  spine. 
Another  incision  is  carried  inward  from  this  at  the  level  of  the  lesser  trochanter. 
The  capsule  is  opened  by  a  crucial  cut;  the  acetabulum  is  enlarged;  the  head 
of  the  bone,  if  it  remains,  is  inserted  into  the  acetabulum;  if  there  is  no  true 
head,  a  new  one  is  formed  and  inserted  into  the  cavity.  The  limb  is  im- 
mobilized in  a  position  of  moderate  abduction.  Massage  and  passive  motion 
are  begun  in  the  fifth  week,  and  are  continued  for  months.* 

*I  have  drawn  upon  the  very  lucid  description  of  these  operations  in  A.  H.  Tubby's 
treatise  upon  "  Deformities." 


Myalgia,   or  Muscular  Rheumatism  553 


XX.  DISEASES  AND    INJURIES  OF  MUSCLES,  TENDONS,  AND 

BURS/C. 

Myalgia,  or  muscular  rheumatism,  is  a  painful  disorder  of  the 
voluntary  muscles  and  of  the  fibrous  and  periosteal  areas  where  they  are 
attached.  The  term  "muscular  rheumatism"  is  not  strictly  correct.  It  is 
possible  that  in  some  cases  the  muscular  structure  is  inflamed,  but  it  is  certain 
that  in  many  cases  the  pain  is  distinctly  neuralgic.  ^luscular  rheumatism 
may  be  due  to  cold  and  wet,  to  over-exertion  and  strain,  to  acute  infectious 
disorders,  to  syphihs,  to  chronic  intoxications  (lead,  mercury,  and  alcohol), 
and  to  disturbances  of  the  circulation.  Gouty  and  rheumatic  persons  are 
especially  predisposed,  men  being  more  liable  to  the  disease  than  women. 
The  disease  is  usually  acute,  but  it  may  be  chronic. 

Symptoms. — Muscular  rheumatism  is  apt  to  come  on  suddenly.  The 
pain,  which  may  be  very  acute  and  lancinating  or  may  be  dull  and  aching, 
is  in  some  cases  constantly  present;  in  other  cases  it  is  awakened  only  by 
muscular  contraction,  and  it  is  frequently  relieved  by  pressure,  though  there 
is  often  some  soreness.  The  skin  above  the  muscle  is  sometimes  tender 
to  light  pressure.  The  disease  usually  lasts  for  a  few  days,  but  it  tends  to 
recur.     There  is  little,  if  any,  fever. 

Lumbago  is  myalgia  of  the  muscles  of  the  loins.  Rheumatic  torticollis  is 
mvalgia  of  the  muscles  of  the  neck.  Usually  one  side  of  the  neck  is  attacked. 
The  chin  is  turned  from  the  affected  side  and  the  neck  is  stiff.  Pleurodynia 
is  myalgia  of  the  intercostal  muscles.  The  pain  is  very  severe,  is  aggravated 
by  deep  respiration,  by  coughing,  and  by  yawning,  there  may  be  tenderness, 
and  the  patient  tries  to  limit  chest-movement.  In  intercostal  neuralgia  the 
pain  is  limited,  is  not  constant,  but  occurs  in  distinct  paro.xysms,  and  is 
linked  with  the  presence  of  the  tender  spots  of  \^alleix.  Pleurodynia  lacks 
the  physical  signs  of  pleurisy.  Cephalodynia  is  myalgia  of  the  muscles  of 
the  scalp.  The  muscles  of  the  shoulder,  upper  dorsal  region,  abdomen,  and 
extremities  may  also  be  attacked  by  myalgia.  Myalgia  must  not  be  confused 
with  the  pains  of  locomotor  ata.xia. 

Treatment. — Remove  any  obvious  cause.  Treat  any  existing  diathesis, 
such  as  gout  or  rheumatism.  Rest  is  of  the  first  importance.  For  lumbago, 
put  the  person  to  bed.  For  pleurodynia,  strap  the  side  of  the  chest.  A 
hvpodermatic  injection  of  morphin  and  atropin  into  the  affected  muscles  at 
once  allays  the  pain,  and  a  deep  injection  of  distilled  water  is  sometimes 
curative.  Relief  may  be  afforded  by  painting  the  surface  with  30  drops  of 
a  mixture  of  equal  parts  of  guaiacol  and  glycerin  and  covering  the  painted 
area  with  cotton.  The  introduction  of  four  or  five  aseptic  needles  into  the 
muscles,  and  their  retention  for  a  few  minutes,  sometimes  act  most  favor- 
ably. Ironing  the  skin  above  the  painful  muscles  with  a  very  warm 
iron,  a  piece  of  flannel  being  interposed,  is  a  useful  domestic  remedy. 
Vigorous  rubbing  of  the  area  with  a  piece  of  ice  allays  the  pain.  Hot  poultices 
do  good.  If  the  pain  is  widely  diffused,  alters  its  seat,  or  is  very  obstinate, 
order  hot  baths  or  Turkish  baths  and  administer  diuretics.  In  chronic  cases 
employ  blisters  or  counter-irritation  by  the  cautery,  give  iodid  of  potassium 
and  nux  vomica,  and  have  the  patient  take  a  Turkish  bath  every  week.     The 


554        Diseases  and  Injuries  of  Muscles.  Tendons,  and  Bursae 

constant  electric  current  tinds  advocates.  In  an  ordinary  severe  case  order 
a  hot  bath,  put  the  patient  to  bed  with  a  hot-water  bag  over  the  part,  and 
administer  lo  grains  of  Dover's  powder;  the  next  morning  order  to  be  taken 
four  times  daily  a  capsule  containing  5  grains  of  salol  and  3  grains  of  phena- 
cetin,  until  the  pain  disappears.  Citrate  of  potassium,  citrate  of  lithium, 
chlorid  of  ammonium,  or  the  salicylate  of  colchicin  may  be  ordered  instead 
of  salol  and  phenacetin. 

Infective  myositis  is  a  widespread  inflammation  of  the  voluntary 
muscles,  due  to  an  unknown  infective  cause.  It  is  a  disorder  accompanied 
by  pain  and  stiffness,  b}'  cutaneous  edema,  and  b}'  \arious  paresthesias. 
Myositis  resembles  trichinosis,  and  is  distinguished  from  it  only  by  spearing 
out  a  bit  of  muscle  and  examining  it  microscopically.  Occasionally  diffuse 
suppuration  occurs. 

Ordinary  myositis  arises  from  injuries,  from  syphihs,  or  from  rheu- 
matism, and  it  presents  the  usual  inflammator}-  symptoms.  Contraction 
and  adhesions  may  follow. 

Treatment  of  Myositis. — Infective  myositis  is  treated  by  anodynes,  stimu- 
lants, nutritious  food,  hot  applications,  and  rest.  If  pus  forms,  it  should  be 
evacuated.  Rheumatic  myositis  calls  for  the  administration  of  the  salicylates, 
the  alkalies,  or  salol.  Syphilitic  myositis  is  treated  with  mercury  and  iodid  of 
potassium.  The  remedies  employed  for  myalgia  are  used  in  traumatic 
myositis. 

Hypertrophy  of  the  muscles  may  arise  from  their  increased  use.  In 
pseudohypertrophic  paralysis  the  bulk  of  the  muscle  is  greatly  augmented, 
but  it  contains  le.ss  mu.scle-structure  and  more  fat  or  connective  tissue. 

Atrophy  of  the  muscles  arises  from  want  of  u.se,  from  injury,  from 
continuous  pressure,  from  interference  with  the  blood-supply,  from  disease  of 
the  nerves  or  their  centers,  or  from  lead-poisoning. 

Degeneration  of  Muscles.— The  muscles  may  undergo  granular 
degeneration,  waxy  degeneration,  fatty  degeneration,  and  calcareous  de- 
generation, and  may  become  pigmented. 

Local  Ossification  and  iVlyositis  Ossificans. — It  is  not  unusual 

for  a  small  ]jortion  of  bone  to  form  in  the  periosteal  insertion  of  a  muscle 
which  is  subjected  to  frequent  strain.  In  persons  who  ride  many  hours  a 
day  there  not  infrequently  develops  the  "rider's  bone,"  which  is  an  area 
of  ossification  in  the  adductor  muscles  of  the  thigh.  Myositis  ossificans,  a 
widespread  ossification  of  the  muscles,  is  a  rare  disorder  the  cause  of  which 
is  unknown,  and  which,  if  not  congenital,  begins  at  least  in  early  life.  In 
some  cases  a  traumatic  origin  seems  probable.  It  is  seen  more  often  among 
males  than  females.  Columns  of  inflammatory  swelling  and  induration 
slowly  develoj),  each  column  running  in  the  direction  of  the  muscular  fibers, 
and  ossification  of  the  mdurated  columns  takes  place.  It  is  stated  that  the 
thumbs  and  great  toes  shorten  (J.  Jackson  Clarke's  "Orthopaedic  Surgery"). 

Tumors  of  the  Muscles. — Primary  tumors  of  the  muscles  are  rare. 
Among  those  which  may  occur  are  .sarcoma,  fibroma,  lipoma,  o.steoma, 
angioma,  myxoma,  and  enchondroma.  Most  cases  of  supposed  j)rimary 
.sarcoma  of  muscle  are  in  reality  cases  of  .syphiloma  (Esmarch). 

Syphilis  may  cause  inflammation.  Gummata  may  form,  or  gum- 
matous infiltration  may  take  place. 


Ischemic   Myositis,   or  Volkniann's   Contracture  555 

Trichinosis  or  trichiniasis  is  a  disease  due  to  the  embryos  of  the 
trichina  spiralis.  The  disease  originates  from  eating  insufficiently  cooked 
meat  which  contains  the  trichina.\  These  nematodes  are  carried  into  the 
intestine,  there  to  develop  and  multiply.  In  from  seven  to  nine  days  a  horde 
of  embryos  develop  in  the  bowel,  and  leave  the  alimentary  canal  by  passing 
through  the  peritoneum  or  by  means  of  the  blood,  and  finally  reach  the 
connective  tissue  of  the  muscles.  From  the  connective  tissue  the  embryos 
migrate  into  the  primitive  muscle-fibers,  where  they  dwell  and  enlarge. 
Mvositis  develops,  and  in  the  course  of  five  or  si.\  weeks  the  parasites  become 
encapsuled  and  develop  no  further.  The  cyst-walls  may  calcify  and  the 
worms  mav  become  calcified,  or  may  live  for  years.  The  eating  of  infected 
meat  is  not  inevitably  followed  by  the  disease,  and  a  few  embryos  lodged 
in  muscle  may  cause  no  symptoms. 

Symptoms. — The  symptoms  of  trichinosis  often  appear  in  a  day  or  two 
after  eating  infected  meat.  The  symptoms  of  acute  gastro-intestinal  catarrh 
or  of  cholera  morbus  are  common,  but  in  some  cases  no  gastro-intestinal 
manifestations  usher  in  the  disease.  In  from  seven  to  fourteen  days  after 
the  infected  meat  is  eaten  the  migration  of  the  parasites  develops  obvious 
svmptoms.  A  chill  may  be  noted;  there  is  usually  fever;  muscular  pain, 
tenderness,  swelling,  and  stiffness  are  complained  of.  This  condition  may 
be  widespread.  Involvement  of  the  muscles  of  mastication  interferes  with 
chewing;  of  the  larynx,  with  talking  and  respiration;  of  the  intercostals 
and  diaphragm,  with  respiration.  Skin-edema  and  itching  are  marked.  In 
some  cases  delirium  exists.  The  writer  saw  in  the  Philadelphia  Hospital  one 
fatal  case  which  was  mistaken  for  erysipelas  because  of  the  high  fever,  the 
delirium,  and  the  edematous  redness  of  the  face  and  neck.  Dyspnea  is 
frequent.  Mild  cases  get  well  in  a  week  or  two;  se\'ere  cases  may  last  many 
weeks.  The  mortality  varies  in  different  epidemics  from  r  to  30  per  cent. 
(Osier).  The  diagnosis  is  made  by  spearing  out  a  piece  of  muscle,  which 
is  then  e.xamined  for  trichinae  under  a  microscope;  or  the  worms  may  be 
detected  in  the  feces  by  means  of  a  pocket-lens.  In  a  case  under  the  care 
of  the  author,  in  St.  Joseph's  Hospital,  there  was  no  record  of  any  attack  of 
gastro-intestinal  disturbance  and  the  first  manifestation  was  enlargement 
of  the  calf  of  the  left  leg.  In  most  cases  of  trichinosis  there  is  eosinophilia, 
but  in  the  author's  case,  previously  referred  to,  eosinophilia  was  not  present. 

Treatment. — To  treat  trichinosis  employ  purgatives  (senna  and  calomel) 
early  in  the  case,  and  give  glycerin,  and  also  santonin  or  filix  mas.  When 
muscular  invasion  has  taken  place,  sedatives,  hypnotics,  nourishing  diet, 
and  stimulants  are  indicated. 

Ischemic  Myositis,  or  Volkmann's  Contracture.— It  is  occasionally 

noticed,  particularly  in  children,  that  after  prolonged  fixation  of  the  forearm, 
especially  after  prolonged  fixation  of  the  elbow-joint,  by  some  appliance 
that  imj)edes  the  freedom  of  circulation  in  the  part,  a  contraction  of  the 
fingers  occurs,  or  possibly  a  rigidity  and  contraction  of  the  wrist.  The  same 
condition  may  come  on  after  a  severe  injury  in  the  neighborhood  of  the 
elbow-joint  or  may  follow  hgation  of  the  main  artery  of  a  limb.  This  condi- 
tion is  due  to  a  muscular  degeneration,  infiltration,  induration,  and  con- 
traction, the  result  of  marked  and  prolonged  ischemia;  and  it  is  frequently 
spoken  of  as  ischemic  myositis  (Dudgeon,  '"Lancet."  Jan.    it,   1Q02).     In 


556        Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 

some  cases,  distinct  neuritis  also  exists.  One  characteristic  of  ischemic 
contracture  is  the  rapidity  with  which  it  comes  on.  Dudgeon  points  out 
that  in  half  a  day,  or  even  in  less  time  in  some  cases,  the  symptoms  appear, 
these  symptoms  being  paralysis  of  the  part  with  contracture.  Pain  is  un- 
usual, unless  the  nerves  are  seriously  involved.  In  some  cases  the  fingers 
and  hand  swell  and  become  discolored.  The  absence  of  pain  frequently 
prevents  the  recognition  of  the  condition;  therefore,  the  causative  sphnt  or 
bandage  pressure  may  be  maintained  for  days  after  the  trouble  has  become 
serious.  When  the  splints  and  bandages  are  removed  and  the  forearm  is 
examined,  there  is  almost  always  tenderness  over  the  muscles  and  the  nerve- 
trunks;  and  in  the  majority  of  cases  in  which  a  splint  was  the  cause,  a  portion 
of  the  skin  will  have  sloughed.  Dudgeon  points  out  the  characteristic  position 
of  the  deformity,  as  follows:  When  the  wrist  is  extended,  the  metacarpo- 
phalangeal joints  are  also  extended;  but  the  interphalangeal  joints  of  the 
fingers  and  the  terminal  joint  of  the  thumb  are  so  strongly  bent  that  the  tips 
of  the  fingers  touch  the  palm,  and  this  position  cannot  be  corrected  by  any 
justifiable  amount  of  force.  As  soon  as  the  wrist-joint  is  bent  to  a  right 
angle,  the  interphalangeal  joints  can  readily  be  extended.  In  a  very  severe 
case  the  wrist  itself  will  become  markedly  flexed,  and  it  will  be  impossible 
to  extend  it.  The  forearm  is  usually  semiflexed  and  the  hand  pronated. 
The  ulceration  or  sloughing  so  frequently  present  is  called  a  splint-sore. 
There  is  always  marked  induration  about  this  splint-sore.  The  flexor  muscles 
themselves  are  indurated  and  usually  wasted.  The  condition  of  sensation 
depends  upon  the  state  of  the  nerves  of  the  part.  When  neuritis  is  absent, 
it  will  be  normal;  but  in  accordance  with  the  amount  of  neuritis  and  de- 
generation, there  will  be  hyperesthesia,  partial  anesthesia,  or  complete  anes- 
thesia. A  curious  feature  of  these  cases  that  is  dwelt  upon  by  Dudgeon 
and  commented  upon  by  Turner  is  the  fact  that  in  young  children  there  is 
a  cessation  of  growth  in  the  bone. 

Treatment. — The  old  view  of  this  condition  was  that  it  is  practically  hope- 
less. Anderson  and  Dudgeon,  however,  maintain  that  restoration  may  usually 
be  obtained,  the  treatment  consisting  in  regular,  active  motion,  passive  move- 
ment, massage,  and  electricity.  Extension  under  ether  is  of  no  benefit  what- 
ever. In  a  persistent  and  long-continued  case  an  operation  may  be  necessary. 
This  operation  may  consist  in  dividing  the  flexor  muscles  in  the  forearm,  as  ad- 
vised by  Davies  Colley,  and  then,  at  a  later  period,  dividing  the  flexor  tendons. 
The  objection  to  this  procedure  is  that  it  destroys  the  capacity  to  flex  the 
fingers  for  all  time.  Another  suggestion  has  been  to  excise  a  piece  from  the 
radius  and  the  ulna,  and  wire  the  fragments  together.  The  best  surgical 
treatment  is  probably  tendon-lengthening,  but  this  should  not  be  done  until 
all  the  improvement  possible  to  secure  by  conservative  treatment  has  been 
obtained  by  at  least  three  months  of  effort. 

Wounds  and  Contusions  of  the  Muscles. — Wounds  of  muscles  may 
be  either  open  or  subcutaneous.  In  a  longitudinal  wound  the  edges  lie  close 
together,  and  hence  drainage  must  be  i)rovided  for  by  the  .surgeon.  In  a 
transverse  wound  the  edges  separate  widely,  and  catgut  stitches  must  be 
inserted.  Contusions  of  muscles,  like  contusions  of  other  tissues,  vary  in 
extent  and  in  severity.  There  are  pain  (which  is  increased  by  attempts  to 
use  the  muscle),  loss  of  function,  swelling  beneath  the  deep  fascia,  and  dis- 


Strains  and   Ruptures  557 

coloration,  which  may  appear  at  once  because  of  superficial  damage  from 
the  initial  injury,  or  which  may  appear  in  dependent  parts  after  many  days 
by  gravitation  of  the  blood  and  the  blood-stained  serum.  As  a  result  of 
contusion,  suppuration,  inflammation,  or  atrophy  may  arise. 

Treatment. — In  a  longitudinal  wound,  drain;  in  a  transverse  wound, 
suture  the  muscle.  The  further  indications  in  wounds  and  contusions  of 
muscles  are  to  obtain  rest  by  means  of  sphnts  and  to  secure  relaxation. 
Limitation  of  swelling  is  secured  by  bandaging.  Inflammation  is  combated 
first  by  cold  and  lead-water  and  laudanum;  later  by  iodin,  blue  ointment, 
ichthyol,  and  intermittent  heat.  To  prevent  loss  of  function,  employ,  as 
soon  as  the  acute  symptoms  subside,  massage,  passive  motion,  and  stimulat- 
ing liniments,  and,  later  in  the  case,  electricity  (galvanism  if  the  reactions  of 
degeneration  exist;  faradism,  if  absent). 

Strains  and  Ruptures.— A  strain  is  a  stretching  of  a  muscle  with 
a  small  amount  of  rupture.  The  muscle  is  swollen,  tender,  stiff,  weak,  and 
sore,  and  attempts  at  motion  produce  sharp  pain.  Strains  are  common  in 
the  deltoid,  the  hamstring  muscles,  the  back,  the  calf,  the  biceps,  and  the 
great  pectoral.  Strain  of  the  psoas  muscle  causes  pain  on  flexing  the  thigh, 
and  is  associated  with  tenderness  in  the  iliac  fossa.  Strain  of  the  right  psoas 
may  be  mistaken  for  appendicitis,  but  it  lacks  the  intense  local  tenderness, 
the  abdominal  rigidity,  and  the  constitutional  symptoms.  "Lawn-tennis 
arm"  is  a  strain  of  the  pronator  radii  teres  muscle.  "Riders'  leg"  is  a  strain 
of  the  adductor  muscles  of  the  thigh.  A  strain  may  be  the  only  injury,  or 
may  be  associated  with  some  other  condition  (fracture  of  bone,  dislocation, 
sprain,  contusion,  etc.).  A  strain  may  be  followed  by  periostitis  at  the  point 
of  insertion  of  the  muscle. 

The  muscle  is  often  rigid,  is  tender,  and  pains  greatly  when  an  attempt 
is  made  to  use  it.  The  skin  over  it,  especially  over  its  point  of  insertion,  is 
usually  tender. 

A  strain  of  the  back  is  a  very  common  accident  which  is  often  associated 
with  sprains  of  the  vertebral  articulations.  There  is  great  pain  when  the 
patient  voluntarily  straightens  up.  If  the  vertebral  ligaments  are  not  damaged, 
the  patient  can  be  straightened  by  passive  motion  without  pain.  The  skin 
is  tender  in  certain  areas.  The  muscles  are  often  rigid.  There  may  be 
unilateral  rigidity.  In  a  back  injury  make  a  careful  examination  to  be  sure 
no  damage  has  been  inflicted  upon  the  vertebrae  or  cord. 

Treatment. — Relaxation  by  suitable  position;  rest  by  the  use  of  splints 
or  by  putting  the  patient  to  bed ;  bandages  for  compression ;  hot  fomentations 
or  a  hot-water  bag,  or  ichthyol.  A^  soon  as  acute  symptoms  subside  employ 
frictions  and  massage.  If  there  is  much  pain  after  a  strain,  administer 
Dover's  powder,  or  even  morphin. 

Rupture  of  a  muscle  is  announced  by  a  sudden  and  violent  pain  and 
by  loss  of  function  arising  during  powerful  muscular  contraction  or  strong 
traction  on  a  muscle.  The  rupture  may  be  announced  by  a  clearly  audible 
snap  (A.  Pearce  Gould).  A  distinct  gap  is  felt  between  the  ends;  great  pain 
develops  on  movement;  there  are  tenderness,  loss  of  power,  and  swelling. 
Strains  and  ruptures  may  be  followed  by  atrophy,  as  are  contusions.  Among 
the  muscles  which  occasionally  rupture  we  may  mention  the  quadriceps, 
biceps,    triceps,    deltoid,   plantaris,   etc.      Rupture  oj    the    plaiitaris    luusele 


5  58        Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 

{coup  de  jouet ;  lawn-tennis  leg)  is  an  injury  which  is  frequently  not  diag- 
nosticated. It  occurs  during  exercise  (walking,  bicycling,  jumping,  playing 
tennis)  or  is  first  complained  of  after  exercise.  It  produces  sudden  pain  in 
the  middle  of  the  calf,  inability  to  walk  except  with  a  rigid  ankle  and  e\erted 
toes,  swelling,  and  often  ecchymosis. 

Treatment. — In  limited  rupture  treat  as  a  severe  strain.  In  treating 
extensive  rupture  of  an  important  muscle,  when  the  ends  are  widely  separated, 
expose  by  aseptic  incision,  unite  the  divided  ends  with  sutures  of  chromic 
catgut,  and  sew  up  the  skin  with  silkworm-gut.  Treat  the  part  in  anv  case 
by  rest  and  relaxation,  and  combat  inflammation  by  appropriate  means. 
Passive  motion  and  massage  are  employed  as  soon  as  union  is  firm.  In 
rupture  of  the  quadriceps  extensor  femoris,  operation  should  be  undertaken, 
because  mechanical  treatment  gives  frequently  a  bad  result  and  confines  the 
patient  to  bed  for  weeks.  Rupture  of  the  plantaris  is  treated  at  first  by  rest 
and  compression  and  later  by  massage  and  the  use  of  an  elastic  bandage. 

Hernia  of  Muscles.— When  a  tear  takes  place  in  a  muscular  sheath 
a  portion  of  the  muscle  protrudes.  The  treatment  is  incision  and  suturing 
of  the  sheath. 

Contractions  of  muscles  may  result  from  injury,  from  joint-disease, 
from  malposition  of  parts  (as  in  old  dislocation  or  torticollis),  or  from  diseases 
of  the  nervous  system.  The  treatment  in  some  cases  is  sudden  extension, 
in  other  cases  gradual  extension,  tenotomy,  or  myotomy.  Macewen  recom- 
mends the  making  of  a  number  of  V-shaped  incisions  in  the  muscle.  In 
some  cases  of  spasmodic  contraction  nerve-stretching  is  of  value. 

Dislocation  of  Muscles  and  Tendons.— The  long  head  of  the  biceps 
is  oftenest  displaced.  The  flexor  carpi  ulnaris,  the  peroneus  brevis,  the 
peroneus  longus,  the  tibialis  posticus,  the  sartorius,  the  plantaris,  the  quad- 
riceps extensor  femoris,  and  the  extensors  back  of  the  wrist  may  be  dislocated. 
What  is  known  as  dislocation  of  the  latissimus  dorsi,  a  condition  in  which 
that  muscle  no  longer  lies  upon  the  angle  of  the  scapula,  is  not  a  dislocation, 
but  a  paralysis.  Most  of  these  accidents  are  associated  with  chronic  joint- 
disease  or  with  fracture,  but  displacement  may  exist  as  a  solitary  injury. 
Dislocation  of  the  long  head  of  the  biceps  may  occur  tolerably  early  in  the 
progress  of  rheumatoid  arthritis  of  the  shoulder-ioint,  and  the  displaced 
tendon  may  be  absorbed. 

Symptoms. — After  dislocation  of  a  tendon  the  muscle  of  the  tendon  can 
still  contract,  but  it  acts  at  a  disadvantage;  thus  the  corresponding  joint 
exhibits  partial  loss  of  function.  The  displaced  tendon  can  be  felt,  and  a 
hollow  exi.sts  where  it  normally  resides. 

When  the  muscle  contracts  the  tendon  is  felt  to  slip  from  its  groove. 
When  the  tendon  of  the  biceps  is  dislocated  the  head  of  the  bone  passes 
forward  f so-called  subluxation  of  the  humerus). 

Treatment, — In  tendon-dislocation  reduction  is  easy,  but  the  displace- 
ment is  apt  to  recur  because  of  laceration  of  the  sheath.  The  treatment 
usually  advised  is  to  eff'ect  reduction  by  relaxation  of  the  limb  and  manipula- 
tion of  the  tendon,  to  place  the  part  upon  a  splint  so  that  the  muscle  belonging 
to  the  tendon  will  be  relaxed,  and  to  a[)f)ly  f)ressure  over  the  point  of  injury. 
This  treatment  generally  fails,  and  if  the  tendon  does  not  become  firmly 
anchored  in   its  proper  situation  in  four  weeks  we  should  operate.      In  some 


Palmar  Abscess  559 

tendons  it  is  enough  to  incise,  freshen  the  edges  of  the  torn  sheath,  and  sew 
up  with  kangaroo-tendon  or  chromic  catgut.  In  a  tendon  lying  in  a  long 
groove,  make  a  halter  for  the  tendon  by  incising  the  periosteum  and  suturing 
it  over  the  tendon.*  Passive  movements  are  begun  at  the  end  of  the  first 
week.  Even  if  the  tendon  will  not  remain  reduced,  a  useful  joint  will  be 
obtained.  Wood,  of  New  York,  advised  in  obstinate  cases  tenotom}-  and 
immobilization. 

Wounds  of  Tendons. — Subcutaneous  wounds  of  tendons  are  usuall\' 
inflicted  by  the  surgeon,  and  they  heal  well.  Open  wounds  require  rigid 
antisepsis  and  suturing  of  the  tendon.  In  wounds  of  the  wrist  especially 
always  suture  the  tendons  (Fig.  282),  and  be  sure  to  bring  the  proper  ends 
into  apposition. 

Rupture  of  Tendons. — A  violent  muscular  etfort  may  rupture  a  tendon, 
and  as  the  accident  occurs  a  snap  may  often  be  heard.  The  symptoms  are 
sudden  pain  and  loss  of  power,  fulness  of  the  associated  muscle  from  re- 
traction, and  absolute  inability  to  bring  the  tendon  into  action.  A  gap  may 
often  be  felt  in  the  tendon. 

Treatment. — The  best  procedure  in  treating  rupture  of  a  tendon  is 
exposure  by  incision  and  the  introduction  of  sutures.  .Some  surgeons  relax 
the  parts  and  apply  splints. 

Thecitis,  or  tenosynovitis,  is  inflammation  of  the  sheath  of  a  tendon. 

Acute  thecitis  may  arise  from  a  contusion,  from  a  wound,  from  repeated 
overaction  in  working,  or  while  engaged  in  some  sport,  from  rheumatism, 
from  gonorrhea,  from  influenza,  from  the  continued  fevers,  or  from  syphilis. 
In  early  syphilis  certain  tendon-sheaths  may  rapidl}'  de\elop  effusion  because 
of  hyperemia  of  the  sheaths  (Taylor). 

Symptoms. —  In  non-sutipitrative  cases  of  thecitis  the  symptoms  are 
pain,  swelling,  tenderness,  and  moist  crepitus  along  the  tendon-sheath,  due  to 
inflammatorv  roughening.  The  crepitus  disappears  as  the  swelling  increases, 
but  it  reappears  as  the  swelling  diminishes.  In  suppurative  cases  the  symp- 
toms are  great  swelling,  pulsatile  pain,  dusky  discoloration,  inflammation 
spreading  up  the  tendon-sheaths,  and  often  the  constitutional  symptoms 
of  sepsis. 

TreatDieiil. — In  treating  non-suppurative  thecitis,  employ  splints  and  apply 
locally  iodin,  blue  ointment,  or  ichthyol,  and  administer  suitable  remedies 
to  combat  any  causative  constitutional  disease.  In  the  suppurative  form 
make  free  incisions,  irrigate,  drain,  and  dress  with  hot  anti.^eptic  fomentations. 

Palmar  Abscess. — .\  thecal  abscess  in  a  flexor  tendon  of  a  finger 
travels  rapidiv  upward  and  mav  ])roduce  a  |)almar  al)scess.  .\  thecal 
abscess  of  either  the  index,  ring,  or  middle  finger  is  usually  arrested 
at  the  lower  end  of  the  ])alm,  but  suppurative  thecitis  of  the  thumb  or  the 
little  finger  may  diffuse  pus  over  a  large  surface  of  the  i)alm  and  ai.so  up 
the  arm  (Fig.  278).  Palmar  ab.scess  is  a  most  serious  aft'ection.  The  pus 
may  dissect  up  all  the  structures  of  the  j)alm,  may  reach  the  dorsum,  or 
may  pass  beneath  the  anterior  annular  ligament  into  the  connective-tissue 
planes  of  the  forearm. 

Treatment. — A  palmar  abscess  demands  free  incision  and  drainage  at 

*  Walsliam's  case  of  dislocation  of  the  peronens  longns,  IJrit.  Mrd.  luui. ,  Nov.  2, 
1895. 


560        Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 


the  earliest  possible  moment.  The  patient  should  be  placed  under  the  in- 
fluence of  ether.  The  incision  is  made  in  the  line  of  the  metacarpal  bone 
and,  if  possible,  below  the  palmar  arches.  A  line  transverse  with  the  web 
of  the  thumb  is  below  the  palmar  arches.  In  an  incision  above  this  hne, 
trv  not  to  cut  either  arch;  but  if  one  be  cut,  at  once  take  means  to  arrest 
the  hemorrhage  (page  319)-  In  a  severe  case  it  may  be  necessary  to  make 
several  palmar  incisions,  to  open  the  tendon-sheaths  on  the  flexor  surface 
of  the  forearm  above  the  wrist,  and  to  make  counter-openings  in  the  back 
of  the  hand,  and  it  is  sometimes  necessary  to  introduce  tubes,  and  drain 
through  and  through.  After  operation  apply  hot  antiseptic  fomentations  and 
put  the  part  upon  a  splint.  When  granulations  begin  to  form,  dry  dressings 
are   substituted   for  the  hot   moist   dressing.     It   may  be  necessary  to   give 

morphin  for  pain,  and  stimulants  may  be 
needed.  There  is  great  danger  of  stiffness 
of  the  fingers  occurring,  the  tendons  becoming 
adherent  to  their  sheaths.  Hence,  passive 
movements  are  inaugurated  as  soon  as 
granulations  begin  to  form. 

Chronic  thecitis  may  follow  acute  theci- 
tis,  but  may  be  due  to  injury,  to  rheumatism, 
to  gummatous  infiltration,  to  rheumatoid  ar- 
thritis, or  to  tuberculous  inflammation  of  a 
tendon-sheath  (compound  ganglion).  Chronic 
thecitis  is  commonest  in  the  tendons  of  the 
fingers,  the  ankles,  and  the  knees;  it  may 
spread  to  a  joint  or  it  may  arise  from  a 
tuberculous  joint.  This  condition  causes 
very  little  pain.  In  ordinary  non-tuberculous 
thecitis  the  part  is  weak,  tender,  painful,  and 
stiff,  crepitates  on  motion,  and  is  swollen. 
In  tuberculous  thecitis  the  sweUing  is  firm  or 
doughy  when  due  to  granulation-tissue,  but 
is  fluctuating  when  due  to  fluid.  Grating  is 
marked.  The  tendon-sheath  may  contain 
numerous  small  bodies  which  are  either  free 
or  are  attached  (rice,  riziform,  or  melon-seed 
bodie.s).  Tubercle  bacilli  are  present  in  the  fluid  or  in  the  granulation 
tissue. 

Treatment. — Tuberculous  cases  are  treated  as  follows:  If  there  is  a  fluid 
effusion  make  a  small  incision,  wash  out  with  salt  solution,  introduce 
some  iodoform  emulsion,  and  close  the  wound.  In  cases  in  which  there 
are  rice-bodies,  open  the  sheath,  evacuate  the  contents,  scrape  the  walls 
thoroughly,  inject  with  iodoform  emulsion,  and  close  the  wound.  (If 
the  annular  ligament  requires  division,  stitch  it;  Fig.  285.)  In  cases  with 
extensive  formation  of  embryonic  tissue  apply  an  Esmarch  bandage,  make 
a  large  incision,  and  remove  all  infected  tissue  from  the  sheath,  around  the 
sheath,  and  from  the  tendon.  In  an  ordinary  traumatic  thecitis  use  for 
the  first  few  days  rest  associated  with  ajjplications  of  ichthyol.  Later  employ 
hot  and  cold  douches,  massage,  and  passive  movements,  strapping  of  the 


Fig.  27S. — Diagram  of  tendoii-sheaths 
of  the  hand  (Tillau.x). 


Felon,   or   Whitlow  561 

part,  inunctions  of  ichthyol,  and  the  hot-air  bath.  If  effusion  is  persistent 
or  rice-Vjodies  exist,  make  an  incision  and  scrape  the  interior  of  the  tendon- 
sheath.  In  rheumatic  cases  give  antirheumatic  remedies  and  employ  the 
hot-air  bath.     In  syphilitic  cases  administer  mercury  and  iodid  of  potassium. 

Ganglia. — In  connection  with  tendon-sheaths  simple  ganglia  may  de- 
velop. They  are  small,  tense,  round  swellings,  which  are  firm,  grow  pro- 
gressively though  slowly,  are  painless  when  uninflamed,  and  contain  a  fluid 
of  the  appearance  and  consistence  of  glycerin-jelly  (Bowlby).  Ganglia  are 
commonest  upon  the  dorsum  of  the  wrist,  and  they  occur  especially  in  those 
who  constantly  use  the  wrist-muscles.  Paget  states  that  a  simple  ganglion 
is  due  to  cystic  degeneration  of  a  synovial  fringe  inside  a  tendon-sheath, 
and  that  the  fluid  of  the  ganglion  does  not  communicate  with  the  fluid  of 
the  tendon-sheath.  Other  pathologists  believe  a  simple  ganglion  to  be  a 
hernia  of  synovial  membrane  through  a  rent  in  a  tendon-sheath,  all  com- 
munication between  the  herniated  part  and  the  tendon-sheath  being  soon 
obliterated.     Compound  ganglion  is  an  old  name  for  tuberculous  thecitis. 

Treatment. — A  ganglion  is  treated  by  aseptic  puncture  with  a  tenotome, 
evacuation,  scarification  of  the  walls,  antiseptic  dressing,  and  pressure.  An 
old-time  method  of  treatment  was  subcutaneous  rupture  brought  about  by 
striking  with  a  heavy  book.  Duplay  treats  a  ganglion  by  injecting  a  few 
drops  of  iodin  through  a  hypodermatic  needle.  The  cvst  is  not  evacuated 
before  injection.  The  parts  are  dressed  antiseptically,  and  cure  is  obtained 
in  one  week.  Recurrent  ganglia,  very  large  ganglia,  and  ganglia  with  verv 
thick  contents  should  be  dissected  out. 

Felon,  or  whitlow,  is  a  violent,  rapidly  spreading  pyogenic  inflamma- 
tion oi  a  finger  or  a  toe  which  resembles  cellulitis,  and  which  is  sometimes 
followed  by  gangrene  or  by  necrosis  of  bone.  As  a  rule,  an  injury  precedes 
the  whitlow — an  abrasion  of  the  surface  which  admits  pus-organisms  or  a 
contusion  which  creates  a  point  of  least  resistance.  The  commonest  seat 
of  a  felon  is  the  last  digit  of  the  finger  or  thumb.  An  abrasion  of  the  surface 
at  this  point  absorbs  pus-organisms  and  the  superficial  lymphatics  carry 
the  bacteria  directly  inward,  lodging  them,  it  may  be,  in  the  skin,  in  the 
subcutaneous  tissues,  in  the  tendon-sheath,  or  beneath  the  periosteum. 

Felons  are  very  rare  in  infants,  but  may  occur  in  children.  \\'omen  are 
more  liable  to  them  than  are  men.  The  fingers  are  much  more  prone  to 
infection  than  are  the  toes,  because  they  are  more  exposed  to  injurv.  Several 
fingers  may  be  attacked  at  once  or  successively  in  persons  of  dilapidated 
constitution.  Whitk)w  is  most  apt  to  occur  and  is  most  severe  in  persons 
broken  down  l^y  disease,  alcoholism,  overwork,  or  worrv.  In  certain  cases 
of  neuritis  painless  suppuration  may  arise.  In  syringomyelia  painless  felons 
are  common  and  they  are  apt  to  be  associated  with  necrosis  of  bone.  Pain- 
less and  destructive  whitlows  constitute  a  characteristic  part  of  Morvan's 
disease. 

There  are  two  forms  of  felons,  the  superjicial  and  the  deep. 

If  the  infection  is  in  the  skin,  the  point  of  infection  becomes  dark  red, 
swollen,  painful,  and  tender.  The  epidermis  is  lifted  up  bv  the  pus  which 
forms,  and  a  considerable  area  may  be  attacked  before  the  spread  of  the 
process  is  arrested.  If  the  subcutaneous  tissues  only  are  involved,  the  symp- 
toms are  those  of  an  ()rdinar\-  cellulitis.  Paronvchia  is  a  cellulitis  starting 
36 


562        Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 


at  the  end  or  side  of  the  digit,  and  involving  the  parts  around  and  below 
the  nail.  The  pus-organisms  obtain  entrance  by  means  of  an  abrasion,  a 
puncture,  or  an  ulcerated  "  step-mother.  "  The  pain  is  throbbing  and  violent; 
is  increased  by  motion,  pressure,  or  a  dependent  position;  the  skin  is  dusky 
red,  but  the  swelling  is  slight.  In  about  forty-eight  hours  pus  forms  in 
the  superficial  parts,  the  epidermis  being  lifted  into  pustules  or  blebs,  and 
pus  mav  also  form  under  the  nail.  A  portion  of  the  nail,  or  the  entire  nail, 
may  be  lost. 

If  the  tendon-sheath  is  involved  as  well  as  the  subcutaneous  tissue,  the 
symptoms  are  those  of  suppurative  thecitis,  with  more  marked  discoloration 
of  the  skin. 

Deep  jeJon,  or  bone-felon,  involves  most  of  the  structures  of  the  finger 
(periosteum,  bone,  tendon,  tendon-sheath,  and  cellular  tissue),  and  may 
destroy  the  digit  or  the  finger..    It  arises  in  the  same  manner  as  paronychia, 

but  the  organisms  are  lodged  in  the  deeper  parts. 
The  pain  is  agonizing,  entirely  preventing  sleep, 
pulsatile  in  character,  associated  with  excruciat- 
ing tenderness,  greatly  aggravated  by  motion  or 
a  dependent  position,  and  often  extending  up 
the  hand  and  forearm.  The  skin  is  dusky  red 
and  edematous,  and  the  part  is  enormously 
swollen.  Pus  forms  quickly;  diffuse  cellulitis 
may  arise;  thecal  suppuration  may  occur; 
sloughing  of  the  tendon  and  subcutaneous 
tissue  may  take  place;  necrosis  of  one  or  more 
bones  may  ensue,  and  in  some  cases  gangrene 
of  the  finger  follows. 

In  deep  whitlow  lymphangitis  of  the  forearm 
and  arm  is  not  unusual,  adenitis  of  the  axillary 
glands  is  common,  and  almost  always  there 
is  fever.  In  superficial  felon  constitutional 
symptoms  are  slight  or  absent,  and  lymph- 
angitis and  adenitis  arise  in  a  minority  of 
cases.  A  felon  may  be  followed  by  a  palmar 
abscess,  and  is  particularly  apt  to  be  if  the  disease  arises  in  the  thumb  or 
little  finger. 

Treatment. — Even  a  superficial  felon  demands  instant  incision  in  all 
cases,  and  the  parts  must  be  irrigated,  dressed  with  hot  antiseptic  fomenta- 
tions, and  the  hand  must  be  placed  upon  a  splint.  A  bone-felon  requires 
prompt  incision  to  the  bone  alongside  the  tendon.  Fig.  279  shows  the  proper 
lines  of  incision  in  the  fingers  and  palm.  Do  not  wait  for  pus  to  form,  but 
allay  tension  and  prevent  pus-formation  by  early  incision.  Do  not  waste 
time  with  poultices;  to  wait  means  agonizing  pain,  sleepless  nights,  consti- 
tutional involvement,  and,  perhaps,  sloughing  of  tendons  or  death  of  bone. 
Incision  and  drainage  constitute  the  treatment,  followed  by  irrigation,  anti- 
septic fomentations,  and  splinting  of  the  extremity.  If  the  patient  cannot 
sleep,  give  morphin.  See  that  the  bowels  are  moved  once  a  day.  Give 
quinin,  iron,  and  milk  punch.  Opening  a  felon  is  exquisitely  painful;  hence 
ether  should  be  given  to  obtain  the  first  stage  of  anesthesia,  nitrous   oxid 


Fig.  279. — 1,2,  and  3,  Incisions 
for  felon  of  finger  and  for  ordinary 
suppuration  ;  4,  palmar  incision. 


Bursitis  563 

should  be  administered,  or  the  superiicial  parts  should  be  frozen  by  a  spray 
of  chlorid  of  ethyl. 

Bursitis  is  inflammation  of  a  bursa.  Acute  bursitis  arises  from  strain 
or  from  traumatism.  The  symptoms  of  acute  bursitis  are  pain,  limited 
swelling,  moist  crepitus,  fluctuation,  and  discoloration  in  the  anatomica:l 
position  of  a  bursa.  Bursitis  of  the  retrocalcaneal  bursa  (Albert's  disease) 
is  a  painful  affection  which  is  often  overlooked.  Walking  causes  great  pain 
in  the  heel.  Raising  up  on  the  toes  is  e.xcessively  painful.  It  is  usually 
associated  with  flat-foot.  In  these  cases  osteophytes  often  form  within  the 
bursa.  There  are  numerous  bursae  about  the  hip.  Some  anatomists  count 
twenty-one.*  The  two  most  important  bursae,  and  the  ones  usually  affected, 
are  the  iliac  and  the  deep  bursa  over  the  great  trochanter.!  Inflammation 
of  the  iliac  bursa  produces  swelling  below  Poupart's  ligament,  which  swelling 
is  tense,  but  exhibits  fluctuation  on  careful  examination.  In  some  cases  the 
sac  can  be  emptied  by  pressure,  the  fluid  passing  into  an  adjacent  bursa 
or  into  the  joint.  The  enlargement  often  presses  on  the  anterior  crural  nerve 
and  causes  pain  throughout  the  nerve's  trajectory.  The  limb,  according 
to  Zuelzer,  is  usually  slightly  flexed,  abducted  and  rotated  outward,  and 
movement  in  an  opposite  direction  causes  pain.  Inflammation  of  the  bursae 
about  the  hip  may  produce  symptoms  resembling  those  of  incipient  coxalgia, 
but  in  bursitis  the  symptoms  do  not  remit  as  in  hip-disease.  In  inflamma- 
tion of  the  gluteal  bursae  there  is  moderate  pain  back  of  the  thigh  and  knee 
which  disappears  when  the  patient  is  at  rest;  there  is  a  marked  limp,  limita- 
tion of  motion,  and  an  area  of  deep  fluctuation  in  the  buttock  (Brackett). 
In  inflammation  of  the  iliac  bursa  flexion  is  not  so  marked  as  in  coxalgia, 
and  the  trochanter  is  never  above  Nelaton's  hne.  In  inflammation  of  the 
deep  trochanteric  bursa  the  position  is  the  same  as  in  iliac  bursitis,  and  re- 
sembles that  of  coxalgia.  In  coxalgia,  however,  there  is  pain  on  pres.sure 
upon  the  front  of  the  joint  or  directly  on  the  trochanter  or  on  tapping  the 
sole  of  the  foot.     These  manipulations  do  not  cause  pain  in  bursitis  (Zuelzer). 

It  is  difficult  to  differentiate  between  inflammation  of  a  deep  bursa  and 
synovitis;  indeed,  in  bursitis  the  joint  is  apt  to  be  secondarily  affected.  This 
difi&culty  is  especially  vexatious  in  distinguishing  between  joint-injury  and 
injury  of  the  bursa  beneath  the  deltoid.  Suppuration  may  take  place  in  a 
bursa.  Direct  force  may  rupture  a  bursa.  The  bursa  beneath  the  deltoid 
is  frequently  ruptured.  When  this  accident  happens  there  are  pain,  marked 
swelling,  a  large  area  of  moist  crepitus,  and  later  extensive  discoloration 
from  blood.  Chronic  bursitis  may  follow  acute  bursitis,  or  the  disease  may 
be  chronic  from  the  start.  Its  symptom  is  swelHng  with  little  or  no  pain 
unless  acute  inflammation  arises.  Chronic  bursitis  of  the  subhyoid  bursa  is 
known  as  Boyer's  cyst. 

Treatment. — Acute  bursitis  is  treated  by  rest,  pressure,  and  the  appli- 
cation of  iodin,  blue  ointment,  or  ichthyol.  If  the  swelling  persists,  aspirate 
and  apply  pressure,  or  incise  the  sac  and  remove  it  partly  or  completely. 
If  pus  forms,  incise,  paint  the  interior  of  the  sac  with  pure  carbolic  acid, 
and  pack  with  iodoform  gauze.  Chronic  bursitis  may  be  cured  by  the  use 
of  pressure  and  the  application  of  blue  ointment,  and  with  treatment  of 
any  causative  diathesis;  but  most  cases  require  incision  and  packing.     A 

*  Synnestvedt,  of  Sweden.  t  Zuelzer,  in  Zeit.  f.  Chir.,  vol.  1. 


564        Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 

ruptured  bursa  is  treated  as  an  acute  bursitis.  Some  cases  of  retrocalcaneal 
bursitis  get  well  from  rest,  but  others  demand  incision  and  drainage.  If 
osteophvtic  formation  takes  place  in  Albert's  disease,  remove  the  bony  sta- 
lactites with  a  rongeur  forceps  or  a  gouge. 

Housemaids'  knee  is  thickening  and  enlargement  of  the  prepatellar 
bursa,  due  to  intermittent  pressure  (Fig.  280).  In  effusion  into  the  knee- 
joint  the  fluid  is  behind  the  patella  and  the  bone  floats  up;  in  housemaids' 
knee  the  fluid  is  above  the  bone  and  the  osseous  surface  can  be  felt  be- 
neath it. 

*'  Miners'  elbow,"  which  is  a  condition  similar  to  housemaids'  knee, 
affects  the  olecranon  bursa. 

"  Weavers'  bottom  "  is  enlargement  of  the  bursa  over  the  tuberosity 


Fig.  2S0,  —  Hf)ii=;cniriiils'  k' 


of  the  ischium.  A  bursa  which  is  simply  thickened  and  enlarged  rarely  gives 
rise  to  annoyance;  but  when  it  inflames,  as  it  is  apt  to  do,  it  causes  the 
ordinary  symptoms  of  bursitis. 

Treatment. — Some  few  cases  of  housemaids'  knee  may  be  cured  by  rest 
and  blistering,  but  in  most  cases  it  is  necessary  to  incise  and  pack  with  iodo- 
form gauze.  In  enlargement  of  the  bursa  beneath  the  ligamentum  patellar, 
if  rest  and  blistering  fail  to  cure,  a.spirate  (^r  incise.  In  enlargement  of  the 
bursa  beneath  the  tenrlon  of  the  semimembranosus  and  also  in  "  weavers' 
bottom"  and  in  "miners'  elbow,"  incise  and  [)ack. 

Bunion.  —A  bunion  is  a  bursa  due  to  pressure,  and  it  is  most  commonly 
situated  above  the  metatarsophalangeal  articulation  of  the  great  toe,  but  is 
occasionally  seen  over  the  joint  of  another  toe.     When  the  big  toe  is  pushed 


Subcutaneous  Tenotomy  of  the  Tendo  Achillis  565 

inward  by  ill-fitting  boots,  a  bunion  forms.  When  a  bunion  is  not  inflamed, 
it  may  cause  but  little  trouble;  but  when  it  inflames,  the  bursa  enlarges  and 
the  parts  become  hot,  tender,  and  excessively  painful.  .Suppuration  may 
occur  and  pus  may  invade  the  joint,  and  the  bone  not  unusually  becomes 
diseased. 

Treatment. — In  treating  a  bunion  the  patient  must  wear  shoes  that  are 
not  pointed,  that  have  the  inner  borders  straight,  and  that  have  rounded 
toes  (Jacobson).  For  a  mild  case  a  bunion-plaster  gives  comfort.  Sayre 
advises  the  use  of  a  linen  glove  over  the  digits,  the  phalanges  being  drawn 
inward  by  a  piece  of  elastic  webbing,  one  end  of  which 
is  fastened  to  the  glove  and  the  other  end  to  a  piece  of 
strapping  from  the  heel.  A  special  apparatus  may  be 
worn  (Fig.  281).  In  many  cases  osteotomy  of  the  first 
phalan.x  or  of  the  first  metatarsal  bone  is  required;  in 
some  cases  excision  of  the  joint  is  necessary;  in  others 
amputation  must  be  performed.  When  the  bursa  is  not 
inflamed,  but  only  thickened,  blisters  should  be  em- 
ployed over  it,  or  there  should  be  apphed  tincture  of 
iodin,  ichthyol,  or  mercurial  ointment.  When  the  bursa  pig.  281.— Bigg's  appa- 
inflames,  ichthyol  ointment  is  applied,  and  intermittent  ratus  for  bunions, 

heat  by  foot-baths  gives  relief.     Suppuration  demands 

immediate  incision  and  antiseptic  dressing.  If  an  ulcerated  bunion  does  not 
heal  by  antiseptic  dressing,  stimulate  it  with  nitrate  of  silver  and  dress  it  with 
unguent,  hydrarg.  nitrat.  (i  part  to  7  of  cosmolin).  Jacobson  recommends 
skin-grafting  for  some  cases. 

Operations  upon  Muscles  and  Tendons. 

Tenotomy  is  the  cutting  of  a  tendon.  It  may  be  open  or  subcutaneous, 
the  open  operation  being  preferred  in  dangerous  regions. 

Open   Division    of  the  Sternocleidomastoid  Muscle  for  Wry= 

neck. — Subcutaneous  tenotomy  for  wry-neck  has  been  largely  abandoned. 
It  is  not  only  more  unsafe  than  the  open  operation,  but  it  never  completely 
divides  all  of  the  contracted  band. 

The  instruments  required  consist  of  a  scalpel,  dis.secting  forceps,  hemo- 
static forceps,  scissors,  needles,  ligatures,  etc.  The  patient  is  placed  recum- 
bent, the  chin  being  drawn  more  to\\'ard  the  opposite  side. 

A  transverse  incision  is  made  over  the  muscle  about  one-fourth  of  an 
inch  above  the  clavicle.  The  superficial  parts  are  divided,  the  muscle  is 
expo.-ed  and  sectioned,  bleeding  is  arrested,  and  the  skin  is  sutured.  Avoid 
the  anterior  jugular  vein,  which  is  underneath  the  muscle,  and  also  the  ex- 
ternal jugular,  which  is  close  to  the  outer  edge  of  the  muscle.  Mikulicz 
advocates  the  removal  of  almost  the  entire  muscle,  leaving,  however,  the 
upper  and  posterior  portion  where  the  spinal  accessory  nerve  passes.  After 
operation  for  wry-neck  support  the  head  with  sand-bags  or  a  plaster-of- 
Paris  dressing  until  healing  occurs,  and  then  inaugurate  motions,  active  and 
passive. 

Subcutaneous  Tenotomy  of  the  Tendo  Achillis.— This  operation 

is  performed  for  club-focn,  in  which  the  heel  is  raised.     The  tendon  is  cut 


566        Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 

about  one  inch  above  its  point  of  insertion.  The  instrument  used  for  the 
first  puncture  is  a  sharp  tenotome.  The  patient  lies  upon  his  back  "with 
his  body  rolled  a  little  toward  the  affected  side"  (Treves),  the  foot  being 
placed  upon  its  outer  side  on  a  sand  pillow.  The  surgeon  stands  to  the 
outer  side.  The  tendon  is  rendered  moderately  rigid,  and  the  sharp  tenotome, 
with  its  blade  turned  upward,  is  inserted  along  the  anterior  border  of  the 
tendon  until  the  surgeon's  finger  feels  the  knife  approaching  the  outer  side. 
The  sharp-pointed  instrument  is  withdrawn  and  a  blunt-pointed  tenotome 
is  inserted  in  its  place.  The  tendon  is  drawn  into  rigidity,  and  the  surgeon 
turns  the  blade  of  his  knife  toward  the  tendon,  places  his  finger  over  the  skin, 
and  saws  toward  his  finger.  The  tendon  gives  way  with  a  snap.  Treves 
states  that  a  beginner  is  apt  not  to  push  the  knife  far  enough  toward  the 
outside,  or  he  may  in  the  first  puncture  push  the  knife  through  the  tendon; 
in  either  case  the  tendon  is  not  completely  cut.  The  little  wound,  which  is 
covered  with  a  bit  of  gauze,  will  be  entirely  closed  in  forty-eight  hours.  In 
club-foot  cases  after  tenotomy  some  surgeons  at  once  correct  the  deformity 
and  immobilize  the  limb  in  plaster;  some  partially  correct  the  deformity  and 
apply  plaster  for  one  week,  at  which  time  they  remove  the  plaster,  correct 
the  deformity  further,  reapply  the  plaster,  and  so  on;  other  surgeons  do  not 
attempt  correction  of  the  deformity  until  the  cut  tendon  has  begun  to  unite, 
when  they  gradually  stretch  the  new  material. 

Subcutaneous  Tenotomy  of  the  Tendon  of  the  Tibialis  Anticus 

Muscle. — The  tendon  is  divided  about  one  and  a  half  inches  above  its  point 
of  insertion.  It  can  be  made  tense  by  extending  and  abducting  the  foot. 
The  sharp-pointed  tenotome  is  entered  upon  the  outside  of  the  tendon,  and 
is  passed  well  around  it.  The  blunt-pointed  tenotome  is  used  to  cut  the  tense 
tendon. 

Subcutaneous  Tenotomy  of  the  Tendons  of  the  Peroneus  Lon= 
gUS  and  Brevis  Muscles.— These  two  tendons  are  cut  together  back  of  the 
external  malleolus,  and  one  and  a  half  inches  above  the  tip  of  the  malleolus, 
so  as  to  avoid  the  synovial  sheath  (Treves).  The  patient  lies  upon  the  sound 
side,  the  outer  aspect  of  the  deformed  foot  being  upward  and  the  inner  aspect 
of  the  ankle  of  the  deformed  side  resting  upon  a  sand  pillow.  A  sharp  tenotome 
is  introduced  close  to  the  fibula,  and  is  carried  around  the  loose  tendons. 
A  blunt-pointed  tenotome  is  now  introduced,  its  edge  is  turned  toward  the 
tendons,  and  these  structures  are  cut  as  they  are  made  tense. 

Subcutaneous  Tenotomy  of  the  Tendon  of  the  Tibialis  Posticus 

Muscle. — This  tendon  is  sectioned  above  the  point  where  its  synovial 
sheath  begins;  that  is,  above  the  internal  annular  ligament  (Treves).  The 
tendon  is  made  tense  and  the  pointed  knife  is  entered  above  the  base  of  the 
inner  malleolus.  The  knife  is  entered  just  back  of  the  inner  edge  of  the 
tibia,  and  is  carried  around  the  muscle  while  it  is  kept  close  to  the  bone. 
The  tendon  is  sectioned  with  a  blunt  knife. 

Subcutaneous  Fasciotomy  of  the  Plantar  Fascia.~The  con- 
tracted bands  are  discovered  by  motions  which  render  them  tense,  and  they 
are  divided  just  in  front  of  the  attachments  to  the  os  calcis.  The  sharf) 
knife  passes  between  the  skin  and  fascia  at  the  inner  side  of  the  sole  of  the 
foot.  The  fascia  is  cut  from  without  inward  by  the  blunt-pointed  tenotome. 
It  is  usually  necessary  to  section  the  fascia  at  more  than  one  point. 


Tendon-suture   and  Tendon-lenc^theninfr 


567 


Tendon=suture  and  Tendon=Iengthening.  — The  instruments  re- 
quired in  these  operations  are  an  Esmarch  apparatus;  curved  needles,  and 
needle-holder;  chromicized  gut,  kangaroo-tendon,  or  silk  for  an  ordinary  case, 
silver  wire  for  a  suppurating  wound.  In  performing  tendon-suture  make  the 
part  aseptic  and  bloodless.  It  is  wise  to  apply  a  rubber  bandage  on  the  prox- 
imal side,  the  bandage  being  applied  centrifugally,  forcing  the  proximal  end  of 
the  tendon  into  view  (Haegler).  If  searching  for  the  proximal  end  of  a 
flexor  of  the  finger,  flex  the  injured  finget,  and  hyper-extend  the  adjoining 
fingers  (Filiget).     If  this  expedient  fails,  enlarge  the  incision,  or,  what  is 

L 


B  — 1 


1 


Fig.  282. — Tendon-sutures:  i,  of  Le  Fort;  2,  of 
Le  Dentu  ;  3,  of  Lejars. 


Fig.  283. — Anderson's  method  of  lendon- 
lengthetiing. 


better,  make  a  large  flap  in  the  skin.  After  finding  the  ends  approximate 
them,  being  sure  the  proper  ends  are  brought  into  contact;  stitch  them  to- 
gether with  a  continuous  suture  or  with  one  of  the  sutures  shown  in  Fig. 
282,  I,  2,  and  3.  In  a  suppurating  wound  suture  by  silver  wire  should  be 
tried,  though  it  usually  fails.  After  suturing,  remove  the  Esmarch  apparatus, 
arrest  bleeding,  close  the  wound  and  dress  it  antiseptically,  relax  the  parts, 
and  place  the  limb  on  a  splint.  If,  after  suturing,  there  is  much  tension, 
s  itch  the  cut  tendon  above  the  sutures  to  an  adjacent  tendon,  and  apply 
a  splint,  the  finger  which  was  injured  being  flexed,  the  others  being  extended. 


\^L^ 


Fig.  284. — Czerny's  method  of   tendon-length- 
ening. 


Fig.    285. — Method    of    suturing    the    annular 
ligament  of  the  wrist. 


If  only  the  distal  end  of  the  tendon  can  be  found,  graft  it  upon  the  nearest 
tendon  with  a  like  anatomical  course  and  function.  When  a  tendon  has 
been  sutured  begin  gentle  massage  in  two  weeks.  Positive  passive  motion 
is  begun  in  three  or  four  weeks.  In  old  injuries,  when  the  ends  cannot  be 
brought  into  apposition,  lengthen  one  end  or  both  ends,  either  by  the  method 
of  Anderson  (Fig.  283)  or  by  the  method  of  Czerny  (Fig.  284).  Dr.  J.  Neely 
Rhoads  ("Med.  News,"  Nov.  28,  1891)  suggested  that  slight  lengthening 
could  be  accomplished  by  "  cutting  half  through  the  tendon  at  dift'erent 
levels  and  from  opposite  sides,  leaving  some  longitudinal  fibers  to  sHp  on 


568        Diseases  and  Injuries  of  Muscles.  Tendons,  and  Bursse 

each  other,  thus  gaining  sHght  elongation"  (H.  Augustus  Wilson,  in  "Inter- 
national Clinics,''  vol.  i,  4th  series).  Poncet  makes  several  zigzag  incisions 
on  each  side  of  the  tendon,  and  when  the  tendon  is  pulled  upon  it  elongates 
decidedly.  One  of  these  methods  of  lengthening  may  be  used  if  there  is 
deformity  from  tendon-contraction.  If  the  tendon  cannot  be  lengthened 
sufl&ciently,  make  a  bridge  of  catgut  from  one  end  of  it  to  the  other,  or 
graft  in  another  tendon  from  one  of  the  lower  animals,  or  graft  the  distal 
end  to  a  tendon  of  like  function. 

The  annular  ligament  is  sutured  as  shown  in  Fig.  285. 

Tendon=transplantation. — In  some  cases  in  which  a  muscle  has  been 
paralyzed,  Nicoladoni  and  others  have  divided  the  tendon  of  the  paralyzed 
muscle  and  have  united  its  distal  end  with  the  tendon  of  a  normal  muscle, 
the  normal  tendon  being  split  to  receive  it.  It  has  also  been  pointed  out 
that  when  a  muscle  or  the  tendon  of  a  muscle  is  sutured  to  a  paralyzed  an- 
tagonistic muscle,  the  transplanted  structure  will  actually  execute  the  func- 
tions of  the  paralyzed  muscle.  For  instance,  a  flexor,  when  so  transplanted, 
may  become  an  extensor  and  act  under  the  mental  impulse  of  extension. 
These  principles  have  been  utilized  when  some  or  many  of  the  muscles  of  a 
limb  have  been  paralyzed,  the  tendon  of  an  unparalyzed  muscle  or  the  tendons 
of  an  unparalyzed  group  of  muscles  being  fastened  to  the  tendons  of  the 
paralyzed  muscle.  It  has  been  shown  that  the  success  of  this  procedure 
depends  upon  the  accuracy  of  diagnosis,  the  division  of  secondary  contrac- 
tures, the  correction  of  existing  deformities,  and  careful  after-treatment. 
(See  the  article  by  Dr.  J.  Hilton  Watterman,  in  "Med.  News,"  July  12, 
1902.)  In  a  paralysis  of  the  lower  extremity,  as  Goldthwait  points  out,  the 
sartorius  usually  retains  power,  and  it  may  be  advisable  in  such  a  case  to 
divide  the  sartorius  and  suture  its  upper  end  to  the  quadriceps  above  the 
patella. 


Torticollis  569 


XXI.    ORTHOPEDIC  SURGERY. 

This  branch  of  surgery  formerly  dealt  only  with  the  treatment  of  de- 
formities by  means  of  mechanical  apphances,  but  of  recent  years  its  domain 
has  been  enlarged  to  include  the  treatment,  surgical  and  mechanical,  of 
deformities,  contractures,  and  many  joint-diseases. 

Torticollis  (wry=neck)  is  a  condition  in  which  contraction  of  certain  of 
the  neck-muscles  causes  an  alteration  in  the  position  of  the  head.  The  disease 
is  one-sided;  the  sternocleidomastoid  is  the  muscle  chiefly  involved,  though 
the  trapezius,  the  splenius,  and  other  muscles  sometimes  sufi'er.  Acute  torti- 
collis, which  is  rare,  is  a  temporary  condition,  and  results  from  cold  or  from 
injury  (see  Myalgia).  Chronic  torticollis  may  be  congenital,  may  be  due  to 
nerve-irritation,  to  an  assumed  attitude  because  of  eye-defect,  to  inflamma- 
tion of  the  glands  or  to  disease  of  the  vertebrae,  and  it  may  be  intermittent, 
but  is  usually  persistent.  The  muscle  stands  out  in  bold  outline,  the  head 
is  turned  to  the  opposite  side,  the  ear  of  the  disordered  side  is  turned  toward 
the  shoulder,  the  chin  is  thrown  forward,  and  spinal  curvature  may  arise. 
The  corresponding  side  of  the  face  atrophies.  There  is  no  pain.  In  many 
cases  the  head  may  be  restored  to  its  normal  position  by  passive  movement 
or  by  voluntary  effort,  but  it  at  once  returns  to  its  habitual  position.  Mikulicz 
asserts  that  torticollis  is  a  chronic  fibrous  myositis,  due  often  to  compression 
during  labor.  He  further  says  that  the  lesion  known  as  hematoma  of  the 
sternomastoid,  which  occasionally  follows  labor,  is  not  hematoma,  but  thicken- 
ing due  to  myositis.  In  spasmodic  wry-neck  the  muscle  is  thrown  repeatedly 
into  clonic  contractions.  In  congenital  torticoUis  the  muscle  and  the  cervical 
fascia  are  shortened,  and  the  muscle  does  not  relax  under  the  influence  of  an 
anesthetic.  In  torticollis  due  to  rheumatism  and  reflex  causes  the  tonically 
contracted  muscle  relaxes  when  the  patient  is  anesthetized. 

Symptoms. — Congenital  wry-neck  is  due  to  central  nervous  disease,  to 
spinal  deformity,  or  to  injury  during  birth,  and  in  this  form  the  sternomastoid 
is  shortened,  hardened,  and  atrophied.  It  may  not  be  noticed  for  some 
years  because  of  the  short  neck  of  infancy.  It  is  associated  with  asym- 
metrical development  of  the  face,  and  is  almost  invariably  upon  the  right 
side.  Spasmodic  wry-neck  may  present  tonic  spasm  only,  intermittent  spasm 
alone,  or  both  may  appear  alternately.  It  sometimes  arises  in  those  whose 
occupation  demands  frequent  rotation  of  the  head,  but  more  often  no  such 
cause  can  be  discovered.  It  is  probably  a  disease  of  the  cortical  area  which 
presides  over  rotation  of  the  head.  (See  article  by  C.  A.  Hamann,  in  "  Buft'alo 
Med.  Jour.,"  Dec,  1901.)  It  is  a  disease  especially  of  adults;  in  women  it  is 
often  linked  with  hysteria.  The  exciting  cause  may  be  a  cold,  a  l)low,  or  a 
mental  storm;  the  predisposing  cause  is  the  neurotic  temperament.  It  may 
be  due  to  enlarged  glands,  to  carious  teeth,  or  to  eye-strain.  In  some  rare 
cases  bilateral  spasm  occurs,  the  head  being  pulled  backward  and  the  face 
being  turned  upward.  Clonic  spasms  may  come  on  unannounced,  or  they 
may  be  preceded  by  pain  and  stiffness;  the  head  can  be  held  still  for  a  moment 
only;  there  is  sometimes  pain,  always  fatigue,  but  during  sleep  the  con- 
tractions cease.  The  attack  will  probably  pass  away,  but  will  almost  cer- 
tainlv  recur. 


570  Orthopedic  Surgery 

Treatment. — Congenital  wry-neck  is  treated  by  myotenotomy  (througli 
an  open  wound)  and  the  use  of  proper  braces  and  supports.  The  old  sub- 
cutaneous myotenotomy  should  be  abandoned,  as  aseptic  incision  enables 
the  surgeon  to  see  and  to  feel  all  the  contracted  bands  of  fascia,  muscle, 
and  tendon,  and  to  avoid  vital  structures  (page  474).  In  spasmodic  wry- 
neck treat  the  neurotic  temperament  and  remove  any  obvious  irritation 
(eye-strain,  carious  teeth,  enlarged  glands).  Drugs  are  practically  useless. 
The  rest  cure  is  sometimes  beneficial.  Tenotomy  is  not  to  be  employed. 
In  persistent  cases  stretch  or  divide  and  exsect  a  part  of  the  spinal  accessory 
nerve  (Keen).  To  reach  this  nerve,  make  an  incision  along  the  posterior 
edge  of  the  sternocleidomastoid  muscle,  find  the  nerve  as  it  emerges  from 
under  the  middle  of  the  muscle,  about  one  and  a  half  inches  below  the  tip 
of  the  mastoid  process,  retract  the  muscle  at  this  point,  and  remove  at  least 
one  inch  of  nerve.  Neurectomy  of  the  spinal  accessory  nerve  paralyzes  the 
sternocleidomastoid  muscle,  in  spite  of  the  fact  that  that  muscle  has  also  a 
nerve-supply  from  the  cervical  nerves.  The  paralysis  is  followed  by  atrophy, 
and  if  the  spasm  affected  the  sternomastoid  muscle  only,  the  operation  will 
cure  the  case.  Unfortunately,  other  muscles  are  usually  involved,  and  cure  will 
only  be  obtained  by  performing  neurectomy  on  the  nerves  which  innervate 
the  affected  muscles.  For  the  treatment  of  rheumatic  wry-neck  see  Myalgia 
(page  553)- 

Dupuytren's  contraction  is  a  contraction  of  the  palmar  fascia,  of  its 
digital  prolongations,  and  of  the  fibers  joining  the  fascia  and  skin.  Fixed 
contraction  of  one  or  more  fingers  occurs.  The  ring-finger  and  the  little  finger 
most  often  suffer,  but  any  finger  or  the  thumb  may  be  involved.  The  condi- 
tion may  be  symmetrical.  The  disease  arises  oftenest  in  men  beyond  middle 
age,  but  is  sometimes  met  with  in  youths.  The  cause  of  this  disease  is 
unknown;  some  refer  it  to  gout  or  rheumatism;  others  to  traumatism,  reflex 
irritation,  or  neuritis.  If  due  to  traumatism,  the  right  hand  should  suffer 
most  frequently;  but  it  occurs  in  the  left  hand  nearly  as  often  as  in  the  right 
(P.  Jansen,  in  "Arch.  f.  khn.  Chir.,"  Bd.  Ixvii,  H.  4).  Jansen  examined 
specimens  from  seven  cases  and  found  connective-tissue  hypertrophy  and 
circulatory  disturbance,  the  contraction  being  a  result  of  the  above-named 
processes. 

Symptoms. — Dupuytren's  contraction  is  indicated  by  a  small  hard  lump 
or  crease  which  appears  over  the  palmar  surface  of  the  metacarpophalangeal 
joint.  This  nodule  grows  and  the  corresponding  finger  is  gradually  pulled 
down.  In  some  cases  the  tip  of  the  finger  is  forced  against  the  palm.  The 
skin  becomes  dimpled  or  puckered. 

Treatment. — In  treating  Dupuytren's  contraction  subcutaneous  multiple 
incisions  may  be  made,  the  tense  fascia  and  the  fasciocutaneous  fibers  being 
cut.  The  finger  is  straightened  and  is  placed  upon  a  straight  splint,  which 
is  worn  continuously  for  a  week  or  ten  days  and  is  worn  at  night  for  at  least 
a  month.  A  more  satisfactory  operation  is  that  of  Keen.  Keen  divides 
the  skin  by  a  V-shaped  cut,  the  base  of  the  V  being  downward,  lifts  up  the 
flap,  and  dissects  out  the  contracted  tissue.  A  cure  is  most  certain  to  be 
obtained  by  Lexer's  radical  operation.  This  surgeon  excises  the  entire 
aponeurosis  and  considerable  portions  of  the  palmar  skin  adherent  to  the 
aponeurosis.  In  order  to  cover  this  wound  it  may  be  necessary  to  slide  a 
pedunculated  flap  into  the  raw  surface. 


Trigger-finger  or  Jerk -finger 


571 


Syndactylism  (webbed  fingers)  is  always  congenital,  and  may  persist 
through  several  generations.  Simple  incision  of  the  web  is  useless;  the 
operation  to  be  performed  is  that  of  Agnew  or  of  Diday  (Figs.  286,  287). 

In  Agnew's  operation  a  flap  of  skin  from  the  dorsum  is  inserted  between 
the  fingers  and  sutured  in  place. 

In  Diday's  operation  a  flap  is  taken  from  the  dorsal  surface  and  another 
flap  is  raised  from  the  palmar  surface,  and  each  flap  is  sutured  to  the  finger 
from  which  it  springs. 

Polydactylism  (supernumerary  digits)  is  always  congenital,  is 
often  hereditary,  and  is  usually  symmetrical.  There  may  be  an  incomplete 
digit,  or  there  may  be  an  entire  and  well-developed  finger  or  toe  with  a  meta- 
carpal or  metatarsal  bone.  The  connection  to  the  metacarpus  or  meta- 
tarsus may  be  by  a  fibrous  pedicle  only.  If  the  digit  is  complete,  with  a 
metacarpal  bone,  no  operation  is  required;  if  it  is  incomplete  or  is  ill-developed, 
it  should  be  removed. 

Trigger=finger  or  Jerk=finger. — The  patient  can  usually  close  the 
fingers,  but  on  trying  to  open  them  one  finger  remains  closed.  It  can  be 
opened  by  grasping  it  with  the  other  hand,  but  flies  open  with  a  snap  like 
an  opening  knife  (Abbe).     In  some  cases  two  fingers  are  involved.     In  a 


Fig.  286. — Agnew's  operation  for  webbed 
fingers  (Pye). 


Fig.  287. — Diday's  operation  for  webbed 
fingers  (Pye). 


reported  case  (Frederick  GriflBith,  "Annals  of  Surgery")  the  ring  and  middle 
fingers  of  the  left  hand  locked  at  the  knuckle-joints  on  attempting  flexion. 
The  locking  occurred  when  about  one-third  the  amount  of  flexion  necessary 
to  grasp  an  object  was  achieved.  By  bending  the  fingers  with  the  other 
hand  unlocking  was  accomplished  and  flexion  was  finished  voluntarily. 
In  attempting  extension  blocking  occurred  at  the  same  point  and  unlocking 
was  accomplished  in  the  same  manner.  In  most  cases,  but  not  in  all,  there 
is  pain  when  locking  occurs.  The  condition  is  gradual  in  onset.  Trigger- 
finger  is  often  associated  with  rheumatism  (in  52  cases  out  of  121,  according 
to  Necker).  It  is  said  by  Tubby  to  be  due  to  enlargement  of  the  flexor 
tendon,  or  to  contraction  of  the  groove  in  the  transverse  ligament  in  the 
palm.  It  may  be  due  to  a  ganglion,  enchondroma,  or  tenosynovitis.  Trau- 
matism or  irritation  may  produce  it.  The  tendon-sheath  may  be  thickened, 
or,  according  to  Marcano,  there  may  be  a  nodule  on  the  tendon  which  rubs 
against  the  sesamoid  bone  (Griffith).     It  may  result  from  occupation. 

Treatment. — If  a  ganglion,  a  loose  cartilage,  or  a  sesamoid  bone  exists, 
treat  by  incision.  If  there  is  inflammation,  use  massage  and  counter-irritation. 
If  there  is  no  obvious  cause,  put  a  compress  over  the  tunnel  in  the  ligament 
and  apply  a  spHnt. 


572  Orthopedic  Surgery 

Mallet=finger. — This  is  called  also  drop-finger  and  rupture  of  the 
extensor  tendon.  It  is  due  to  a  blow  in  the  direction  of  flexion  when  the 
finger  is  extended.  It  is  supposed  to  be  due  partly  to  stretching  and  partly 
to  rupture  of  the  extensor  tendon  at  the  point  at  which  it  is  the  posterior 
hgament  of  the  distal  interphalangeal  joint.  Abbe  has  shown  that  baseball 
players  are  hable  to  a  condition  which  is  the  reverse  of  this,  in  which  the 
last  phalanx  is  dislocated  backward.  Drop-finger  is  treated  by  incision 
and  suture  of  the  tendon  to  the  periosteum  (Abbe). 

Genu  valgum  (knock-knee)  resuhs  from  an  unnatural  growth  of  the 
internal  condyle,  causing  the  shaft  of  the  femur  to  curve  inward  and  the 
internal  lateral  hgament  of  the  knee-joint  to  stretch,  the  knees  coming  close 
together  and  the  feet  being  widely  separated.  This  deforjnity  is  usually 
noted  when  the  child  begins  to  walk,  but  it  may  not  appear  until  puberty 
or  even  long  after.  Knock-knee  may  arise  from  rickets,  from  an  occupation 
demanding  prolonged  standing,  or  from  flat-foot.  It  may  occur  in  one  kree 
or  in  both  knees. 

Treatment. — Mild  rachitic  cases  of  knock-knee  may  remain  in  slight 
deformity,  or  may  get  well  from  improvement  of  the  general  health.  In 
ordinary  cases  simply  treat  the  rickety  condition.  The  patient  is  forbidden 
to  stand  or  to  walk,  and  the  limb,  after  being  put  as  straight  as  can  be,  is 
fijxed  on  an  external  splint  and  a  pad  is  put  over  the  inner  condyle.  Later 
in  the  case  plaster-of-Paris  is  used.  Some  surgeons  prefer  to  immobilize 
while  the  leg  is  flexed  to  a  right  angle  with  the  thigh.  In  a  severe  case  the 
surgeon  can  immobilize  after  forcibly  straightening  (causing  an  epiphyseal 
separation)  or  after  the  performance  of  osteotomy  (Fig.  257).  Osteotomy 
is  preferable  to  fracture  by  a  mechanical  apphance  (osteoclasis). 

Genu  varum  (bow=legS)  is  the  opposite  of  knock-knee.  Usually  both 
legs  are  bowed  out,  the  knees  being  widely  separated,  the  tibiae  and  femurs, 
as  a  rule,  being  curved,  and  the  feet  being  turned  in.  This  disea.se  in  early 
life  is  due  to  rickets,  the  weight  of  the  body  producing  the  deformity.  In 
older  people  incurable  bow-legs  may  arise  from  arthritis  deformans. 

Treatment. — Some  mild  ca.ses  of  genu  varum  recover  as  a  result  of 
improvement  in  the  health.  Ordinary  cases  are  treated  by  braces, by  pla.ster- 
of-Paris  bandages,  and  by  attention  to  the  general  health.  When  the  bones 
have  hardened,  osteotomy  is  necessary. 

Club=hand. — A  congenital  deformity  in  which  the  hand  deviates  from 
the  normal  relation  to  the  forearm.  It  is  usually  as.sociated  with  other  de- 
formities. In  some  cases  the  radius  and  possibly  some  of  the  carpal  bones 
are  absent. 

Treatment. — By  massage  and  passive  motion,  by  immobilization,  by 
tenotomy  or  osteotomy. 

Talipes  (club=foot)  is  a  permanent  deviation  of  the  foot.  There  are 
several  forms.  Talipes  equinns  (Fig.  288)  is  a  confirmed  extension;  talipes 
calcaneus  (Fig.  289)  is  a  confirmed  flexion;  talipes  varus  is  a  confirmed  ad- 
duction and  inversion;  and  talipes  valgus  is  a  confirmed  abduction  and 
eversion.  Two  of  these  forms  may  be  combined,  as  in  talipes  equino-varus 
(Fig.  290),  talij)es  ecjuino-valgus,  talipes  calcaneo-varus,  and  talipes  cal- 
caneo-valgus.  The  causes  of  talipes  are  congenital  or  acquired.  The  con- 
genital form   is  due  to  persistence  of  the  fetal  form  of  the  foot.     Acquired 


Talipes 


;73 


cases  may  arise  from  infantile  paralysis,  from  spastic  contractions,  from 
cicatrices,  from  traumatisms,  from  arrest  of  bony  growth  following  upon  the 
inflammation  of  bone,  or  from  hysterical  contractures. 

Talipes  eqiiinus  is  rarely  congenital.  In  this  condition  the  patient  walks 
upon  the  toes  and  cannot  bring  the  heel  to  the  ground. 

Talipes  Calcaneus. — The  patient  walks  upon  the  heel  and  cannot  bring 
the  toes  to  the  ground.  The  true  form  is  .seen  in  congenital  cases,  the  fle.xors 
of  the  foot  being  shortened,  and  the  tendo  Achillis  being  lengthened. 

Talipes  varus  is  rarely  met  with  without  ecjuinus.  In  this  condition  the 
patient  walks  on  the  outer  edge  of  the  foot. 

Talipes  valgus  is  met  with  in  flat-foot.  The  patient  walks  on  the  inner 
edge  of  the  foot. 

Talipes  equino-varus. — The  heel  is  raised  and  the  patient  walks  upon  the 
outer  edge  of  the  foot.     This  is  the  usual  congenital  form. 

Talipes  eguino-valgus  is  very  rarely  congenital.  The  heel  is  raised  and 
the  patient  walks  upon  the  inner  side  of  the  foot. 

Talipes  calcaneo-varus  is  a  combination  of  calcaneus  and  varus. 


Fig.  2S8. — Talipes 
equinus  (Albert). 


Fig.  289. — Talipes  cal- 
caneus (Albert). 


tM 


-^^  <4. 


Fig.  290. — Double  equiiio-varus  ("  .American  Text- 
book of  Surgery"). 


Talipes  calcaneo-valgiis  is  a  combination  of  calcaneus  and  valgus. 

Treatment. — In  congenital  cases  the  condition  is  usually  manifest  on 
both  sides,  and  is  nearly  always  talipes  equino-varus.  Congenital  club-foot 
should  be  treated  in  infancy,  and  when  a  restoration  to  position  can  be  effected 
by  the  hands  of  the  surgeon,  is  treated  by  plaster-of-Paris  bandages.  If 
a  child  has  begun  to  walk,  it  may  still  be  possible  to  correct  the  deformity 
eventually  by  manipulations,  by  plaster-of-Paris  bandages,  or  by  club-foot 
shoes,  but  most  cases  require  tenotomy  of  the  tendo  Achillis  before  the  appli- 
cation of  the  shoe  or  the  plaster.  The  club-foot  shoe  may  do  good  service, 
but  in  many  instances  it  is  painful  and  is  not  so  efficient  as  plaster-of-Paris. 
In  severe  cases,  before  applying  the  plaster,  the  patient  is  given  ether:  the 
surgeon  cuts  the  tendons  of  the  anterior  and  posterior  tibial  muscles,  the 
plantar  fascia,  and  the  tendo  Achillis,  in  the  order  named,  and  forcibly  corrects 
the  deformity.  In  old  cases  with  alteration  in  the  shape  of  the  bones,  cunei- 
form osteotomy,  or  the  removal  of  the  cuboid  or  other  tarsal  bones,  may 
be  indicated.  In  these  cases  Phelps  advises  an  open  transverse  division  of 
all  rigid  plantar  soft  parts.  Buchanan  employs  subcutaneous  division  of 
all    resistant    structures.      Occasionally    in    relapsed    and    inveterate    cases 


574 


Orthopedic  Surgery 


astragalectomy  is  performed.  It  is  seldom  practised  upon  young  children. 
(See  page  547-)  In  some  cases  of  talipes  calcaneus  shortening  of  the  tendo 
Achillis  is  advised;  but  such  an  operation  is  only  of  temporary  value,  as 
stretching  occurs  after  two  years  or  more.  In  talipes  due  to  infantile  paral- 
ysis the  operative  treatment  is  the  same,  but  we  should  not  immobilize  in 
plaster  but  rather  in  some  apparatus  which  can  easily  be  removed  to  permit 
the  use  of  massage  and  electricity.  In  paralytic  cases  Nicoladoni's  operation  is 
occasionally  employed.  This  consists  in  dividing  the  tendon  of  the  paralyzed 
muscle  and  attaching  its  distal  end  to  the  adjacent  tendon  of  a  healthy  muscle. 
(For  full  consideration,  see  a  work  on  Orthopedic  Surgery.) 

Pes  planus  (flat=foot)  is  a  condition  in  which  there  is  loss  of  the  arch 
of  the  foot  due  to  muscular  paralysis  or  ligamentous  weakness,  to  prolonged 
standing,  or  to  trauma.  Flat-foot  is  especially  apt  to  occur  in  rickets.  Spuri- 
ous fiat-foot,  or  inflammatory  flat-foot,  occurs  in  Pott's  fracture,  and  in 
inflammation  of  the  ankle-joint  or  the  tendon  of  the  peroneus  longus  muscle. 
Paralytic  flat-foot  is  seen  after  infantile  paralysis.  Static  flat-foot  is  due  to 
disproportion  between  the  body  weight  and  the  support  of  that  weight. 
All  children  are  born  with  pronated  feet;  the  arch  usually  begins  to  form  soon 
after  birth,  but  in  some  individuals  it  never  forms.  Flat-foot,  according  to 
de  Vlaccos,  is  thus  produced:  If  we  suppose  a  straight  line  prolonged  down- 
ward from  the  center  of  the  leg,  most  of  the  astragalus  and  os  calcis  will 
be  external  to  it;  hence,  the  body  weight  presses  on  the  inner  side  of  the 
foot,  and  tends  to  flatten  the  arch  and  cause  outward  rotation,  tendencies 
which  are  antagonized  by  the  flexors  of  the  toes  and  by  the  tibialis  posticus 
muscle.  The  os  calcis  pronates  and  is  pushed  to  the  side,  the  astragalus 
moves  after  the  os  calcis,  and  the  Hgaments  are  stretched  ("Rev.  de  Chir.," 
Aug.,  1901).  Pes  planus  is  productive  of  much  pain  upon  standing  or  walking; 
in  fact,  the  individual  may  be  completely  crippled.  Pain  is  quickly  relieved 
upon  sitting  down.  Walking  upon  the  toes  is  not  painful.  A  distinctly  flat 
foot  can  at  once  be  recognized  by  wetting  the  sole  of  the 
patient's  foot  with  a  colored  fluid  and  causing  him  to  step 
iirmly  upon  a  piece  of  paper  (Fig.  29$,  a,  b).  Beginning 
flat-foot  is  frequently  overlooked,  the  patient  being 
treated  for  gout  or  rheumatism.  Even  a  slight  case  can 
be  detected  by  carefully  observing  the  inner  surface  of 
the  foot.  When  weight  is  placed  upon  it,  it  is  seen  to 
descend  as  the  arch  falls.  A  more  accurate  method  is 
measurement,  to  find  the  middle  of  the  foot.  In  flat- 
foot  the  extremity  is  lengthened.  Golding-Bird  points 
out  that  the  middle  of  the  foot  is  the  point  of  articula- 
tion of  the  inner  cuneiform  and  the  metatarsal  bone  of 
the  great  toe.  In  flat-foot  the  greatest  change  is  in  the 
posterior  half  of  this  line.  The  extent  to  which  the  posterior  measurement 
exceeds  the  anterior  is  the  degree  of  flat-foot.  The  excess  may  reach  three- 
fcjurths  of  an  inch. 

Treatment. — In  paralylic  flat-joot,  which  arises  from  infantile  paralysis, 
emy;loy  e.xerci.se,  electricity,  and  massage.  In  sialic  flal-}ool  rest  in  bed  is 
employed  for  two  weeks,  and  then  exercise  is  practised  several  hours  a 
day  to  increase  the  arch.     Rising  upon  the  toes  again  and  again  is  valuable. 


Fig.  291. —  Print  of 
a  normal  foot-sole  (a) 
and  of  a  flat  foot-sole 
(i!)  'Albert). 


Hammer-toe  575 

After  exercise  the  patient  rests  for  a  time,  sitting  tailor-fashion  with  the 
legs  crossed  under  him.  Massage  is  valuable.  A  shoe  should  be  made 
containing  a  piece  of  steel  so  arranged  as  to  raise  the  arch  of  the  foot. 
The  patient's  general  health  must  also  be  attended  to.  In  very  severe 
cases,  with  fixation  and  bone-formation,  operation  may  be  required.  Gleich 
shortens  the  foot  and  raises  the  arch  by  sawing  through  the  os  calcis  and 
fastening  the  posterior  part  of  this  bone  at  a  lower  level.  Trendelenburg 
advises  supramalleolar  osteotomy.  This  operation  permits  of  adduction, 
and  the  adducted  foot  should  be  put  up  in  an  immovable  dressing  of  plaster- 
of-Paris.  Ogston  resects  the  astragaloscaphoid  joint;  Golding-Bird  and 
Davy  remove  the  scaphoid  bone;  Stokes  removes  a  wedge-shaped  piece  from 
the  head  and  neck  of  the  astragalus. 

Pes  cavus  (hollow=foot)  is  an  increase  in  the  arch  of  the  foot,  due,  pos- 
sibly, according  to  Golding-Bird,  to  paralysis  of  the  peronei  muscles.  When 
the  peronei  muscles  are  paralyzed,  the  adductors  act  unopposed,  and  secondary 
contraction  of  the  plantar  fascia  occurs.  Certain  it  is  that  a  contracted 
plantar  fascia  is  the  chief  obstacle  to  correction.  In  many  cases  the  cause 
is  the  wearing  of  shoes  which  are  too  short  for  the  feet.  The  pressure  made 
upon  the  toes  causes  spasm  of  the  plantar  flexors  and  this  spasm  permits 
the  fascia  to  contract. 

Treatment. — A  shoe  is  worn  containing  a  plate  of  steel  in  the  sole,  and 
pressure  is  applied  over  the  instep.  Tenotomy,  division  of  the  plantar  fascia, 
or  excision  of  bone  may  be  required.  In  paralytic  cases  apply  electricity 
and  massage  to  the  paralyzed  muscles. 

Hallux  valgus,  or  varus,  a  displacement  of  the  great  toe  outward  or 
inward,  may  occur  in  the  young,  but  it  is  most  frequent  in  old  men.  It 
arises  often  from  wearing  narrow  shoes,  but  may  be  due  to  gout  or  to  rheu- 
matic gout.  In  hallux  valgus  a  bunion  is  apt  to  form  over  the  metatarso- 
phalangeal joint. 

Treatment. — ^An  arrangement  may  be  worn  to  straighten  the  toe  and 
to  protect  the  bunion  (Fig.  281).  The  prominent  and  hypertrophied  inner 
portion  of  the  head  of  the  metatarsal  bone  may  be  removed  by  means  of  a 
chisel,  osteotomy  may  be  performed  upon  the  metatarsal  bone,  the  joint 
may  be  excised,  or  amputation  may  be  required. 

Hammer=toe  (Fig.  292)  is  a  condition  in  which  there  is  flexion  of  one 
or  more  toes  at  the  first  interphalangeal  joint.  Shattuck 
shows  that  this  condition  is  due  to  contraction  of  "the 
plantar  fibers  of  the  lateral  ligaments  of  the  joint.  "*  This 
disease  usually  begins  in  youth  and  may  be  congenital. 
A  bunion  is  apt  to  form,  and  the  joint  may  become  dis- 
located. ^'S-  292-— Hammer-toe. 

Treatment. — -Terrier's  plan  of  treatment  consists  in 
making  a  dorsal  flap,  removing  a  bursa  if  one  is  found,  dividing  the  exten.sor 
tendon,  opening  the  articulation,  removing  each  articular  surface  with  cutting 
forceps,  suturing  the  soft  parts,  and  applying  a  plantar  splint  for  two  weeks. f 
Some  surgeons  excise  the  joint.  Probably  amputation  of  the  toe  is  the  best 
treatment. 

*  "American  Text-book  of  Surgery."  t  Rev.  de  Chir.,  July.  1S95. 


5/6  Orthopedic   Surgery 

Metatarsalgia  (Morton's  Disease).— This  disease  was  first  described 
by  Dr.  Thomas  G.  Morton,  of  Philadelphia,  in  1876.  It  is  a  painful  condi- 
tion of  the  foot,  due  to  jamming  of  a  nerve  between  the  heads  of  the  fourth 
and  fifth  metatarsal  bones.  The  head  of  the  fifth  metatarsal  bone  is,  by 
lateral  pressure,  forced  against  and  below  the  neck  of  the  fourth  metatarsal, 
and  as  a  result  the  superficial  branch  of  the  external  plantar  nerve  and  its 
two  digital  branches  are  squeezed.  It  is  usually  associated  with  flat-foot. 
Pain  is  produced  by  walking,  and  the  suffering  may  be  so  severe  that  the 
patient  is  obliged  to  sit  down  at  once.  When  the  shoe  is  removed  and  the 
foot  is  rested,  the  pain  soon  abates.  The  pain  is  felt  on  the  outer  and  inner 
sides  of  the  little  toe,  the  outer  side  of  the  fourth  toe,  and  about  the  head 
of  the  fifth  and  the  neck  of  the  fourth  metatarsal  bones.  Pain  can  be  de- 
veloped by  grasping  the  foot  in  the  hand  and  squeezing  it.  If  flat-foot  exists, 
there  is  also  pain  due  to  this  trouble. 

Treatment. — Mild  cases  may  be  cured  occasionally  by  wearing  well- 
fitting  shoes  and  employing  massage.  Some  cases  require  a  brace.  Severe 
cases  demand  resection  of  the  fourth  metatarsophalangeal  joint,  or  amputa- 
tion of  the  fourth  toe,  and  with  it  the  head  of  the  fourth  metatarsal  bone. 
Graham,  of  Washington,  has  cured  cases  by  excising  a  portion  of  the  super- 
ficial branch  of  the  external  plantar  nerve. 

Coxa  vara  is  a  disease  characterized  by  bending  of  the  neck  of  the  femur, 
the  hip-joint  being  perfectly  healthy,  and  the  condition,  as  a  rule,  being 
unilateral.  This  condition  was  described  by  Miiller  in  1889.  Coxa  vara 
begins,  as  a  rule,  between  the  thirteenth  and  twentieth  years,  and  the  com- 
monly accepted  view  has  been  that  the  deformity  is  rachitic,  but  Kredel 
has  reported  two  congenital  cases.*  Traumatic  coxa  vara  may  follow  frac- 
ture of  the  neck  of  the  femur  in  a  child.  The  patient  develops  a  limp,  and 
grows  tired  after  slight  exertion,  but  there  is  no  swelling  nor  tenderness,  and 
little  or  no  pain.  Shortening  after  a  time  becomes  apparent,  and  the  tro- 
chanter can  be  detected  above  Nelaton's  line.  The  extremity  is  adducted. 
The  .T-rays  show  the  deformed  bone. 

Treatment. — As  long  as  bending  is  progressing  employ  rest.  When  the 
bone  hardens  it  may  be  necessary  to  perform  osteotomy  below  the  trochanters. 

Flail=joints. — After  an  attack  of  infantile  paralysis  involving  the  entire 
lower  extremity  of  each  side,  the  limbs  become  limp  and  swing  flail-like 
when  the  extremity  is  made  to  move,  and  the  joints  are  much  relaxed.  In 
such  cases  the  psoas  and  iliacus  muscles  are  never  completely  paralyzed, 
and  the  aim  of  the  surgeon  is  to  utiHze  these  muscles  in  enabling  the  patient 
to  walk.  In  many  cases  the  application  of  apparatus  is  sufficient.  In  others 
ankylosis  may  be  established  in  the  ankles  and  knees  by  operation.  If 
ankylosis  is  established  in  these  joints,  the  psoas  and  iliacus  muscles  become 
able  to  move  the  legs. 

*Centralbl.  f.  Chir.,  Oct.  17,  1896. 


Diseases  of  Nerves 


577 


XXII.    DISEASES    AND    INJURIES   OF    NERVES. 

I.  Diseases  or  Nerves. 

Neuritis,  or  inflammation  of  a  nerve,  may  be  limited  or  be  widely 
distributed  (multiple  neuritis).  The  first-mentioned  form  will  here  be  con- 
sidered. The  causes  of  neuritis  are  traumatism,  wounds,  overaction  of 
muscles,  gout,  rheumatism,  syphilis,  fevers,  and  alcoholism. 

Symptoms. — The  symptoms  of  neuritis  are  as  follows:  exxessive  pain, 
usually  intermittent,  in  the  area  of  nerve-distribution.  The  pain  is  worse 
at  night,  is  aggravated  by  motion  and  pressure,  and  occasionally  diffuses 
to  adjacent  nerve-areas  or  awakens  sympathetic  pains  in  the  opposite  side 
of  the  body.  The  nerve  is  very  tender.  The  area  of  nerve-distribution 
feels  numb  and  is  often  swollen.  Early  in  the  case  the  skin  is  hyperesthetic; 
later  it  may  become  anesthetic.  The  muscles  atrophy  and  present  the 
reactions  of  degeneration;  that  is,  the  muscles  first  cease  to  respond  to  a 
rapidly  interrupted,  and  next  to  a 
5/ou'/j  interrupted,  faradic  current; 
faradic  excitability  diminishes,  but 
galvanic  excitability  increases. 
When,  in  neuritis,  faradism  pro- 
duces no  contraction,  a  slowly  inter- 
rupted galvanic  current  which  is  so 
weak  that  it  would  produce  no 
movement  in  the  healthy  muscle 
causes  marked  response  in  the  de- 
generated muscle.  In  health  the 
most  vigorous  contraction  is  ob- 
tained by  closing  with  the  —  pole; 
in  degenerated  muscles  the  most 
vigorous  contraction  is  obtained  by 
closing  with  the  -|-  pole.  When  vol- 
untary power  returns,  galvanic  ex- 
citability declines;  but  power  is 
often  nearly  restored  before  faradic 
excitability  becomes  manifest  (Buz- 
zard). 

Treatment. — The  treatment  of 
neuritis  consists  of  rest  upon  splints, 
and  the  use  of  an  ice-bag  early  in  the 
case  and  a  hot-water  bag  later. 
Blisters  over  the  course  of  the  nerve 
are  of  value,  especially  in  traumatic 
neuritis.     Massage   and   electricity 

must  be  used  to  antagonize  degeneration.     A  descending  galvanic  current 
allays  pain  to  some  extent.     Deep  injections  of  chloroform  or  cocain  may 
allay  pain.     Treat  the  patient's  general  health,  especially  any  constitutional 
37 


Fig.  293. — Distribution  of  the  cutaneous  sensi- 
tive nerves  upon  the  head  :  onia,  o»n\  The  occipit. 
niaj.  and  minor  (from  the  N.  cervical.  II  and  III)  ; 
am,  N.  auricular  magn.  (from  N.  cer\'ic.  Ill)  ;  cs, 
N.  cervical,  superfic.  (from  N.  cervic.  Ill)  ;  l\, 
first  branch  of  the  fifth  {so,  N.  supraorbit.;  st.  N. 
supratrochl.  ;  it,  N.  infratrochl.  ;  <%  N.  ethmoid.; 
/,  N.  lachrj'mal.)  ;  /o.  second  branch  of  the  fifth 
(s)n,  N.  subcutan.  malK  seu  zygoniaticus) ;  I's, 
third  branch  of  the  fifth  (at,  N.  auriculo-tempor. ; 
b,  N.  buccinator;  ?/?,  N.  mental.);  B,  posterior 
branches  of  the  cervical  nerves  (Seeligmiiller). 


578  Diseases  and  Injuries  of  Nerves 

disease  or  causative  diathesis.  The  sahcylate  of  ammonium  or  phenacetin 
may  be  given  internally.     In  some  cases  nerve-stretching  is  advisable. 

Neuralgia  is  manifested  by  violent  paroxysmal  pain  in  the  trajectory 
of  a  nerve.  This  disease,  unless  it  is  excessively  severe  and  persistent,  is 
treated,  as  a  rule,  by  the  physician.  Neuralgia  of  stumps  and  scars  is  a 
surgical  condition,  and  is  due  to  neuromata,  or  entanglement  of  nerve-filaments 
in  a  cicatrix.  Tic  douloureux  and  other  intractable  neuralgias  require 
careful  removal  of  any  cause  of  reiiex  irritation.  Causal  reflex  irritation 
may  arise  from  disease  of  the  stomach,  eyes,  uterus,  nose,  throat,  etc.  Tic 
douloureux  has  been  treated  by  removal  of  the  Gasserian  ganglion;  removal 
of  Meckel's  ganghon;  ligation  of  the  common  carotid  artery;  neurectomy 
of  terminal  branches  of  the  fifth  nerve;  division  of  motor  nerves;  massive 
doses  of  strychnin  (Dana  and  purgatives  (Esmarch).  The  distribution  of 
the  fifth  nerve,  the  seat  of  pain  in  tic  douloureux,  is  shown  in  Fig.  293. 

Treatment  of  Neuralgia  of  Stumps. — Excise  the  scar;  find  the  bulbous 
end  of  the  nerve  and  cut  it  off.  Senn  tells  us  to  section  the  nerve  by  V- 
shaped  cuts,  the  apex  of  the  V  being  toward  the  body,  and  to  suture  the 
flaps  together.  Senn's  method  will  prevent  recurrence.  In  some  cases 
reamputation  is  performed.  In  entanglement  of  a  nerve  in  a  scar  remove 
a  portion  of  a  nerve  above  the  scar  and  also  the  neuroma  in  the  scar. 

2.  Wounds  and  Injuries  of  Nerves. 

Section  of  Nerves  (as  from  an  incised  wound). — After  nerve-section 
the  entire  peripheral  portion  of  the  nerve  degenerates  and  ceases  structurally 
to  be  a  nerve  in  a  few  weeks,  but  after  many  months,  or  even  years,  the  nerve 
may  regenerate.  The  proximal  end  degenerates  only  in  the  portion  immedi- 
ately adjacent  to  the  section;  it  rapidly  regenerates,  and  a  bulb  or  enlarge- 
ment composed  of  fibrous  tissue  and  small  nerve-fibers  forms  just  above 
the  line  of  section;  this  bulb  adheres  to  the  perineural  tissues.  The  entire 
distal  end  degenerates,  but  new  axis-cylinders  form  in  this  segment  by  pro- 
liferation of  the  nuclei  on  the  sheath  of  Schwann.  Union  of  a  divided  nerve 
is  brought  about  by  the  projection  of  axis-cylinders  from  the  proximal  end 
or  from  each  end  and  the  fusion  of  these  cylinders.  The  nearer  the  two 
ends  are  to  each  other,  the  better  the  chance  of  union. 

'Symptom.s. — Pronounced  changes  occur  in  the  trajectory  of  a  divided 
nerve.  The  muscles  degenerate,  atrophy,  and  shorten,  and  develop  the  re- 
actions of  degeneration.  When  union  of  the  nerve  occurs  the  muscles  are 
restored  to  a  normal  condition.  If  the  nerve  contains  sensory  fibers,  complete 
anesthesia  (to  touch,  pain,  and  temperature)  usually  follows  its  division;  but 
if  a  part  is  supplied  by  another  nerve  as  well  as  by  the  divided  one,  anesthesia 
will  not  be  complete.  Trophic  changes  arise  in  the  paralyzed  parts.  Among 
these  changes  are  muscular  atrophy;  glossy  skin;  cutaneous  eruptions;  ulcers; 
dry  gangrene;  painless  felons;  falling  of  the  hair;  brittleness,  furrowing  or 
casting  off  of  the  nails;  joint-inflammations;  and  ankylosis.  Immediately 
after  nerve-section  vaso-mottjr  paralysis  comes  on,  and  for  a  few  days  the 
paralyzed  part  pre.sents  a  temperature  higher  than  normal.  The  diagnosis  as 
to  which  nerve  is  cut  depends  ujjon  a  study  of  the  distriljution  of  ])aralysis  and 
anesthesia.* 

*  See  ]jowlby  on  "  Injuries  of  Nerves." 


The  Symptoms  of  Division  of  Nerves  579 

The  S3miptoms  of  Division  of  Nerves. — Brachial  Plexus. — If  one  or  more 
cords  of  the  brachial  plexus  are  divided,  motor  paralysis  and  anesthesia  appear 
in  the  hmb,  the  extent  of  the  paralysis  and  the  area  of  the  anesthesia  depending 
upon  the  cord  or  cords  involved.  It  should  be  remembered  that  the  inner  cord 
of  the  brachial  plexus  gives  origin  to  the  ulnar  nerve,  the  inner  and  outer 
cords  give  branches  which  fuse  to  form  the  median  nerve.  The  posterior  cord 
gives  origin  to  the  subscapular,  the  circumflex,  and  the  musculospiral  nerves. 
The  outer  cord  gives  origin  to  the  external  anterior  thoracic  and  the  musculo- 
cutaneous, as  well  as  to  the  outer  trunk  of  origin  of  the  median. 

Evulsion  of  the  brachial  plexus  is  sometimes  effected  by  an  injury,  when 
the  arm  is  not  lost.  Algernon  T.  Bristow  ("Annals  of  Surgery,"  Sept.,  1902) 
reports  3  cases  of  this  rare  injury,  and  has  collected  24  undoubted  instances. 
One  of  his  own  cases  was  operated  upon  the  third  day  after  the  accident.  In 
this  case  there  was  complete  paralysis  of  the  upper  extremity,  with  the  excep- 
tion of  the  sensory  area  of  the  intercostohumeral  and  the  circumflex  nerves. 
The  accident  had  been  inflicted  by  the  patient's  forearm  becoming  entangled 
in  a  rope,  which  was  pulled  upon  by  a  steam  winch.  On  reaching  the  hospital 
he  felt  severe  pain,  referred  to  the  arm.  There  was  much  swelling  in  the  inner 
portion  of  the  subclavian  triangle,  the  left  pupil  was  contracted,  and  it  seemed 
likely  that  the  nerves  had  been  evulsed  close  to  the  intervertebral  foramina. 
From  the  fact  that  sensation  was  preserved  in  the  skin  of  the  convexity  of  the 
shoulder,  down  to  the  insertion  of  the  deltoid,  Bristow  concluded  that  some 
fibers  of  the  posterior  cord  of  the  plexus  had  escaped  division;  but  when  the 
operation  was  performed,  this  conclusion  was  found  to  be  erroneous.  An  in- 
cision was  made,  and  it  was  found  that  the  plexus  had  given  way  at  the  point 
where  the  four  cervical  nerves  and  the  last  dorsal  unite  to  form  the  three  trunks. 
In  order  to  reach  the  lower  ends,  it  was  necessary  to  saw  the  clavicle  and  divide 
the  two  pectoral  muscles;  and  the  torn  ends  of  the  nerve-trunks  were  found 
underneath  the  clavicle.  Suturing  was  performed.  The  ends  of  the  sawn 
clavicle  were  sutured  together,  the  wound  was  closed  and  dressed,  and  the  arm 
was  put  up  in  Sayres's  dressing. 

This  article  of  Bristow's  is  of  extreme  interest.  He  discusses  the  injury  to 
the  sympathetic  and  the  reason  that  sensation  was  preserved  over  the  area 
usually  supplied  by  the  circumflex.  After  the  performance  of  this  operation 
sensation  over  the  entire  upper  arm  returned.  We  agree  with  Bristow  that 
after  such  an  injury  early  operation  is  the  only  thing  that  offers  anv  prospect  of 
the  return  of  function.  I  myself  once  operated  upon  a  patient  that  had  devel- 
oped paralysis,  motor  and  sensory,  after  violent  stretching  of  the  arm.  In  the 
light  of  Bristow's  case,  I  assumed  that  evulsion  of  the  plexus  had  probably 
taken  place.  Incision  disclosed  the  fact  that  the  plexus  was  intact,  but  was 
surrounded  with  dense  scar-tissue.  This  tissue  was  removed,  so  as  to  loosen  the 
nerves;  but  I  have  lost  track  of  the  patient,  and  do  not  know  the  result.  My 
patient  was  operated  upon  many  months  after  the  injury.  It  is  well  to  bear 
in  mind  that  in  an  injury  of  the  supraclavicular  division  of  the  brachial  ple.xus 
there  will  probably  be  palsy  of  the  great  serratus  muscle. 

Posterior  Thoracic  Nerve. — Division  of  this  nerve  causes  paralvsis  of  the 
serratus  magnus  muscle,  which  is  made  evident  l)y  eversion  and  rotation  of  the 
scapula  when  the  arm  is  taken  forward. 

Suprascapular  Nerve. — Division  of  this  ner\e  produces  some  anesthesia 


58o 


Diseases  and  Injuries  of  Nerves 


over  the  scapula  and  paralysis  of  the  supraspinatus  and  the  infraspinatus 
muscles. 

Circumflex  Nerve. — Division  of  the  circumflex  nerve  produces  paralysis 
of  the  deltoid  muscle,  so  that  it  becomes  impossible  to  lift  the  arm  to  a  right 
angle  with  the  body.  There  is  some  slight  retention  of  power  in  the  anterior 
fibers,  which  are  supphed  by  the  anterior  thoracic  nerve.  The  skin  over  the 
lower  part  of  the  muscle  is  usually  anesthetic. 

Musculocutaneous  Nerve. — Division  of  this  nerve  produces  paralysis  of  the 
biceps  and  of  the  brachiaHs  anticus  muscles.  This  palsy  becomes  especially 
evident  when  the  forearm  is  supinated,  because  in  this  position  the  supinator 
longus  can  no  longer  act  as  a  flexor  of  the  elbow.  There  is  anesthesia  of  the 
radial  side  of  the  forearm,  anteriorly  and  posteriorly. 

The  Musculospiral  or  Radial  Nerve. — Division  of  this  nerve  high  up,  near 
the  plexus,  causes  paralysis  of  the  extensor  muscles  of  the  elbow  and  the  wrist, 
of  the  supinators,  and  of  the  long  extensors  of  the  thumb  and  fingers.   When 


Fig.  294. — Paralysis  of  musculospiral  nerve 
after  fracture  of  the  humerus  ("  wrist-drop  "); 
but  when  fingers  have  been  flexed  into  palm,  a, 
they  can  be  extended  b,  at  first  interphalangeal 
joints  by  lumbricals  and  interossei,  which  are 
supplied  by  the  ulnar  and  median  nerves 
(Erichsen). 


Fig.  295.— Distribution  of  sensory  nerves 
on  the  backs  of  the  fingers  :  r,  Musculospiral 
or  radial  nerve;  u,  ulnar  nerve;  wz,  median 
nerve  (Krause). 


divided  near  the  middle  of  the  humerus,  the  triceps  usually,  but  not  inva- 
riably, escapes.  If  the  injury  is  below  the  branch  going  to  the  supinator  longus, 
that  muscle  will  escape;  otherwise  it  will  become  paralyzed.  The  extensor 
palsy  causes  wrist-drop  and  loss  of  the  power  of  extending  the  first  phalanges 
of  the  fingers  and  thumb;  and,  as  Gowers  has  pointed  out,  flexion  is  reduced  to 
one-third  of  the  normal,  the  flexors  having  lost  power  "  from  the  loss  of  antergic 
support. "  As  a  rule,  in  musculospiral  palsy  there  is  loss  of  supination.  Sen- 
sibility is  sometimes  greatly  affected,  and  sometimes  very  slightly.  Anesthesia 
rarely  occurs  in  the  upper  arm;  and  even  in  the  hand  .sensation  may  be  normal, 
or  nearly  so.  Fig.  294  shows  the  position  of  the  parts  in  musculospiral  palsy 
and  Figs.  295  and  298  the  sensory  distribution  of  the  nerve. 

The  Median  Nerve. — After  division  of  the  median  nerve  there  is  paralysis 
of  the  pronators;  the  flexor  carpi  radialis;  the  finger  flexors,  except  the  ulnar 
portion  of  the  deep  flexor;  the  abductors,  and  the  flexors  of  the  thumb;  and 
the  two  radial  lumbricales.     The  forearm  can  be  placed  in  a  position  midway 


The  Symptoms  of  Division   of  Nerv^es 


581 


between  pronation  and  supination;  but  further  pronation  cannot  be  volun- 
tarily effected.  In  executing  flexion  of  the  wrist,  a  strong  deviation  toward  the 
ulnar  side  takes  place.  The  thumb  is  in  a  position  of  extension  and  adduction, 
and  cannot  be  brought  into  apposition  with  the  finger-tips.  The  second 
phalanges  of  the  fingers  cannot  be  flexed  on  the  first,  and  the  distal  phalanges 
of  the  first  and  second  fingers  cannot  be  voluntarily  flexed.  The  corresponding 
phalanges  of  the  third  and  fourth  fingers  can  be  flexed,  this  being  accomplished 
by  the  unparalyzed  ulnar  half  of  the  deep  fle.xor.  Flexion  of  the  first  phal- 
anges is  still  possible,  as  it  is  accomplished  by  means  of  the  interossei.  The 
extensor  action  of  the  interossei  muscle  upon  the  middle  and  distal  phalanges, 
being  unopposed,  may  eventually  cause  subluxation.  The  sensory  distribu- 
tion of  the  median  nerve  is  shown  in  Figs.  295,  296,  297,  and  298.  It  is 
the  sensory  nerve  of  the  radial  side  of  the  palm,  the  front  of  the  thumb,  the  fi^rst 


Fig.  296. — Section  of  median  nerve;  areas 
of  anesthesia  (heavy  shading)  and  of  dyses- 
thesia (light  shading)  on  palmar  surface  of 
hand  (Bovvlby). 


*  Fig.  297. — Section  of  median  nerve;  re- 
gions of  anesthesia  and  dysesthesia  on  dorsal 
surface  of  hand  (Bowlby). 


and  second  fingers  and  half  of  the  third  finger,  and  the  back  of  the  last  phalanx 
of  the  index  and  the  middle  finger  (Gowers).  The  sensory  changes  after 
median  paralysis  are  quite  variable — sometimes  widespread  and  complete,  at 
other  times  trivial,  and  occasionally  absent.  Gowers  says  that  if  there  is 
anesthesia  it  is  usually  of  the  palmar  surface,  and  may  also  occur  on  the  dorsal 
aspect  of  the  ends  of  the  first  two  fingers. 

TJie  Ulnar  Nerve. — When  the  ulnar  nerve  is  divided,  there  is  paralvsis  of 
the  flexor  carpi  ulnaris,  of  the  ulnar  portion  of  the  deep  flexor,  of  the  muscles  of 
the  httle  finger,  of  the  adductor  poUicis,  and  of  the  inner  end  of  the  flexor  brevis 
poUicis  (Gowers).  It  becomes  impossible  to  adduct  the  thumb,  and  the 
majority  of  the  movements  of  the  httle  finger  are  abolished.  Fle.xion  of  the 
fingers  is  impossible  at  the  first  joints,  and  extension  is  impossible  at  the  other 
joints;  but,  as  Gowers  points  out,  the  loss  is  slighter  in  the  first  two  fingers  than 
in  the  others,  because  the  lumbricales  of  the  first  two  fingers  are  supplied  by  the 


582 


Diseases  and  Injuries  of  Nerves 


median  nerve.  Interosseal  flexion  is  impossible;  and  the  opponents  of  the 
interossei,  acting  without  normal  antagonism,  contract  and  produce  what  is 
known  as  a  claw-hand  (Fig.  299),  a  condition  in  which  the  first  phalanges  are 
overextended  and  the  others  are  flexed.  The  sensory  loss  in  ulnar  paralysis  is 
extremely  variable.     The  sensory  distribution  is  to  the  ulnar  side  of  the  hand, 


Anterior  surface.  Posterior  surface. 

Fig.  298.— Distribution  of  the  cutaneous  nerves  to  the  shoulder,  arm,  and  hand.  The  region  of 
the  N.  radialis  is  represented  by  the  unbroken  hatched  line,  that  of  the  N.  ulnaris  by  the  broken 
hatched  lines,  a,  Anterior,  d,  posterior  surface;  sc,  Nn.  suprascapular  (plexus  cervicalis) ;  ax, 
chief  branch  of  N.  axillar.;  cps,  cpi,  Nn.  cutanei  post.  sup.  and  inf.  (from  N.  radialis)  ;  ra,  terminal 
branches  of  N.  radialis  ;  cm,  cl,  Nn.  cutanei  medius  (also  to  the  plexus)  and  lateralis  (chiefly  to  the 
N.  medianus)  ;  cp,  N.  cutan.  palmar.,  N.  rad.;  and,  N.  cuLan.  niedialis  ;  »ii',  N.  medianus  ;  ii,  N.  ul- 
naris; epu,  N.  cutan.  palm,  ulnaris  (Heide). 


both  back  and  front,  involving  the  little  finger,  the  ring-finger,  and  the  ulnar 
half  of  the  middle  finger  (Figs.  295.  298,  and  300). 

Lumbar  Plexus. — The  lumbar  plexus  supplies  the  cutaneous  surface  of  the 
lower  portion  of  the  abdomen,  of  the  front  and  the  sides  of  the  thigh,  and  of  the 
inner  portion  of  the  leg  and  foot  (Fig.  301).     It  innervates  the  flexors  and 


The  Symptoms  of  Division  of  Nerves 


583 


adductors  of  the  hip-joint,  the  extensors  of  the  knee,  and  the  cremaster 
muscle.  The  branches  sent  to  the  leg  are  the  obturator  and  the  anterior 
crural  nerves. 

Sacral  Plexus. — The  sacral  ple.xus  supplies  the  extensors  and  rotators  of  the 
hip,  the  knee-flexors,  and  all  the  muscles  of  the  foot;  also  the  skin  of  the  gluteal 
region,  the  back  of  the  thigh,  the  outer  portion  and  the  posterior  part  of  the 
lower  leg,  and  most  of  the  foot  (Gowers)  (Tig.  301).  Its  chief  branches  are 
those  to  the  external  rotators  of  the  hip — the  gluteal  nerve,  the  small  sciatic, 
and  the  great  sciatic. 

The  Anterior  Crural  Nerce. — When  this  nerve  is  divided,  the  extensor 


Fig.  299. — Paralysis  of  ulnar  nerve  from  wound  at  A ;  contracture  of  common  extensor  with  posterior 
luxation  of  first  phalanges;  B,  head  of  metacarpal  bone  (Duchenne). 


Fig.  300. — Showing  sensory  loss  and  ordinary  position  in  injuries  of  tlie  ulnar  nerve  (Bowlby). 


muscles  of  the  knee  are  paralyzed.  The  psoas  muscle  is  not  aft'ected,  even  if 
the  nerve  is  divided  within  the  abdomen;  but  high  division  may  produce 
paralysis  of  the  iliacus  muscle.  In  anterior  crural  palsy  the  skin  is  anesthetic 
over  almost  the  entire  thigh,  the  inner  surface  of  the  leg  and  foot,  and  the  inner 
sides  of  the  first  and  second  toes  (Fig.  301). 

The  Obturator  Nerve. — In  obturator  palsy  the  adductor  muscles  of  the 
thigh  are  paralyzed,  and,  in  consequence,  the  patient  is  unable  to  cross  one  leg 
over  the  other.  Gowers  points  out  that  external  rotation  of  the  thigh  is  also 
interfered  with. 

TJie  Superior  Gluteal  Nerve. — The  division  of  this  ner\e  paralvzes   the 


584 


Diseases  and   Injuries  of  Nerves 


gluteus   medius  and   the   gluteus  minimus 
abduction  and  circumduction  of  the  thigh" 
The  Small  Sciatic  iVerz'e.— Division  of 


^  \  u  \  V; 


UN-' 


\  iGi 


er 


\  ^p  \^^ 


K 


'Icpmj 


<?; 


<    i 


vieti 


peA 


Anterior  surface.  Posterior  surface. 

Fig.  301. — Di.stribution  of  the  cutaneous  nerves  of 
the  lower  extremity  :  zV,  N.  ilio-inguinal.  (plex.  lumb.) ; 
H,  N.  lumbo-inguinal.  (to  the  genitocrural,  plex.  lum- 
bal.);  sey  N.  spermat.  ext.  (to  the  genitocrural);  cp, 
N.  cutan.  post.  (plex.  ischiad.);  cl,  N.  cutan.  lateral. 
Cplex.  lumb.)  ;  cr,  N.  cruralis  (plex.  lumbal.)  ;  obt,  N. 
obturator,  (plex.  lumb.) ;  sa,  N.  saphen.  (plex.  lum- 
bal.) ;  cpe,  N.  commun.  peron.  (N.  peron.  tibial.)  ;  cii, 
N.  commun.  tibial. ;  fiey' ,  J>er" ,  N.  peronaei  ram.  su- 
perfic.  et  prof. ;  cpm,  N.  cutan.  post.  med.  (plex. 
ischiad.)  ;  cpp,  N.  cut.  plant,  propr.  (N.  tib.)  ;  pint, 
pll,  N.  plantar,  medial,  et  lateral.  (N.  tib.)  (Henle). 


cle,  and  the  muscles  of  the  plantar  surface 
flexed  at  the  two  distal  joints,  and  extended 


muscles,    and  there  is  "loss  of 
(Gowers). 

this  nerve  paralyzes  the  gluteus 
maximus  muscle,  and  produces 
anesthesia  of  the  upper  half  of 
the  calf  of  the  leg  and  of  the  mid- 
dle third  of  the  back  of  the  thigh 
(Gowers)  (Fig.  301). 

The  Great  Sciatic  Nerve. — If 
this  nerve  is  divided  near  the 
sciatic  notch  there  is  a  paralysis 
of  the  flexor  muscles  of  the  leg. 
These  muscles,  as  Gowers  points 
out,  are  also  extensors  of  the  hip. 
There  is  likewise  paralysis  of  all 
the  muscles  below  the  knee.  If, 
however,  the  injury  is  below  the 
upper  third  of  the  thigh,  there  is 
no  paralysis  of  the  flexors  of  the 
leg.  If  the  nerve  is  damaged  on 
a  level  below  the  small  sciatic, 
there  is  anesthesia  of  the  outer 
portion  of  the  leg,  of  the  sole  of 
the  foot,  and  of  most  of  the  dor- 
sum of  the  foot  (Fig.  301). 

The  External  Popliteal  Nerve. 
— When  this  nerve  is  damaged, 
there  is  paralysis  of  the  tibialis 
anticus  muscle,  the  extensor 
longus  digitorum,  the  extensor 
brevis  digitorum,  and  the  pero- 
nei;  and  the  patient  is  unable  to 
flex  the  ankle  and  extend  the  first 
phalanges  of  the  toes.  When  he 
tries  to  walk,  he  cannot  lift  the 
foot  from  the  ground;  and  event- 
ually there  is  the  development  of 
talipes  equinus  (Gowers).  The 
anesthesia  is  manifest  on  the 
outer  portion  of  the  anterior  sur- 
face of  the  leg,  and  also  on  the 
dorsum  of  the  foot  (Fig.  301). 

The  Internal  Popliteal  Nerve. 
— Damage  to  this  nerve  paralyzes 
the  posterior  tibial  muscle,  the 
flexor  longus  digitorum,  the  mus- 
cles of  the  calf,  the  pophteus  mus- 
of  the  foot.  The  toes  become 
at  the  proximal  joints.     Walking 


Pressure   upon   Nerves  585 

is  greatly  interfered  with.  There  is  loss  of  the  power  of  rotating  the  flexed  leg 
inward,  if  the  damage  is  above  the  branch  to  the  popiiteus  muscle;  and  exten- 
sion of  the  ankle-joint  is  lost.  As  the  consequence,  talipes  calcaneus  develops 
(Gowers).  The  anesthesia  is  variable,  but  usually  involves  the  sole  of  the  foot, 
and  the  outer  surface  and  lower  portion  of  the  back  of  the  leg  (Fig.  301). 

The  Plantar  Neroes. — Division  of  the  internal  plantar  nerve  paralyzes  the 
short-toe  flexor,  the  two  inner  lumbricales,  and  the  plantar  muscles  of  the  great 
toe,  except  the  adductor  (Gowers).  There  is  anesthesia  of  the  inner  portion  of 
the  sole  of  the  foot,  and  of  the  plantar  surface  of  the  three  inner  toes  and  of  half 
of  the  fourth  toe  (Fig.  301). 

Division  of  the  external  plantar  nerve  causes  paralysis  of  the  muscles  of  the 
little  toe,  of  the  adductor  of  the  great  toe,  of  all  the  interossei,  of  the  two  outer 
lumbricales,  and  of  the  flexor  accessorius  (Gowers).  There  is  anesthesia  of 
the  skin  of  the  outer  half  of  the  sole  of  the  foot,  of  the  little  toe,  and  of  half  of 
the  fourth  toe  (Fig.  301). 

Treatment. — In  all  recent  cases  of  nerve-section,  suture  the  ends  of  the 
divided  nerve.  In  123  cases  of  primary  suture,  119  were  cured  in  from  one 
day  to  one  year  (Willard) .  The  return  of  sensation  may  be  rapid  or  may  be 
slow;  muscular  power  returns  more  slowly  than  sensation.  If  the  patient 
is  not  seen  until  long  after  the  accident,  incise  and  apply  sutures  (secon- 
dary sutures) ;  if  the  nerve  cannot  be  found,  extend  the  incision,  find  the  trunk 
-■"above  and  trace  it  down,  and  find  the  trunk  below  and  follow  it  up.  In  130 
'cases  of  secondary  suture,  80  per  cent,  were  more  or  less  improved  (Willard). 
Even  after  primary  suture  loss  of  function  is  bound  to  occur  for  a  time.  After 
secondary  suture  sensation  may  return  in  a  few  days,  but  it  may  not  return 
until  after  a  much  longer  period ;  in  any  case  muscular  function  is  not  restored 
for  months.  Aiter  partial  section  of  a  nerve  the  ends  should  be  sutured.  In 
performing  secondary  suture  it  may  be  necessary  to  effect  "lengthening"  in 
order  to  approximate  the  ends.  Transplantation  of  a  portion  of  nerve  is  some- 
times practised.  Transplantation  is  bridging  the  gap  by  means  of  a  portion  of 
nerve  from  one  of  the  lower  animals  or  from  a  recently  amputated  human  limb. 
Nerve-transplantation  may  fail  utterly;  it  may  be  followed  by  great  improve- 
ment; but  absolute  and  perfect  restoration  of  function  cannot  be  obtained. 
R.  Peterson  *  has  made  a  study  of  the  20  recorded  cases  of  nerve-transplan- 
tation. Eight  of  the  operations  were  primary  and  12  were  secondary.  The 
periods  after  the  injury  at  which  operation  was  performed  varied  from  forty- 
eight  hours  to  a  year  and  a  quarter.  Four  of  the  8  primary  cases  improved. 
Eight  of  the  12  cases  of  secondary  operation  showed  improvement  in  motion 
or  sensation.  The  distance  between  the  nerves  did  not  seem  to  affect  the 
results.  No  case  recovered  completely,  but  in  one  case  sensation  returned 
completely  and  only  the  abductors  of  the  thumb  remained  weak.  In  most 
cases  benefited  sensation  returned  by  the  tenth  day  and  motion  within  two  and 
a  half  months.  In  one  of  the  successful  cases,  that  of  A.  \V.  Mayo  Rob- 
son,!  the  spinal  cord  of  a  rabbit  was  used. 

Pressure  upon  nerves  may  arise  from  callus,  scars,  a  dislocated  bone, 
a  tumor,  or  pressure  from  an  external  body. 

The  symptoms  may  be  anesthetic,  paralytic,  or  trophic. 

*  Ainer.  Jour,  of  Med.  i^ciences.  April,  1S99. 
I  Anier.  Jour,  of  Med.  Sciences,  April,  1899. 


586  Diseases  and   Injuries  of  Nerves 

The  treatment  is  as  follows:  Remove  the  cause  (reduce  a  dislocated  bone, 
chisel  away  callus,  excise  a  scar,  etc.) ;  then  employ  massage,  douches,  exer- 
cise, and  electricity. 

Dislocation  of  the  Ulnar  Nerve  at  the  Elbow. — This  condition  is 

very  rare.  It  may  occur  as  a  complication  of  a  fracture  or  a  dislocation,  or  as 
an  uncomplicated  condition.  It  may  be  produced  by  violence  or  by  muscular 
effort,  which  ruptures  the  fascia  the  function  of  which  is  to  retain  the  nerve 
back  of  the  inner  condyle  of  the  humerus.  In  some  cases  the  symptoms  are 
slight  and  transitory,  the  nerve  functionating  well  in  its  new  situation.  As  a 
rule,  there  are  pain,  numbness,  or  anesthesia  of  the  ulnar  trajectory,  some 
stiffness  of  the  elbow,  and  stiffness  of  the  little  finger  and  ring-finger.  The 
nerve  can  be  felt  in  front  of  the  inner  condyle  of  the  humerus.  In  some  cases 
neuritis  follows,  with  trophic  changes. 

Treatment. — Expose  the  nerve  by  an  incision,  incise  the  fibrous  tissue 
back  of  the  inner  condyle,  and  press  the  nerve  into  the  bed  prepared  for  it  and 
hold  it  in  place  by  sutures  of  kangaroo-tendon  passing  through  the  triceps  ten- 
don. Wharton  advises  suturing  also  "the  margin  of  the  fascial  expansion  of 
the  triceps  tendon  superficial  to  the  nerve."* 

Contusion  of  Nerves. — The  symptoms  of  contusion  of  nerves  may  be 
identical  with  those  of  section.  Sensation  or  motion,  or  both,  may  be  lost. 
The  case  may  recover  in  a  short  time,  or  the  nerve  may  degenerate  as  after 
section. 

The  treatment  at  first  is  rest,  and  later  electricity,  massage,  frictions,  and 
douches. 

Punctured  Wounds  of  Nerves.— The  symptoms  of  punctured 
wounds  of  nerves  may  be  partly  irritative  (hyperesthesia,  acute  pain,  and 
muscular  spasm)  and  partly  paralytic  (anesthesia,  muscular  wasting,  and 
paralysis) .    . 

The  treatment  after  the  puncture  has  healed  is  the  same  as  that  for  con- 
tusion. 

3.   Operations  upon  Nerves. 

Neurorrhaphy,  or  Nerve=suture. — When  a  nerve  is  completely  or 
partially  divided  by  accident,  it  should  be  sutured.  The  instruments  required 
are  an  Esmarch  apparatus,  a  scalpel,  blunt  hooks,  dissecting  forceps,  hemo- 
static forceps,  curved  needles  or  sewing  needles,  a  needle- 
holder,  and  catgut,  silk,  or  kangaroo-tendon.  In  pri- 
mary  suture  render  the  part  bloodless  and  aseptic.  En- 
—  large  the  incision  if  necessary.  If  the  ends  can  readily 
be  approximated,  pass  two  or  three  sutures  through  both 
Fig.  302.— Nerve-suture.  the  nerve  and  its  sheath  and  tie  them  (Figs.  302  and 
303).  If  the  ends  cannot  be  approximated,  stretch  each 
end  and  then  suture.  Remove  the  Esmarch  band,  arrest  bleeding,  suture  the 
wound,  dress  antiseptically,  and  put  the  part  in  a  relaxed  position  on  a 
splint.  After  union  of  the  wound  remove  the  splint  and  use  massage, 
■frictions,  electricity,  and  the  douche.  The  operation  in  some  instances  fails, 
but  in  many  cases  succeeds.     In  some  few  cases  sensation  returns  in  a  few 

•"  A  report  of  fourteen  cases  of  dislocation  of  the  ulnar  nerve  at  the  elbow,  by  H.  R. 
Wharton,  Amer.  Jour,  of  Med.  Sciences,  Oct.,  1895. 


Neurectasy,   Neurotomy,  and  Neurectomy 


587 


days,  but  in  most  cases  does  not  return  for  many  weeks  or  months.  Sensation 
is  restored  before  motor  power.  Secondary  suture  is  performed  upon  cases 
long  after  division  of  a  nerve.  The  part  is  rendered  aseptic  and  bloodless; 
an  incision  is  made;  the  bulbous  proximal  end  is  easily  found  and  loosened 
from  its  adhesions;  the  shrunken  distal  end  is  sought  for  and  loosened  (it 
may  be  necessary  to  expose  the  nerve  below  the  wound  and  trace  its  trunk 


Fig.  303. — Nerve-suture  :  a,  Direct  ;  h,  perineurotic  ;  c,  paraneurotic  ;  d,  e,  neuroplasty  (Senn). 


jT^. 


upward);  the  entire  bulb  of  the  proximal  end  is  cut  off;  about  one-quarter 
of  an  inch  of  the  distal  end  is  removed  (Keen) ;  each  end  is  stretched,  and 
the  ends  are  approximated  and  sutured  together.  If  stretching  does  not  per- 
mit of  approximation,  adopt  the  expedient  shown  in  Fig.  303,  d,or  in  Fig. 
304,  or  graft  a  bit  of  nerve  from  a  recently  amputated  limb  or  from  a  lower 
animal  (it  makes  no  difference  as  to  whether  the  grafted  nerve  were  motor, 
sensory,  or  mixed).  A.  W.  Mayo  Robson  has  suc- 
ceeded in  grafting  the  spinal  cord  of  a  rabbit  in  the 
median  nerve  of  a  man.  The  restoration  of  func- 
tion was  almost  complete.  Allis  suggested  short- 
ening the  limb  by  excising  a  piece  of  bone,  and 
the  operation  has  been  carried  out  successfully 
by  Keen,  Rose,  and  others.  Letievant  attaches 
the  cut  end  of  the  peripheral  portion  of  a  divided 
nerve   to  an   adjacent  uncut  nerve.     Assaky  uses 

the    suture  a   distance,  composed  of  catgut  passing  from  end  to  end  and 
serving  as  a  bridge  for  reparative  material  (Fig.  303). 

Neurectasy,  Neurotomy,  and  Neurectomy. — Neurectasy,  or  nerve- 
stretching,  may  be  applied  to  motor,  sensory,  or  mixed  nerves.  A  ne:ve 
can  be  stretched  about  one-twentieth  of  its  length.  Neurectasy  has  been 
employed  for  neuralgia,  neuritis,  muscular  spasm,  hyperesthesia,  anesthesia, 
painful  ulcer,  perforating  ulcer,  and  the  pains  of  locomotor  ataxia.  The 
operation,  which  was  once  the  fashion,  seems  to  benefit  some  cases,  but 
it  is  not  now  thought  so  highly  of  as  formerly.  The  incision  for  neurec- 
tasy is  identical  with  the  incisi<in  for  neurectomy  or  neurotomy  of  the  same 
nerve.  Neurotomy,  or  section  of  a  nerve,  is  only  [performed  u])on  small 
and  iHirely  sensory  nerves.     It  is  performed  chietly  t\)r  periplieral  neuralgia 


Fig.  304. — Suture  of  a  nerv-e  by 
splitting-  tlie  ends  (Beach). 


588  Diseases  and   Injuries  of  Nerves 

or  for  some  other  painful  malady.  It  is  useless,  because  sensation  soon 
returns.  Paget  saw  complete  return  of  sensation  in  four  weeks  after  division 
of  the  median  nerve.  Corning  endeavors  to  prevent  this  regeneration  by 
inserting  oil  between  the  ends.  He  uses  oil  of  theobroma  containing  enough 
paraffin  to  make  the  melting-point  105°  F.  The  oil  is  melted,  is  injected 
around  the  nerve,  and  cold  is  applied.  The  nerve  is  now  sectioned  with 
a  canaliculated  knife,  the  ends  are  separated  widely,  more  oil  is  injected, 
and  cold  is  again  applied.  The  theory  is  that  this  oil,  which  is  solid  at  the 
temperature  of  the  body,  devitalizes  the  nerve  at  the  point  of  section  and 
acts  as  a  barrier  to  the  passage  of  regenerating  fibers.  This  method  has 
been  applied  especially  in  cervicobrachial  neuralgia.*  Neurectomy,  or  ex- 
cision of  a  portion  of  a  nerve-trunk,  is  only  applicable  to  sensorv  nerves 
and  to  painful  affections. 

Sympathectomy, — Jonnesco's  Operation. — It  has  long  been  known 
that  division  of  the  sympathetic  nerve  in  the  neck  may  produce  important 
changes  in  the  eye  and  in  the  cerebral  circulation.  In  1893  Jaboulay  divided 
the  sympathetic  on  each  side,  for  the  purpose  of  treating  epilepsy.  The 
removal  of  the  ganglia  of  the  sympathetic  was  proposed  by  Baracz;  and  the 
operation  was  first  performed  by  Jonnesco,  in  i8g6,  for  epilepsy.  The 
operation  is  performed  by  some  surgeons  for  epilepsy,  for  exophthalmic 
goiter,  and  for  glaucoma.  In  operating  for  glaucoma,  the  superior  cer- 
vical ganglion  on  .each  side  is  removed,  as  it  is  from  this  that  the  sympa- 
thetic fibers  that  pass  to  the  eye  are  derived.  If  the  operation  is  done  at 
all,  it  should  be  a  bilateral  operation. 

The  operation  is  used  in  epilepsy  on  the  theory  that  there  is  an  anemic 
condition  of  the  brain  in  this  disease,  which  is  corrected  by  producing  a 
hyperemia;  and  that  the  hyperemia  improves  cerebral  nutrition.  The  opera- 
tion in  epilepsy  is  largely  theoretical,  although  Jonnesco  claims  12  per  cent, 
of  cures  in  a  large  number  of  operations.  In  exophthalmic  goiter  there 
seems  to  be  some  distinct  evidence  that  the  operation  may  be  beneficial. 
Personally,  I  have  not  employed  it  in  epilepsy;  and,  at  the  present  time, 
I  should  not  be  inclined  to  do  so.  In  exophthalmic  goiter,  if  any  operation 
is  necessary,  I  should  perform  partial  thyroidectomy ;  but  in  progressive  glau- 
coma, which  is  always  so  absolutely  hopeless,  the  operation  is  a  justifiable 
procedure  and  occasionally  seems  to  have  a  distinct  influence  in  retarding 
the  development  of  the  disease. 

The  incision  should  be  made  along  the  posterior  margin  of  the  sterno- 
cleidomastoid muscle.  I  have  become  convinced,  in  performing  two  opera- 
tions of  this  kind  and  through  studies  made  upon  the  dead  body,  that  the 
ganglion  may  be  more  easily  reached  from  behind  the  sternocleidomastoid 
than  from  in  front  of  it.  The  internal  jugular  \ein  and  the  carotid  artery 
are  lifted  upward  and  forward;  and  the  superior  ganglion  will  usually 
adhere  to  the  under  portion  of  the  carotid  sheath,  and  be  lifted  up  with  it. 
Theoretically,  it  is  not  necessary  to  open  the  carotid  sheath  in  this  operation; 
but,  practically,  this  had  better  be  done,  so  that  one  may,  without  any  possi- 
bility of  doubt,  distinguish  between  the  pneumogastric  and  the  sympathetic 
nerve.     The  moment  the  nerve  is  cut,  the  pupil  on  that  side  will  contract. 

Stretching  of  the  Sciatic  Nerve.— Some  surgeons  stretch  the  sciatic 

*  Medical  Record,  Dec.  5,  1896. 


Extracranial  Operation  for  Neuralgia  of  the  Fifth  Nerve       589 

nerve  by  anesthetizing  the  patient  and  holding  the  leg  and  thigli  in  line, 
strong  flexion  being  made  upon  the  hip,  the  entire  lower  extremity  being 
used  as  a  lever  (Keen).  This  method,  which  has  caused  death,  inflicts  need- 
less damage,  and  stretching  after  an  incision  has  been  made  is  safer  and 
better.  The  instruments  required  are  a  scalpel,  hemostatic  forceps,  dissect- 
ing forceps,  a  dissector,  retractors,  and  a  scale  with  a  handle  and  a  hook. 
The  patient  lies  prone,  the  thighs  and  legs  being  extended.  An  incision  four 
inches  in  length  is  made  a  little  external  to  the  middle  of  the  thigh,  and  going 
at  once  through  the  deep  fascia ;  the  biceps  muscle  is  found  and  is  drawn  out- 
ward ;  the  nerve  is  discovered  between  the  retracted  biceps  on  the  outside  and 
the  semitendinosus  on  the  inside,  resting  upon  the  adductor  magnus  muscle. 
The  nerve,  which  is  caught  up  by  the  finger,  is  first  pulled  down  from  the  spine 
and  then  up  from  the  periphery,  and  finally  the  hook  of  the  scale  is  inserted 
beneath  the  trunk  and  the  nerve  is  stretched  to  the  extent  of  forty  pounds. 
Very  rarely  is  even  a  single  ligature  needed.  The  wound  is  sutured  and 
dressed.  If  the  incision  is  made  at  a  higher  level  below  the  gluteofemoral 
crease,  the  sciatic  nerve  will  be  found  just  by  the  outer  border  of  the  biceps. 

Neurectomy  of  the  I nfra= orbital  .Nerve. — The  instruments  required 
in  this  operation  are  a  scalpel,  dissecting  forceps,  aneurysm  needle,  hemostatic 
forceps,  blunt  hooks,  a  dissector,  and  metal  retractors.  The  patient  Ues 
upon  his  back,  the  head  being  a  little  raised  by  pillows.  The  surgeon  stands 
to  the  outside  of  and  faces  the  patient.  A  curved  incision  one  and  a  half 
inches  long  is  made  below  the  lower  border  of  the  orbit.  The  nerve  lies  in 
a  line  dropped  from  the  supra-orbital  notch  to  between  the  two  lower  bicuspid 
teeth.  The  nerve  is  found  upon  the  levator  labii  superioris  muscle.  A 
piece  of  silk  is  passed  under  the  nerve  by  an  aneurysm  needle  and  firmly 
fastened.  The  upper  border  of  the  incision  is  drawn  upward;  the  perios- 
teum of  the  floor  of  the  orbit  is  elevated  and  held  by  a  retractor;  the  roof 
of  the  infra-orbital  canal  is  broken  through;  the  nerve  is  picked  up  far  back 
with  the  blunt  hook  and  is  divided  with  scissors,  and  the  entire  nerve  is 
drawn  out  by  making  traction  upon  the  silk.  The  bleeding  in  the  orbit  is 
checked  by  pressure.     The  wound  is  stitched  without  drainage. 

Neurectomy  of  the  Supra=orbital  Nerve. — Before  sterilizing  the 
parts  shave  oft"  the  eyebrow.  The  instruments  required  and  the  position  of 
the  patient  are  as  for  the  operation  upon  the  infra-orbital  nerve.  A  curved 
incision  one  inch  long  discloses  the  nerve  as  it  emerges  from  the  supra-orbital 
notch  or  foramen  at  the  junction  of  the  inner  and  middle  thirds  of  the  e}'e- 
brow.     The  ner\e  is  pulled  forward  and  cut  off  above  and  below. 

Neurectomy  of  the  Inferior  Dental  Nerve.— The  instruments  are 
the  same  as  for  any  other  neurectomy,  and  in  addition  a  chisel,  a  mallet,  and 
a  rongeur  forceps.  Make  a  curved  incision  around  the  angle  of  the  jaw. 
Lift  the  supra-maxillary  branch  of  the  facial  nerve  downward  (Kocher). 
Separate  the  masseter  muscle  with  a  periosteum-elevator  and  slight  touches 
with  the  knife.  Chisel  an  opening  in  the  center  of  the  ascending  ramus 
(Velpeau's  rule).  This  opening  exposes  the  beginning  of  the  dental  canal. 
If  necessary,  the  opening  may  be  enlarged  with  a  rongeur.  Pull  the  nerve 
out  with  a  hook  and  remo\-e  a  piece  from  it. 

Extracranial  Operation  for  Neuralgia  of  the  Fifth  Nerve.— The 
operation   for  removal  of  the   Gasserian   ganglion   is  dilficult,  bloody,  and 


590 


Diseases  and   Injuries  of  Nerves 


dangerous.  Removal  of  portions  of  the  pain-haunted  nerve-trunks  some- 
times cures  the  condition  and  often  amehorates  it  for  a  considerable  time. 
The  serious  operation  of  removing  the  ganglion  may  be  performed  if  pe- 
ripheral operations  fail  or  in  violent  and  intractable  cases  of  long  standing 
in  which  pain  is  felt  in  more  than  one  branch.  Removal  of  nerves  by  ordinary 
neurectomy  often  gives  comfort  for  a  few  months,  but  rarely  gives  pro- 
longed rehef.  If  we  seek  striking  benefit  by  an  extracranial  operation,  it 
must  be  thoroughly  done. 

Rose's  Method  of  Neurectomy.* — This  operation  is  a  modification  of 
the  Braun-Lossen  method  and  is  employed  when  the  second  division  of  the 
fifth  nerve  is  the  seat  of  pain.  Besides  the  instruments  laid  out  for  any  or- 
dinary operation,  the  surgeon  requires  chisels,  fine  saws,  blunt  hooks,  peri- 
osteum separators,  silver  wire  (No.  22),  and  drills.  The  infra -orbital 
nerve  is  exposed  by  an  incision,  a    ligature  is  tied  around   it,    the   roof   of 


Fig.  305. — a,  The  Eraun-Lossen  incision;  c, 
Rose's  incision  for  reaching  the  sphenomaxillary 
lossa  fRose). 


Fig.    306. — Lower    jaw    and    zygoma.       Drill- 
holes and  saw-cuts  are  shown  (Rose). 


the  infra-orbital  canal  is  opened  by  a  chisel,  and  the  nerve  is  traced  back 
as  far  as  possible.  The  wound  is  then  packed  temporarily  with  gauze. 
The  next  step  in  the  operation  is  to  open  a  way  into  the  sphenomaxillary 
fossa  (Fig.  305).  The  knife  is  inserted  slightly  below  the  external 
angular  process  of  the  frontal  bone,  is  carried  back  along  the  zygoma, 
down  in  front  of  the  ear  to  ju.st  above  the  angle  of  the  jaw,  and  then  forward 
for  two  inches.  This  flap,  which  is  composed  of  skin  and  subcutaneous 
fat  only,  is  dissected  forward,  and  Steno's  duct  and  branches  of  the  facial 
nerve  are  not  damaged.  The  flap  is  wrapped  in  gauze  and  temporarily 
stitched  to  the  .side  of  the  no.se.  The  zygoma  is  exposed  by  a  transverse 
incision.  At  the  root  of  the  zygoma  two  holes  are  drilled  one-fourth  of  an 
inch  apart  and  two  more  holes  one-fourth  of  an  inch  apart  are  drilled  through 
the  zygomatic  process  of  the  malar  line.  The  zygoma  is  then  divided  by  a 
*  See  article  by  Wm.  Rose,  Practitioner,  March,  1900. 


Remox'al   of  the   Gasserian   Gansjlion 


591 


saw  (Fig.  306).  The  posterior  saw  hne  runs  between  the  two  drill-holes  at  the 
root  of  the  zygoma.  The  anterior  cut  passes  between  the  two  anterior 
drill-holes.  The  direction  of  the  first  cut  is  directly  downward.  The  direction 
of  the  second  cut  is  downward  and  forward  from  above.  The  arch  is  freed 
and  detached  downward  and  backward.  The  e.xposed  tendon  of  the  tem- 
poral muscle  is  retracted  backward.  The  removal  of  a  little  fat  exposes 
the  pterygoma.xillary  fossa.  The  internal  maxillary  arterv  is  exposed,  two 
ligatures  are  apphed,  and  the  vessel  is  divided  between  them.  The  finger 
feels  for  the  sphenomaxillary  and  pterygomaxillary  fissures.  The  external 
pterygoid  muscle  is  separated  from  the  greater  wing  of  the  sphenoid  and  from 
the  root  of  the  external  pterygoid  process.  On  the  edge  of  the  greater  wing 
of  the  sphenoid  a  long  prominence 
is  usually  detectable.  It  overhengs 
the  sphenomaxillary  fossa  and  should 
be  cut  away  by  the  use  of  a  chisel. 
The  superior  maxillary  nerve  is  lifted 
on  a  blunt  hook,  is  grasped  with  for- 
ceps, and  is  twisted  off  as  near  the 
ganglion  as  possible  (Fig.  307).  The 
distal  end  is  drawn  upon  and  the  nerve, 
having  been  previously  loosened,  is 
drawn  back  through  the  infra-orbital 
canal.  The  zygomatic  arch  is  wired 
in  place,  the  temporal  fascia  is  sutured 
with  buried  sutures,  and  the  skin- 
wound  is  closed.  If  the  pain  involved 
not  only  the  second  division,  but  also 
the  third  division,  the  operation  pre- 
viously described  should  be  performed 
first,  and  the  third  division  should  be 
attacked  a  few  weeks  later.  The  third 
division  is  reached  by  removing  the 
coronoid  process.  The  inferior  dental 
and  lingual  nerves  are  found,  and  are 
traced  up  to  the  foramen  ovale,  and 
are  twisted  off  close  to  the  ganglion,  and  the  distal  portions  are  removed. 

Removal  of  the  Gasserian  Ganglion.— This  operation  is  dangerous, 
bloody,  and  difticult,  and  is  only  undertaken  in  very  severe  cases  of  tic  dou- 
loureux, and  in  cases  upon  which  less  grave  procedures  ha\e  failed.  The 
operation  usually  cures  the  pain  if  the  patient  recovers  from  the  actual  pro- 
cedure. The  mortality  is  from  10  to  15  per  cent.  Carson  collected  100 
cases,  Murphy  and  Xeft'  42  cases.  The  mortality  in  this  group  of  142  cases 
was  15  per  cent.  Most  of  the  cases  reported  In-  Murphv  and  Xeft'  were 
operated  upon  during  or  after  1S99,  and  in  this  group  the  mortality  was 
10  per  cent.  (''Progressive  Medicine,"  March,  1903).  In  Lexer's  series  of 
201  cases,  referred  to  below,  the  mortality  was  17  per  cent.  In  manv  cases 
a  perfect  cure  is  obtained.  In  some  few  the  pain  returns  upon  the  side 
operated  upon.  Occasionally  it  arises  on  the  side  not  operated  upon.  In 
some  cases  ulceration  of  the  cornea  follows  operation.     Such  ulceration  may 


Fi^.  307. — (7.  The  zygomatic  arch,  turned 
down  alter  sawing ;  b,  tendon  of  the  temporal 
muscle  retracted  ;  r,  superior  maxillary  nerve 
and  Meckel's  ganglion  ;  d,  infra-orbital  ner\-e 

emerging    from   canal ;    t',   internal    maxillary 
arterv. 


592 


Diseases  and  Injuries  of  Nerves 


be  trivial,  may  result  in  opacity,  or  may  destroy  the  eye.  Paralysis  of  the 
abducens  occurs  in  some  cases.  The  hemorrhage  may  be  so  profuse  as  to 
require  packing  of  the  wound  and  suspension  of  the  operation  for  a  few 
days.  Lexer  ("Arch.  f.  khn.  Chir.,"  Bd.  Ixv,  H.  4)  gives  a  table  of  201  cases. 
Of  the  survivors,  93.4  per  cent,  were  apparently  cured.  In  two-thirds  of 
the  cases  the  trouble  was  right-sided.  In  10  the  operation  was  temporarily 
abandoned  because  of  hemorrhage.  The  experience  of  surgeons  in  general 
is  that  after  the  removal  of  the  ganglion  there  is  apt  to  be  some  atrophy  of 
the   tongue   and   the   eye   usually   becomes   insensitive   and   watery. 

The  Hartley  Operation  for  Removal  of  the  Gasserian  Ganglion, — 
This  operation  was  first  performed  by  Hartley  in  i8gi,  five  months  before 
Krause  performed  it.  The  .surgeon  is  provided  with  the  instruments  for 
osteoplastic  resection  of  the  skull.  Krause  and  others  employ  a  surgical 
engine.  Special  retractors, 
various  hooks,  scalpels,  a 
dry  dissector,  dissecting 
and     hemostatic     forceps, 

and   an  electric  forehead-  ^^  .  v    -  ™ 

light  are  required.     Long  §/  \      -~  Ik 

strips   of    gauze    must  be 


Fig.  308. — Hartley's  osteoplas- 
tic flap  in  removal  of  Gasserian 
ganglion  (Tiffany). 


Fig  309 — Removal  of  Gasseuan  ganglion:  «,  Middle 
menmgeal  artery,  il,  ophthalmiL  du  isioii  ;  ili,  submaxillary 
division;   G,  ganglion  (Krause). 


ready  for  packing  in  case  of  hemorrhage.  The  patient  is  placed  recumbent, 
with  head  turned  to  the  opposite  side.  The  application  of  a  provisional  liga- 
ture or  clamp  to  the  external  carotid  artery  is  advocated  by  some,  but  this  step 
will  not  control  the  venous  bleeding,  which  is  the  most  harassing  hemorrhage 
encountered.  A  large  osteoplastic  flap  is  formed  in  front  of  the  ear  (Fig.  308), 
and  is  broken  out.  Hemorrhage  is  arrested.  It  may  be  found  that  the  menin- 
geal artery  has  been  ruptured.  If  this  accident  has  happened,  and  the  vessel 
lies  in  a  bony  canal,  plug  with  Horsley's  wax.  If  the  vessel  is  bleeding  upon  the 
dura,  ligate  by  pa.ssing  suture-ligatures  around  it.  If  it  is  torn  off  at  the  fora- 
men spino.sum,  pack  with  iodoform  gauze,  and  postpone  the  conclusion  of  the 
operation  for  forty-eight  hours.  It  may  be  neces.sary  at  any  stage  of  this 
formidable  operation  to  pack  the  wound  and  postpone  completion  for  two 


Abbe's  Operation   of  Intracranial   Xeurectomx'  593 

days.  Some  surgeons  (Krause,  Bergmann)  ligate  the  meningeal  artery  as 
a  routine  procedure;  but  this  operation  is  often  difficult  and  requires  much 
time.  If  the  unligated  vessel  is  divided,  the  hemorrhage  can  be  arrested 
by  gauze  packing  or  by  plugging  the  foramen  spinosum.  The  head  and 
body  of  the  patient  should  now  be  elevated.  This  allows  the  brain  to  drop 
posteriorly  and  renders  forcible  retraction  unnecessary,  and,  further,  it  lessens 
venous  bleeding  (Lexer).  The  next  step  is  to  Hft  up  the  dura  and  with 
it  the  brain  (Fig.  309).  Find  the  inferior  maxillary  nerve  and  clamp  it  with 
hemostatic  forceps.  Find  the  superior  maxillary  nerve  and  clamp  it.  Loosen 
the  nerve  from  their  beds  with  a  dry  dissector.  Twist  the  clamp-forceps 
so  as  to  reel  up  the  nerves.  This  pulls  out  the  ganglion  intact  with  the 
motor  root  and  the  root  of  origin,  as  far  back  as  the  pons  (Krause's  method). 
Arrest  bleeding;  close  the  flap;  sew  the  lids  of  the  affected  side  together; 
and  cover  the  eye  with  a  watch-crystal. 

Gushing  has  modified  the  Hartley  operation  so  as  to  permit  of  extra- 
dural manipulation  below  the  arch  made  by  the  middle  meningeal  artery 
and  thus  lessen  the  danger  of  laceration  of  the  artery  ("Jour.  Amer.  Med. 
As.soc.,"  April  28,  1900).  He  trephines  the  wall  of  the  temporal  fossa  very 
low  down,  opens  into  the  skull  below  the  arch  of  the  meningeal  vessels, 
and  thus  avoids  the  meningeal  at  the  foramen  spinosum  of  the  sphenoid 
bone  and  the  sulcus  arteriosus  of  the  parietal  bone. 

Horsley's  Intradural  Method. — An  opening  is  made  into  the  middle 
fossa  of  the  .skull,  the  dura  is  opened,  and  the  ganghon  is  found  and  removed. 
This  operation  is  easier  than  the  extradural  method,  but  is  believed  to  be 
more  dangerous. 

The  Frazier=SpilIer  Operation  of  Intracranial  Neurotomy  of 
the  Sensory  Root  of  the  Trigeminus.— If  experience  shows  that  after 

division  of  the  sensory  root  the  nerve  does  not  regenerate,  and  it  seems  prob- 
able that  it  does  not,  the  operation  must  be  regarded  as  a  valuable  addition 
to  our  resources.  In  this  operation  the  zygoma  is  temporarily  resected. 
The  temporal  fossa  is  exposed,  the  bony  wall  is  trephined,  and  the  trephine 
opening  is  enlarged  by  the  use  of  a  rongeur.  The  dura  is  separated  and 
the  ganglion  and  its  sensory  root  exposed.  The  dural  envelope  of  the 
ganglion  is  opened,  is  separated,  and  the  sensory  root  is  exposed.  The 
sensory  root  is  then  picked  up  on  a  blunt  hook  and  divided.  It  is  fre- 
quently possible,  Frazier  tells  us,  to  separate  the  sensory  root  from  the 
motor  root. 

Abbe's  Operation  of  Intracranial  Neurectomy.— Ligate  the  exter 
nal  carotid  artery  of  the  diseased  side,  make  a  vertical  incision  over  the  middle 
of  the  zygoma  down  to  the  bone.  An  opening  into  the  skull  is  made  by  a 
mallet  and  gouge,  and  this  opening  is  enlarged  bv  a  rongeur  until  it  is  one 
and  one-half  inches  in  diameter.  The  dura  is  lifted  from  the  middle  fossa 
and  the  nerves  are  exposed.  Each  nerve-trunk  is  clamped,  is  divided  near  its 
foramen  of  exit,  and  is  separated  from  the  ganglion  by  cutting  or  by  twisting 
with  the  forceps.  A  strip  of  sterile  rubber  tissue,  one  and  one-half  inches  in 
length  and  three-fourths  of  an  inch  in  width,  is  laid  over  the  round  foramen 
and  the  oval  foramen  and  is  pressed  into  place  by  gauze.  In  a  few 
moments  the  gauze  is  withdrawn  and  the  ganglion  is  allowed  to  descend 
upon  the  rubber  tissue.      The  wound  is  then  closed.     (See  Robt.  Abbe,  in 


594  Diseases  and   Injuries  of  Nerves 

•'Annals  of  Surgery,"  Jan.,  1903.)     The  rubber  tissue  is  used  to  block  the 
foramina  of  exit  and  prevent  future  emergence  of  regenerating  nerves. 

Operation  for  Facial  Paralysis  of  Extracerebral  Origin  (Facio= 
accessory  Anastomosis  and  Faciohypoglossal  Anastomosis).— Op- 
eration for  this  condition  was  first  performed  in  1S95.  (See  "Remarks  on  the 
Operative  Treatment  of  Facial  Palsy  of  Peripheral  Origin,"  by  Chas.  A. 
Ballance.  Hamilton  A.  Ballance,  and  Purves  Stewart,  "Brit.  Med.  Jour.," 
Mav  2.  1903;  and  also  the  "Surgical  Treatment  of  Facial  Paralysis  by 
Ner\'e  Anastomosis,"  by  Harvey  Gushing,  "x\nnals  of  Surgery,"  May, 
1903.)  The  procedure  first  employed  by  Ballance  was.  after  noting  by 
galvanism  that  muscular  fiber  still  remained,  to  expose  the  facial  nerve  at 
its  point  of  exit  from  the  stylomastoid  foramen,  to  cut  the  nerve-trunk  across 
as  high  up  as  possible,  to  expose  the  spinal  accessory,  and  to  suture  the 
distal  end  of  the  facial  into  the  trunk  of  the  spinal  accessory.  The  spinal 
accessory  was  half  cut  through  to  make  a  bed  for  the  end  of  the  facial.  The 
paper  above  referred  now  recommends  end-to-side  anastomosis  between  the 
divided  facial  and  the  hypoglossal.  The  authors  have  operated  five  times 
for  facial  palsy,  and  Faure,  Kennedy,  Gushing,  and  Keen  have  done  similar 
operations.  The  conclusions  of  the  Ballances  and  Stewart  are  as  follows 
("Brit.  Med.  Jour.,"  May  2,  1903): 

"  I.  Peripheral  facial  palsy  is  remediable  by  facio-accessory  anastomosis, 
but  the  extent  of  recovery  appears  to  be  limited  to  associated  movements 
in  conjunction  with  the  shoulder.  In  most  cases  the  previous  deformity 
disappears  when  the  face  is  at  rest. 

"  2.  For  reasons  above  stated  we  would  in  future  recommend  faciohypo- 
glossal anastomosis  rather  than  facio-accessory. 

"3.  The  cases  most  suitable  for  operation  are  those  in  which  the  paralysis 
has  lasted  so  long  that  no  recovery  is  to  be  expected — say,  facial  palsy  lasting 
six  months  without  any  sign  of  recovery.  In  our  opinion  the  sooner  the 
operation  is  done  after  this  date,  the  better. 

"4.  A  suppurative  causal  condition  producing  an  infective  neuritis  renders 
the  prognosis  after  operative  treatment  less  favorable  than  in  cases  due  to 
trauma. " 


Diseases  of  the   Head 


595 


XXni.    DISEASES    AND    INJURIES  OF    THE    HEAD. 

I.  Diseases  of  the  Head. 

In  approaching  a  case  of  brain  disorder,  first  endeavor  to  locate  the  seat 
of  the  trouble;  next,  ascertain  the  nature  of  the  lesion;  and,  finally,  deter- 
mine the  best  plan  of  treatment,  operative  or  otherwise.  In  all  operations 
upon  the  brain  the  surgeon  must  be  able  to  determine  accurately  the  situations 
of  certain  fissures  and  convolutions,  the 
finding  of  the  situations  of  these  convolu- 
tions and  fissures  comprising  the  science 
of  craniocerebral  topography. 

The  regional  terms  used  in  craniocere- 
bral topography  are  derived  from  Broca 
(Fig.  311).  The  middle  meningeal  artery 
is  found  at  the  pterion,  one  and  one- 
quarter  inches  posterior  to  the  external 
angular  process,  on  a  level  with  the  roof 
of  the  orbit  (Fig.  310).  The  fissures  and 
convolutions  of  the  brain  are  shown  in 
Figs.  312-314.  The  fissure  0}  Bichat  is 
marked  by  a  line  on  each  side  drawn  from 
the  inion  to  the  external  auditory  process. 

A  line  from  the  glabella  to  the  inion  overlies  the  median   fissure  and  the 
superior  longitudinal  sinus.     The  fissure  oj  Rolando  is  very  important,  as 


Fig.  310. — The  meningeal   artery  exposed 
by  trephining  (after  Esmarch). 


Fig.  311. — Skull,  showing  the  points  named  by  Broca:  As,  Asterion  (junction  of  the  occipital, 
parietal,  and  temporal  bones)  ;  basion,  middle  of  anterior  wall  of  foramen  magnum  ;  i>,  bregma  ijunc- 
tion  of  the  sagittal  and  coronal  sutures') ;  G.  ophyron  (on  a  level  with  the  superior  border  of  the  eye- 
brows, and  corresponding  nearly  to  the  glabella,  the  smooth  swelling  between  the  eyebrows )  ;  ^.  gonion 
(angle  of  the  lower  jaw)  ;  /,  inion  (external  occipital  protuberance)  ;  L,  lambda  ( junction  of  sagittal 
and  lambdoidal  sutures);  JV,  nasion  (junction  of  the  nasal  and  frontal);  Ob,  obelion  (the  sagittal 
between  the  parietal  foramina) ;  P,  pterion  (point  of  junction  of  great  wingof  sphenoid  and  the  frontal, 
parietal,  and  squamous  bones.  This  may  be  H-shaped  or  K-shaped  or  "  retourne,"  in  which  the 
frontal  and  temporal  just  touch)  ;  S,  stephanion  (or,  better,  the  superior  stephanion,  intersection  of 
ridge  for  temporal  fascia  and  coronal  suture) ;  S',  inferior  stephanion  (intersection  of  ridge  for  tem- 
poral muscle  and  coronal  suture). 


marking  the  motor  region  of  the  brain.  It  begins  near  the  median  line,  half 
an  inch  posterior  to  the  middle  of  the  distance  between  the  inion  and  glabella 
(Keen).     This  fissure  runs  downward  and  forward   at  an   angle  of  67.5° 


596 


Diseases  and    Injuries   of  the   Head 


Fig.  312.— View  of  the  brain  from  above  (Ecker). 


for  a  distance  of  three  and  three-eighths  inches.     Chiene  finds  the  fissure 

of  Rolando  by  the  following  method:  He  takes  a  square  piece  of  paper  and 

folds  it  into  a  triangle  (Fig  316,  i);  the  angle  b  A  c  of  this  triangle  is  45°; 

the  edge  d  a  is  folded  back  on  the 
dotted  line  a  e;  the  angle  d  a  e 
equals  half  of  45°,  or  22.5°,  and  the 
angle  c  A  e  equals  the  same  (Fig. 
316,  2) ;  unfold  the  paper  in  the  line 
c  a;  in  the  figure  thus  formed  b  a  c 
=  45°  and  E  A  c  =  22.5°;  E  A  B  = 
67.5°,  which  is  the  angle  desired. 
Place  the  point  X  in  the  mid-line  of 
the  head,  over  the  point  of  origin  of 
the  Rolandic  fissure ;  the  side  a  b  is 
laid  along  the  middle  line  of  the 
head,  and  the  line  A  e  corresponds 
to  the  fissure  of  Rolando.*  Fig. 
315  shows  Chiene's  scheme  for 
locating  various  points  upon  the 
brain.  Horsley  determines  the  situ- 
ation of  the  Rolandic  fissure  by  the 
use  of  his  metal  cyrtometer  (Fig. 
317).  He  places  the  point  marked 
zero  over  the  inioglabellar  line  and 
midway  between  the  inion  and  the 

glabella.     To  find  the  fissure  oj  Sylvius  (Fig.  313,  S,  s',  s"),  draw  a  line  from 

the  external  angular  process  to  the  occipital  protuberance.     The  fissure  of 

Sylvius  begins  on  this  line  one 

and  one-eighth  inches  behind  f 

the  external  angular  process; 

the  main  branch  of  the  fissure 

runs  toward  the  parietal  emi- 
nence; the  ascending  branch 

of  the  fissure  corresponds  to 

the  squamososphenoidal  su- 
ture, and  continues  uj^ward  in 

the   same   line   half   an   inch 

above  the  suture.     The  pre- 

central   sulcus    (Fig.    313,   f) 

limits  anteriorly  the  ascending 

frontal    convolution;    it   runs 

parallel  with  and  just  behind 

the     coronal     suture,    and    a 

finger's   breadth    in    front   of 

the  fissure  of  Rolando.     The 

inlraparielal  fissure  (Figs.  312, 

313,  ip)  limits  the  motor  region  posteriorly.     It  begins  opposite  the  junction  of 

the  lower  and  middle  thirds  of  the  fissure  of  Rolando,  passes  upward  in  a  line 
*  "  American  Text-l)(jok  of  Surgery." 


Fig.  313.— Outer  surface  of  the  left  hemisphere  of  the  brain 
(Ecker). 


Diseases  of  the   Head 


597 


Fig-.  314.— Inner  surface  of  the  right  hemisphere  of  the  brain  (Ecker). 


Fig.  315.— Chiene's  lines  for  localizing  brain-areas:  M  d  c  A,  Rolandic  or  motor  area;  A,  anterior 
branch  of  middle  meningeal  and  bifurcation  of  fissure  of  Sylvius ;  a  c,  horizontal  part  of  Sylvian 
fissure ;  the  highest  part  of  the  lateral  sinus  touches  p  s  at  r  ;  m  a,  precentral  sulcus  ;  i,  beginning  of 
superior  frontal  sulcus  ,  m  b  c,  contains  the  supramarginal  convolution  ;  b,  angular  gyrus. 


^,,.-''''^- 

^ 

^^.^"^'^^  '"\  /^ 

is-----. 

/ 

/ 

' 

/ 

Fig.  316.— Chiene's  method  of  fixing  position  of  Rolandic  fissure  ("  American  Text-book  of 

Sureerv  "). 


598 


Diseases  and   Injuries  of  the   Head 


parallel  with  the  longitudinal  fissure  and  midway  between  the  Rolandic  fissure 
and  the  parietal  eminence,  passes  by  the  parieto-occipital  fissure,  and  down- 
ward and  backward  into  the  occipital  lobe.     The  motor  areas,  which  on  the 


Fig.  317. — Horsley's  cyrtometer. 


outer  surface  are  adjacent  to  the  fissure  of  Rolando,  are  shown  in  Figs.  312  and 
3 13.  The  superior  longitudinal  sinus  is  overlaid  by  a  line  from  the  inion  to  the 
glabella.     The  lateral  sinus  is  indicated  by  a  line  running  from  the  occipital 

protuberance  horizontally  outward  to  a  point 
one  inch  posteriorly  to  the  external  auditory 
meatus,  and  from  this  point  by  a  second  Hne 
dropped  to  the  mastoid  process.  The  supra- 
meatal  triangle  of  Macewen  is  bounded  by 
the  posterior  root  of  the  zygoma,  the  posterior 
bony  wall  of  the  auditory  meatus,  and  a  hne 
joining  the  two.  The  mastoid  antrum  is 
opened  through  Macezven^s  triangle  to  avoid 
injury  to  the  lateral  sinus.  Barker's  point 
the  proper  spot  to  apply  the  trephine  in  ab- 
scess of  the  temporosphenoidal  lobe,  is  one 
and  one-fourth  inches  above  and  one  and  one- 
fourth  inches  behind  the  middle  of  the  external 
auditory  meatus.  Fig.  318  shows  clearly  the 
main  points  of  craniocerebral  topography,  ob- 
tained by  methods  approved  by  many  scien- 
tists. 

Kronlein's    method    of    localizing    certain 
points  is  the  most  generally  serviceable.     (See 
Fig.  319.)     A  line,  known  as  the  base  line, 
z  M,  is  carried  horizontally  backward  from  the 
lower  border  of  the  orbit  through  the  Upper 
border  of  the  external  auditory  meatus.     An- 
other horizontal   line,  K  k',  is  drawn  parallel 
with   this,   on   a   level   with   the   supra-orbital 
ridge.     A  line  z  k  is  erected  from  the   middle 
of  the  zygoma   to  the  supra-orbital   line.     A   vertical  line  is  drawn  from  the 
artic  ulation  of  the   lower  jaw,   A,  and  is  prolonged   to  R.     A  vertical  line  is 
drawn  from  the  posterior  border  of  the  mastcjid  base  (m  k')  and  is  taken  to  P, 


Fig.  318.  —  Head,  skull,  and 
cerebral  fissures :  B  corresponds  to 
Broca's  convolution  ;  EAP,  external 
angular  process  ;  FR,  fissure  of  Ro- 
lando ;  IF,  inferior  frontal  sulcus; 
IPI",  intraparietal  sulcus;  MMA, 
middle  meningeal  artery  ;  OPr,  oc- 
cipital protuberance;  PE,  parietal 
eminence ;  PCJF",  parieto-occipital 
fissure;  SF,  Sylvian  fissure;  A,  its 
ascending  limb  ;  TS,  tip  of  temporo- 
sphenoidal lobe.  The  pterion  (to 
the  left  of  B)  is  the  region  where 
three  sutures  meet,  viz..  those  bound- 
ing the  great  wing  of  the  sphenoiil 
where  it  joins  the  frontal,  parietal, 
and  temporal  bones  (adapted  from 
Marshall  l.v  [fare). 


Diseases  of  the  Scalp 


599 


the  middle  line  of  the  skull.  A  line  is  drawn  from  K  to  p,  and  between  the 
points  R  and  p'  it  overlies  the  fissure  of  Rolando.  The  angle  of  P  K  k'  is 
bisected  by  the  line  k  s,  which  corresponds  to  the  fissure  of  Sylvius  from  its 
point  of  bifurcation  to  its  posterior  termination.  K  marks  the  bifurcation  of 
the  fissure  of  Sylvius.  To  reach  the  anterior  branch  of  the  middle  meningeal 
artery  trephine  at  k;  to  reach  the  posterior  branch,  trephine  at  k'. 


Supra-orbital  line  {upper  horizontal  )     JCA,,^^ 


Auriculo-orbital  line  {loiver  horizontal) 


M 


Fig.  319. — Kronlein's  method  of  locating  the  fissures  of  Rol.ando  {RP")  and  of  Sylvius  (A'S); 
Kronlein's  points  of  trephining  for  hemorrhage  from  the  middle  meningeal  (A'A'');  and  von  Berg- 
mann's  region  for  trephining  for  abscess  of  the  temporosphenoidal  lobes  {AaK''M)  ("American 
Text-book  of  Surgery"). 


Diseases  of  the  Scalp. — The  scalp  is  composed  of  skin,  subcutaneous 
fat,  and  the  occipitofrontalis  muscle  and  aponeurosis.  The  scalp  is  liable 
to  inflammation  from  various  causes,  and  also  to  other  diseases — namely, 
tumors,  cysts,  warts,  moles  (local  cutaneous  hypertrophies),  cirsoid  aneurvsm 
(page  306),  nevi,  and  lupus.  Abscesses  oj  the  scalp  are  common.  If  an 
abscess  forms  beneath  the  pericranium,  the  pus  diffuses  over  the  area  of 
one  bone,  being  limited  by  the  attachment  of  the  pericranium  in  the  sutures. 


6oo  Diseases  and   Injuries   of  the   Head 

If  an  abscess  forms  in  the  tissue  between  the  occipitofrontalis  and  the  peri- 
cranium, it  is  widely  diffused.  Treves  calls  this  subaponeurotic  connective 
tissue  "the  dangerous  area."  Abscess  of  the  subcutaneous  tissue  is  apt  to 
be  limited  because  of  the  great  amount  of  fibrous  tissue.  Abscess  is  treated 
bv  instant  incision  at  the  most  dependent  part,  and  drainage. 

Diseases  and  Malformations  of  the  Bones  of  the  Skull.— The 

bones  of  the  skull  are  liable  to  caries,  necrosis,  osteitis,  periostitis,  atrophy, 
hypertrophy,  tumors,  etc.  (see  Diseases  of  Bones). 

Microcephalus. — By  microcephalus  is  meant  unnatural  smallness  of 
the  head  due  to  imperfect  development.  Marked  microcephalus  is  not  a 
common  condition,  but  it  is  an  occasional  cause  or  associate  of  idiocy.  A 
child  may  be  born  with  a  skull  completely  ossified  even  at  the  fontanelles, 
or  the  ossification  may  become  complete  soon  after  birth,  but  in  many  cases 
of  microcephalus  ossification  takes  place  late  or  not  at  all.  In  microcephalus 
the  face  is  usually  fairly  well  developed;  the  jaws  are  prominent;  the  fore- 
head is  flat;  the  cranium  and  brain  are  small;  the  convolutions  of  the  brain 
are  simpler  than  is  natural;  there  is  apt  to  be  marked  asymmetry  of  the 
two  sides  of  the  brain;  internal  hydrocephalus  may  exist;  areas  of  sclerosis 
and  atroph}'  are  common;  porencephaly  is  not  unusual.  Some  patients  have 
perfect  motor  power;  others  are  slow  and  inco-ordinate.  Epilepsy,  chorea, 
and  athetosis  frequently  complicate  the  case.  Idiots  of  this  type  often  pre- 
sent deformities  such  as  cleft  palate,  strabismus,  distorted  ears,  hypertrophied 
tongue,  deformed  genitals  or  e.xtremities,  ill-shaped  and  irregularly  developed 
teeth.  They  e.xhibit  irregular  muscular  movements,  are  frequently  paralyzed 
in  childhood  (infantile  paraplegia  or  hemiplegia),  and  suffer  from  subsequent 
contractures.  They  are  active,  destructive,  excitable,  and  are  liable  to  be 
violent  and  almost  demoniacal.  As  Clouston  says,  they  look  impish  and 
unearthly. 

Treatment. — Skilled  training  in  a  school  for  the  feeble-minded  or  in 
an  institution  for  idiots  is  necessary  in  treating  microcephalus.  Idiots  have 
but  little  power  of  attention,  and  sensory  impressions  give  rise  to  but  few 
concepts,  and  these  are  feeble  and  fleeting.  In  order  to  educate  the  idiot 
it  is  highly  desirable  that  speech  be  acquired,  and  "  the  more  strongly  the 
attention  can  be  aroused,  the  more  perfect  does  speech  become"  (Kirchhoff). 
The  principle  of  the  education  of  idiots  is  to  stimulate,  co-ordinate,  and 
guide  sight,  hearing,  and  feeling. 

Lannelongue,  of  Paris,  has  suggested  an  operation  in  cases  of  idiocy 
with  premature  ossification  (see  Linear  Craniotomy,  page  634).  In  this  pro- 
cedure the  author  has  no  confidence.  Idiocy  is  a  general  disorder  and  not 
a  local  brain  disease.  Soft  parts  mould  bone,  and  bone  does  not  mould 
soft  parts.  There  is  no  evidence  that  the  brain  is  being  compressed;  in 
fact,  the  sim[)licity  of  the  convolutions  suggests  the  contrary.  In  many 
typical  cases  of  microcephalic  idiocy  there  is  no  synostosis  even  years  after 
Ijirth.  The  operation  has  been  much  abused.  It  is  sometimes  fatal,  and, 
althcjugh  a  fatality  may  gratify  the  family,  a  surgeon  is  not  a  legal  execu- 
tioner. The  remarkable  improvement  which  has  been  reported  in  some 
cases  results  probably  from  misconception;  the  new  surroundings,  the  strange 
faces,  the  firm  discipline,  the  effect  of  the  anesthetic,  and  the  shock  of  the 
operation  attract  the  feeble  attention  and  rf)use  the  sluggish  senses.     Many 


Spurious   Meningocele  6oi 

cases  are  brought  for  operation  because  they  are  for  the  time  being  unusually 
intractable  and  excitable,  and  the  return  to  the  usual  level  of  conduct  after 
operation  is  regarded  as  a  permanent  gain  when  it  is  often  but  a  temporary 
alleviation.  We  believe  that  scientific  training  is  the  proper  treatment, 
and  that  the  efficiency  of  training  is  not  increased  by  the  previous  perform- 
ance of  craniotomy,  and  we  follow  the  precept  of  Agnew,  that  a  surgeon 
might  as  well  cut  a  piece  out  of  a  turtle's  back  to  make  a  turtle  grow  as  to 
cut  a  piece  out  of  the  skull  to  make  the  brain  grow. 

Diseases  and  Malformations  Involving  the  Brain. — Meningocele 
is  a  congenital  protrusion  of  the  cerebral  membranes  through  a  bony  aper- 
ture, the  sac  containing  some  extracerebral  fluid.  Meningocele  feels  and 
looks  like  a  cyst  (is  translucent  and  fluctuates) ;  it  does  not  usually  pulsate, 
it  has  a  small  base,  it  becomes  tense  on  forcible  expiration,  and  it  may  be 
reduced  by  compression. 

Encephalocele  is  a  congenital  protrusion  not  only  of  membranes,  but 
also  of  a  portion  of  the  brain  as  well,  the  sac  containing  some  extracerebral 
fluid.  Encephalocele  is  small,  opaque,  does  not  fluctuate,  has  a  broad  base, 
does  pulsate,  becomes  tense  on  forced  expiration,  and  attempts  at  reduction 
cause  pressure-symptoms. 

Hydrencephalocele  is  a  congenital  protrusion  of  membranes  and  brain- 
substance,  the  interior  of  the  mass  communicating  with  the  ventricles  and 
containing  ventricular  fluid.  This  is  the  most  frequent  and  the  most  dan- 
gerous form.  Hydrencephalocele  is  larger  than  a  meningocele,  is  translucent, 
fluctuates,  rarely  pulsates,  is  pedunculated,  is  rendered  a  little  tense  on  forced 
expiration,  and  cannot  be  reduced.* 

Treatment. — For  hydrencephalocele  nothing  can  be  done,  and  early  death 
is  inevitable.  In  rare  instances  an  encephalocele  is  converted  into  a  meningo- 
cele, and  the  bony  aperture  closes,  thus  bringing  about  a  cure.  Among 
the  expedients  for  treating  meningocele  and  encephalocele  are  electrolysis, 
injection  of  Morton's  fluid  (gr.  x  of  iodin,  gr.  xxx  of  iodid  of  potassium, 
5j  of  glycerin),  pressure  and  excision.  In  cases  of  meningocele,  when  por- 
tions of  the  nerve-centers  are  not  contained  in  the  sac,  A.  W.  Mavo  Robson 
advises  the  performance  of  a  plastic  operation.  He  hgates  the  neck  of  the 
sac,  excises  the  sac,  sutures  the  skin-flaps  separately,  and  leaves  the  stump 
outside  the  line  of  superficial  sutures.  It  is  usually  possible  to  tell  by  pal- 
pation if  nerve-centers  are  in  the  sac,  but  if  in  doubt,  make  an  exploratory 
incision,  and  sweep  the  finger  around  inside  of  the  sac.f 

Spurious  Meningocele  (the  Puffy  Tumor  of  Pott). — It  occasionally 
happens,  after  a  fracture  of  a  child's  skull,  that  cerebrospinal  fluid  gathers 
beneath  the  pericranium  and  bulges  the  pericranium  and  scalp.  When  a 
spurious  meningocele  forms,  the  bone  must  have  been  broken  and  the  dura 
and  arachnoid  ruptured.  This  protrusion  fluctuates,  pulsates,  and  is  influ- 
enced by  respiration.  In  some  cases  there  is  communication  with  the  ven- 
tricles of  the  brain.  The  parietal  and  frontal  regions  are  the  most  usual 
seats  of  the  trouble.  The  opening  in  the  skull  may  close;  it  may  remain 
stationary;  it  may  actually  enlarge  by  bone-absorption.  In  some  cases  the 
spurious  meningocele  undergoes  spontaneous  cure;  in   some  cases  rupture 

*  "  American  Te.xt-book  of  Surgery."' 

f  .^mer.  Jour,  of  Med.  Sciences,  Sept.,  1S95. 


6o2  Diseases  a*nd   Injuries  of  tlie   Head 

occurs;  in  other  cases  death  takes  place  as  a  result  of  the  cerebral  injury. 
(See  Joseph  Sailer  on  "  Spurious  Meningocele, "  "  University  Med.  Magazine, " 
Sept.,  igoo.) 

Treatment. — Close  the  opening  by  a  plastic  operation. 

Hydrocephalus. — In  external  hydrocephalus  the  fluid  is  between  the 
membranes  and  the  brain;  in  internal  hydrocephalus  the  fluid  is  in  the  ven- 
tricles.    Hydrocephalus  may  be  acute  or  chronic,  congenital  or  acquired. 

Acute  hydrocephalus,  which  results  from  meningitis  (particularly  tuber- 
culous meningitis),  is  usually  internal,  but  maybe  e.xternal.  The  symptoms 
are  headache,  elevated  temperature,  delirium,  stupor,  convulsions,  paralysis, 
and  choked  disk. 

Treatment  of  acute  hydrocephalus  by  medical  means  is  of  no  avail. 
Tapping  of  the  ventricles  may  be  tried. 

Chronic  hydrocephalus  is  usually  congenital.  The  cranium  enlarges 
enormousl}-  and  the  bones  of  the  skull  are  widely  separated.  The  broad 
forehead  overhangs  the  eyes.  The  child  is  an  idiot,  and  very  often  does 
not  learn  to  walk  or  to  talk.  Convulsions  and  palsies  are  common,  and 
blindness  is  frequent.     Such  children  usually  die  young. 

The  treatment  of  chronic  hydrocephalus  is  rarely  of  much  avail.  Pressure  by 
strapping  with  adhesive  plaster  has  been  tried.  Tappings  through  a  fontanelle 
may  be  performed  by  means  of  a  trocar  (only  lij  or  5iij  of  fluid  being  withdrawn 
at  a  time).  If  much  fluid  is  allowed  to  flow  out,  the  head  must  be  strapped 
afterward.  If  the  skull  ossifies,  the  lateral  ventricles  may  be  tapped.  It 
has  been  proposed  to  drain  by  tapping  the  thecaof  the  spinal  cord  (Quincke). 
This  last  operation  is  called  lumbar  puncture  (page  654).  The  operation 
which  promises  most  was  devised  by  Sutherland  and  Cheyne,  and  is  known 
as  intracranial  drainage  ("Brit.  Med.  Jour.,"  Oct.  15,  1898).  Their  theory 
is  that  in  hydrocephalus  fluid  distends  the  ventricles  because  the  channels  of 
communication  between  the  ventricles  and  the  subarachnoid  spaces  are  closed. 
The  subarachnoid  spaces  communicate  directly  with  veins,  hence  fluid  cannot 
collect  under  pressure  in  these  spaces.  Intracerebral  drainage  establishes  a 
communication  between  the  subarachnoid  space  and  one  ventricle.  It  is  not 
necessary  to  operate  on  both  sides  because  the  lateral  ventricles  communicate. 
A  small  opening  is  made  in  the  skull.  The  dura  is  incised.  A  number  of 
strands  of  catgut,  which  are  tied  together,  are  pushed  through  the  brain  so 
that  one  end  of  the  catgut  mass  lies  in  a  ventricle  and  the  other  end  beneath 
the  dura.     The  dura  and  scalp  are  then  sutured. 

2.   Injuries  or  the  Head. 

Caput  SUCCedaneum  is  a  collection  of  bloody  serum  under  the  scalp 
of  a  new-born  child  and  results  from  the  pressure  of  labor.  The  pressure 
was  about  but  not  at  the  point  where  the  bloody  serum  gathered.  No  treat- 
ment is  required. 

ScaIp=WOUnds. — Scalp-wounds  bleed  profusely  because  the  scalp  is 
very  vascular,  because  many  of  the  blood-vessels  are  in  fibrous  tissue  and 
cannot  contract  and  retract,  and  because  even  blunt  force  .s]:)lits  the  scalp 
almost  like  an  incision.  Scalp-wounds  are  treated  as  are  other  wounds. 
Kven  a  large  piece  of  scalf)  with  only  a  narrow  [jcdicle  may  not  slough;  hence 


Concussion   or   Laceration   of  the   Brain  603 

trv  to  save  any  piece  that  has  an  attachment.  Always  shave  a  wide  area 
and  disinfect  the  shaven  area  and  the  wound.  Arrest  hemorrhage,  and 
exercise  great  care  in  cleansing  the  wound  and  the  parts  about  it.  Stitch 
the  wound  with  silkworm-gut.  Very  few  sutures  are  needed  if  the  wound  is 
longitudinal,  but  many  are  required  if  it  is  transverse.  The  permanent  arrest 
of  hemorrhage  is  rarely  effected  by  ligatures,  but  rather  by  sutures  judiciously 
placed.  If  drainage  is  required,  use  a  few  strands  of  silkworm-gut;  but  drain- 
age is  rarely  used  unless  we  know  the  wound  is  grossly  infected.  Wet  antiseptic 
dressings  are  used  for  the  first  few  days  and  moderate  pressure  is  applied  by 
wet  gauze  bandages.     Avulsion  of  the  scalp  is  discussed  on  page  203. 

Contusions  of  the  Head. — Scalp-swelling  from  hemorrhage  is  usually 
considerable.  The  patient  may  be  stunned  or  dazed.  The  swelling  of 
hematoma  must  not  be  mistaken  for  fracture  with  depression.  In  hematoma 
there  is  a  central  depression,  hard  pressure  on  the  center  finds  bone  on  a 
level  with  the  general  contour  of  the  bone,  and  the  margin  of  a  hematoma 
is  circular,  is  not  quite  hard,  and  is  elevated  above  the  general  contour.  In 
depressed  fracture  the  edge  is  on  a  level  with  or  below  the  level  of  the  general 
bonv  contour,  and  the  margin  is  sharp  and  irregular.  The  treatment  is 
by  bandage-pressure.     If  suppuration  arises,  at  once  incise. 

Concussion  and  Laceration  of  the  Brain.— For  many  years  it  has 
been  customary  to  regard  concussion  as  a  condition  produced  by  molecular 
vibrations  in  the  nervous  substance  of  the  brain.  Buret's  classical  observa- 
tions have  profoundly  modified  surgical  thought,  and  have  led  to  the  opinion 
that  in  concussion  of  the  brain  there  is  injury  to  the  brain  itself,  a  rupture 
of  cerebral  vessels  brought  about  by  the  advance  and  recession  of  a  wave 
of  cerebrospinal  fluid.  This  wave  iirst  flows  in  the  direction  of  the  force. 
Keen  says  that  there  may  be  slight  brain-injuries  which  can  properly  be 
called  "concussions,"  but  it  is  better  to  consider  concussion  as  synonymous 
with  laceration  of  the  brain.  It  seems,  however,  highly  improbable  that 
slight  cases  of  concussion  are  accompanied  by  vascular  rupture  or  organic 
mischief;  the  symptoms  are  too  transitory,  and  reaction  too  rapid  and  com- 
plete to  permit  of  any  such  view.  These  slight  cases  are  identical  with  and 
at  least  cannot  be  distinguished  from  shock.  The  cause  of  concussion  is 
violent  force,  either  direct  (as  a  blow  upon  the  head)  or  indirect  (as  a  fall 
upon  the  buttocks).  This  force  shakes,  oscillates,  or  jars  the  brain,  giving 
rise  to  waves  of  cerebrospinal  fluid,  which  sometimes  rupture  vascular  twigs, 
large  vessels,  or  even  the  membranes.  In  the  slighter  ruptures  concussion 
only  exists;  in  the  severe  ruptures  compression  soon  arises. 

Symptoms. — In  a  slight  case  of  brain-concussion  the  patient  may  or  may 
not  fall;  his  face  is  pale;  he  feels  weak,  giddy,  nauseated,  and  confused;  he 
often  vomits,  but  soon  reacts,  and  the  pulse  is  slow.  In  a  severe  case  he  lies  with 
complete  muscular  relaxation,  cold  extremities,  pale  and  cold  skin,  shallow  and 
quiet  respiration,  frequent,  small,  soft,  and  irregular  pulse  (pulse  may  not  be 
detectable),  and  fluttering  heart.  He  seems  unconscious,  but  can  usually  be 
roused  to  monosyllabic  response  by  shouting,  pinching,  or  holding  a  bright  light 
near  his  face.  Occasionally,  however,  there  is  complete  unconsciousness.  The 
urine  and  feces  are  often  passed  involuntarily.  The  pupils  may  be  unaltered, 
may  be  dilated  or  contracted,  may  be  equal  or  unequal,  but  in  any  case  they  will 
react  to  light.     Paralysis  rarely  exists,  but  if  there  is  paralysis  it  is  temporary. 


6o4  Diseases  and  Injuries  of  the   Head 

The  temperature  at  first  is  subnormal  In  a  severe  cortical  laceration  there 
will  be  twitchings  or  even  general  convulsions,  or  the  patient  will  lie  curled  up 
with  Umbs  flexed  and  eyelids  shut,  and  will  resist  all  attempts  to  open  his  eyes 
or  mouth  or  to  move  his  limbs  (A.  Pearce  Gould).  Erichsen  called  this  con- 
dition "cerebral  irritability."  As  the  patient  reacts  he  will  most  probably 
vomit.  Within  twenty-four,  hours  he  usually  improves,  but  is  feverish  and 
complains  of  headache  and  lassitude,  sometimes  becomes  delirious,  and  in 
rare  cases  develops  mania.  After  concussion  recovery  may  be -complete,  but, 
on  the  contrary,  a  person's  whole  nature  may  change:  he  may  develop  hysteria, 
insanity,  or  epilepsy,  and  in  many  cases  there  is  complaint  for  a  long  time  of 
headache,  insomnia,  low  spirits,  and  lassitude.  If  the  patient  in  concussion 
recedes  from,  instead  of  advancing  toward,  recovery,  coma  will  set  in  or  in- 
flammation will  develop.  The  prognosis  is  always  uncertain.  Any  concus- 
sion producing  unconsciousness  is  a  serious  injury,  because  considerable 
laceration  has  probably  occurred. 

Treatment. — In  treating  brain-concussion,  bring  about  reaction  by  the 
administration  of  aromatic  spirits  of  ammonia  (no  alcohol,  as  this  agent  excites 
the  brain),  bv  pouring  a  few  drops  of  ammonia  on  a  handkerchief  and  holding 
it  near  the  nose,  by  surrounding  the  patient  (who  lies  in  bed  with  a  pillow)  with 
hot  bottles,  by  hot  irrigation  of  the  head,  by  the  application  of  mustard  over  the 
heart,  and  by  the  administration  of  enemata  of  hot  coffee  or  hot  saline  fluid. 
Do  not  pour  fluid  into  the  patient's  mouth  until  he  becomes  able  to  swallow.  If 
he  cannot  swallow,  rely  on  hot  enemata  and  hypodermatic  injections  of  strych- 
nin. Place  the  patient  in  bed  in  a  quiet  room,  and  watch  him.  If  reaction 
is  inordinate,  apply  cold  to  the  head,  give  arterial  sedatives  and  diuretics,  and 
purge.  For  some  days  or  for  some  weeks,  according  to  the  case,  insist  on  an 
easy  life.  Give  a  plain  diet  containing  a  minimum  of  meat,  administer  an 
occasional  purgative,  and  secure  sleep.  Sleep  can  often  be  obtained  by  some 
simple  expedient,  such  as  the  administration  of  warm  milk,  placing  a  hot-water 
bag  to  the  abdomen  or  feet,  or  applying  a  mustard  plaster  for  a  short  time  to 
the  back  of  the  neck.  In  cases  where  obstinate  wakefulness  exists,  it  becomes 
necessary  to  give  bromid,  chloral,  sulphonal,  trional,  or  some  other  hypnotic. 
Morphin  is  avoided  because  it  is  thought  to  increase  venous  congestion  of  the 
brain,  but  the  elder  Gross  often  used  it,  especially  in  cerebral  irritation.  If 
signs  of  compression  arise,  it  is  best  to  trephine,  as  the  compressing  agent  may 
be  a  clot  (see  page  605).  If  inflammation  arises,  some  surgeons  will  not  tre- 
phine; but  it  is  wise  and  proper,  especially  if  the  damage  seems  to  be  localized, 
to  incise  the  scalp  and  inspect  the  bone.  If  a  fracture  is.  discovered  and  the 
symptoms  are  serious,  perform  an  exploratory  trephining,  open  the  dura,  and 
secure  drainage  for  inflammatory  products. 

In  any  severe  contusion  the  surgeon  should  at  once  incise  the  scalp  and 
inspect  the  bone.  For  many  weeks  after  a  grave  concussion  a  patient  must 
be  kept  away  from  business  and  be  watched  because  of  the  ywssibility  of  an 
abscess  of  the  brain  arising,  and  because  of  the  liability  of  sucli  patients  to 
develop  hysteria,  neurasthenia,  or  insanity. 

Compression  of  the  Brain.— The  causes  of  brain-compression  are 
hemorrhage  (Fig.  323),  depressed  fracture  (Fig.  320),  tumor,  inflammatory 
exudate,  pus,  and  foreign  bodies.  Death  tends  to  happen  from  respiratory 
failure,  not  from  heart-failure  (Horsley). 


Compression  of  the   Brain 


605 


Symptoms. — In  great  or  sudden  brain-compression  complete  coma  exists 
without  voluntary  movement.  The  skin  is  hot  and  perspiring;  the  respirations 
are  slow  and  stertorous,  and  the  cheeks  flap  during  expiration;  the  pulse  is  slow 
and  full,  and  may  be  irregular;  the  pupils  are  somewhat  dilated,  and  do  not 
respond  readily  to  light.  In  a  unilateral  compression  the  pupil  on  the  side  of 
the  compressing  cause  is  apt  to  be  much  dilated  if  the  compression  is  affecting 
the  base  of  the  brain.  In  cerebral  compression  there  are  usually  retention  of 
urine,  and  often  incontinence  of  feces;  paralysis  exists,  which  may  be  very 
limited  (monoplegia),  may  be  of  one  side  (hemiplegia),  or  may  be  general. 
In  hemorrhage  into  the  interior  of  the  brain  the  unconsciousness  is  immediate 
or  nearly  so.  In  bleeding  from  the  middle  meningeal  artery  a  period  of  con- 
sciousness intervenes  between  the  injury  and  the  coma,  in  which  period  blood 
collects  and  the  coma  comes  on  gradually.  In  compression  from  depressed 
fracture  or  from  a  foreign  body  the  .symptoms  usually 
come  on  at  once,  but  they  may  be  deferred  for  some 
hours.  Compression  from  inflammation  or  pus  be- 
gins gradually  after  a  considerable  time  has  elapsed. 

A  diagnosis  must  be  made  between  coma  due  to 
brain-injury  and  the  comatose  conditions  of  apoplexy, 
uremia,  epilepsy,  hysteria,  diabetes,  opium-poisoning, 
and  alcoholic  intoxication.  In  hospital  practice  cases 
of  unconsciousness  without  a  known  history  are  fre- 
quent. In  attempting  to  diagnosticate  examine  care- 
fully for  any  evidence  of  traumatism,  and  inquire  as  to 
how  and  where  the  patient  was  found,  if  any  fit  oc- 
curred, and  if  a  bottle  or  a  pill-box  was  found  near 
by  or  in  the  pockets.  The  surgeon  should  himself  ex- 
amine the  pockets.  Smell  the  breath  to  notice  alcohol 
or  opium,  but  always  remember  that  a  man  may  be 
stricken  with  apoplexy  while  he  is  drunk,  and  may 
fracture  his  skull  by  falling  when  under  the  influence 
of  opium  or  of  alcohol.  Draw^  the  urine  with  the  ca- 
theter if  any  water  is  in  the  bladder;  examine  the 
urine  for  albumin  and  sugar,  and  take  the  specific 
gravity.  In  doubtful  cases  of  coma  use  the  ophthal- 
moscope. In  post-epileptic  coma  the  temperature  is  never  below  normal,  there 
are  no  unilateral  symptoms,  the  condition  resembles  sleep,  and  the  patient  can 
be  aroused.  Hysterical  coma  occurs  in  boys  and  women;  there  are  no  ob- 
jective symptoms,  and  the  patient,  though  s\vallowing  what  is  put  into 
his  mouth,  cannot  be  roused  (Gowers).  In  uremia,  besides  the  condition 
of  the  urine  (and  always  remember  that  a  person  with  albuminuria  is 
apt  to  develop  apoplexy),  there  is  a  persistent  subnormal  temperature,  and 
convulsions  are  prone  to  occur.  There  is  edema  of  the  legs,  and  paralysis  and 
stertor  are  absent.  In  apoplexy  hemiplegia  exists,  and  the  initial  temperature 
is  for  a  short  time  subnormal.  A  single  convulsion  mav  have  ushered  in  the 
case.  Alcoholic  unconsciousness  is  often  diagnosticated  when  apoplexy  reallv 
exists.  A  man  will  smell  of  alcohol  who  has  had  one  drink,  but  one  drink  will 
not  produce  coma ;  hence  the  smell  of  alcohol  is  not  conclusive.  In  any  case  of 
doubt  some  hours  of  watching  will  clear  up  the  diagnosis.     Regard  a  doubtful 


Fig.  320. — Fracture  of 
skull  with  depressed  frag- 
ments. Compression  of 
brain  by  bone  (Scudder). 


6o6 


Diseases  and  Injuries  of  the   Head 


case  as  serious  until  the  truth  is  clear.  In  opium-poisoning  the  pupils  are  con- 
tracted to  a  pin-point,  the  respirations  are  usually  slow,  shallow,  and  quiet,  and 
may  be  stertorous;  but  there  is  no  paralysis.  Always  remember  that  hemor- 
rhage into  the  pons  will  produce  pin-point  pupils,  but  it  also  causes  paralysis 
(crossed  paralysis  if  in  the  lower  half  of  the  pons)  and  high  temperature  with 
sweating.  In  opium-poisoning  the  temperature  is  subnormal.  In  diabetic 
co?na  the  pupils  will  react  to  a  very  bright  light,  the  temperature  is  subnormal, 
and  the  breath  and  the  urine  smell  like  chloroform. 

Treatment. — The  treatment  of  brain-compression  depends  on  the  cause. 
Hemorrhage  (extradural  or  subdural)  requires  trephining  and  arrest  of  bleed- 
ing; coma  from  depressed  fracture  demands  trephining  and  elevation;  foreign 
bodies  must  be  removed;  abscesses  must  be  evacuated;  some  tumors  are  to  be 
removed.  In  cerebral  compression,  if  death  is  threatened  by  respiratory 
failure,  make  artificial  respiration,  and  at  once  trephine  over  the  supposed 

region  of  compression  (Victor  Hors- 
ley).     Horsley  has  shown  that  irri- 
gation of  the  head  with  hot  water 
\\  is  of  great  value  in   bringing  about 

a\  reaction     from    shock   in    cases    of 

brain-injury. 


RuJture  on-  larger  SccUe ; 
i>  ^/neJt  bristle  in  lumen. 
^5^-        of  artery. 


Middle  meninj/ 
post,  branch.. 


Kuptia-e' 
^artery 


Fig.  321. — Frontal  section  of  skull.  Middle 
meningeal  hemorrhage.  The  dura  bulges  in- 
ward toward  the  skull  cavity  (diagram) 
(Scudder). 


Fig.  322.  —A  case  of  rupture  of  middle  men- 
ingeal artery.  Preparation  of  dura.  In  the 
Warren  Museum.  The  specimen  is  \ie\ved 
from  the  outer  side  (Scudder). 


Intracranial  hemorrhage  may  be  either  spontaneous  or  traumatic.  In 
the  vast  majority  of  instances  spontaneous  hemorrhage  comes  from  the  len- 
ticulostriate  artery  (Charcot's  artery  of  cerebral  hemorrhage),  and  produces 
apoplexy,  a  disease  belonging  to  the  physician  except  in  some  ingravescent 
cases,  for  which  ligation  of  the  common  carotid  on  the  same  side  as  the  rupture 
is  indicated.  In  adults  traumatism  is  almost  always  the  cause  of  a  meningeal 
hemorrhage.  The  blood  may  flow  from  a  sinus,  or  from  the  middle  meningeal 
artery  or  one  of  its  branches.  Traumatism  during  delivery  is  a  not  unusual 
cause  of  hemorrhage  from  the  middle  meningeal  artery  (Richardiere).  Violent 
paroxysms  of  coughing  in  whooping-cough  occasionally  produce  extradural 
hemorrhage  or  subdural  hemorrhage.  Geo.  S.  Brown  reports  such  a  case.  He 
diagnosticated  the  condition  and  o])enited  successfully  ("New  York  Med. 
Jour.,"  A}jril  25,  1003). 

Traumatic  Meningeal  Hemorrhage.  -Hemorrhage  may  take  ])lace 
(i)  between  the  bone  and  the  dura  {extradural);  (2)  between  the  (hu'a  and  the 
brain  (subdural);  and  (3)  in  the  brain-substance  {cerebral). 


Extradural   Hemorrliaije 


607 


I.  Extradural  hemorrhage  arises  usually  from  the  middle  meningeal 
artery  or  from  one  of  its  branches.  A  spicule  of  bone  may  penetrate  a 
venous  sinus  and  produce  extradural  hemorrhage,  or  a  sinus  may  rupture. 
Rupture  of  the  meningeal  artery  or  one  of  its  branches  is  usually,  but  not 
always,  accompanied  by  fracture  (Fig.  323);  in  fact,  in  some  cases  not  even  a 
bruise  can  be  found  (Fig.  322).  The  ruptured  vessel  maybe  upon  the  oppo- 
site side  to  that  on  which  the  force  was  applied,  hence  the  evidence  of  scalp- 
injury  is  not  a  certain  sign  of  the  side  of  the  skull  involved.  The  accident  may 
or  may  not  cause  temporary  unconsciousness;  but  even  if  it  does,  from  this 
unconsciousness  the  patient  almost  always  reacts,  and  there  is  a  distinct  period 
of  consciousness  between  the  accident  and  the  lasting  coma,  the  coma  being  due 
to  pressure  from  a  continually  increasing  mass  of  extravasated  blood  (Fig. 
321).  If  the  main  trunk  or  a  large  branch  is  rup- 
tured, the  period  of  consciousness  is  short;  if  a  small 
branch  is  ruptured,  the  period  of  consciousness  is 
prolonged  for  hours  or  perhaps  for  days.  As  the  clot 
forms  and  enlarges  the  patient  becomes  heavy,  dull, 
stupid,  and  sleepy;  he  sleeps  so  soundly  he  can 
scarcely  be  aroused,  and  snores  loudly,  and  finally 
passes  into  stupor  and  then  into  coma.  The  other 
signs  of  this  condition  are  paralysis  of  the  side  oppo- 
site the  blood-clot  (not  necessarily  of  the  side  oppo- 
site point  of  appHcation  of  the  force,  for  the  artery 
may  rupture  from  contre-coup  on  the  uninjured  side) ; 
this  paralysis  is  apt  at  first  to  be  localized,  but  it  grad- 
ually and  progressively  widens  its  domain.  If  the 
clot  extends  toward  the  base,  the  pupil  on  the  same 
side  as  the  clot  ceases  to  react  to  light,  becomes  im- 
mobile, and  dilates  widely,  and,  if  the  clot  be  on  the 
left  side,  aphasia  is  noted.  As  the  clot  enlarges  ad- 
jacent centers  become  involved.  The  face  becomes 
paralyzed,  then  the  arm,  and  finally  the  leg.  Not  un- 
usually epileptiform  attacks  occur,  starting  in  dis- 
charges from  the  centers  which  are  irritated  by  the 
advancing  clot  before  their  function  is  abolished  by 

pressure.  The  pulse  becomes  full,  strong,  usually  slow,  but  occasionally 
frequent;  the  breathing  becomes  stertorous;  the  temperature  rises,  that  of 
the  paralyzed  side  exceeding  that  of  the  sound  side.  In  a  compound  fracture 
the  pressure  of  escaping  blood  may  force  brain-matter  out  of  the  wound 
(Keen).  In  extradural  hemorrhage  from  a  sinus  the  symptoms  cannot  be 
differentiated  from  those  produced  b}-  arterial  rupture. 

Treatment. — In  treating  extradural  hemorrhage  localize  the  clot,  not  by 
the  seat  of  the  wound  or  contusion,  but  entirely  by  the  symptoms.  Endeavor 
to  bring  about  reaction;  but  if  the  state  of  shock  deepens  or  does  not  improve, 
and  if  pressure-symptoms  increase,  operate  at  once.  To  reach  the  middle 
meningeal  artery  or  its  anterior  branch,  trephine  one  and  one-fourth  inches 
back  of  the  external  angular  process,  at  the  level  of  the  upper  border  of  the  orbit 
(Fig.  310).  If  this  incision  does  not  expose  the  clot,  trephine  again  at 
the  level  of  the  upper  border  of  the  orbit  and  just  below  the  parietal  emi- 
nence.    The  first  incision  gives  access  to  the  main  trunk  and  to  the  anterior 


F'g-  323.— Fracture  of 
skull  with  middle  menin- 
geal hemorrhage.  Com- 
pression of  brain  by  blood 
(Scudder). 


6o8 


Diseases  and   Injuries   of  the   Head 


branch;  the  second  incision  exposes  the  posterior  branch.  If  signs  indicate 
that  the  clot  is  travehng  to  the  base,  the  trephine  should  be  used  half  an  inch 
lower  than  the  point  first  directed.  Arrest  bleeding  by  a  suture  ligature  or  by 
packing  (page 3 22),  and  always  open  the  dura  and  inspect  the  brain.  By  this 
procedure  a  subdural  hemorrhage  may  be  discovered  which,  without  it,  would 
have  been  missed.     Drainage  must  be  employed. 

2.  Subdural  hemorrhage  is  usually  due  to  depressed  fracture  and  rupture 
of  the  middle  cerebral  artery  or  of  a  number  of  small  vessels.  The  symptoms 
are  identical  with  those  of  extradural  bleeding,  but  are  usually  very  rapid  in 
onset  and  are  accompanied  by  a  more  distinct  drop  in  temperature,  and 
graver  depression. 

The  treatment  is  trephining  at  the  first  point  named  in  the  previous  article, 
enlarging  the  opening  upward  and  backward  with  a  rongeur,  opening  the 
dura,  turning  out  the  clot,  ligating  the  bleeding  point  or  packing,  elevating  any 
depression  of  bone,  draining,  and  stitching  the  dura  with  catgut.  Hemor- 
rhage from  internal  pachymeningitis  requires  the  same  treatment. 

3.  Cerebral  Hemorrhage. — The  symptoms  of  cerebral  hemorrhage  are 
identical  with  those  of  apoplexy.     The  treatment  is  the  same  as  that  for  apo- 


Fig.   324. — Section  of   outer  and   inner  tables, 
with  two  parallel  lines  (after  Agiiew). 


F'g-  325-  —  Greater  yielding  of  the  inner 
table  than  of  the  outer  after  the  application  of 
violence  (after  Agnew). 


plexy,  except  in  ingravescent  cases,  when  the  common  carotid  on  the  same 
side  as  the  clot  may  be  ligated. 

Rupture  of  a  sinus  usually  arises  from  compound  fracture  or  during 
a  brain-operation.  The  treatment,  if  the  rupture  happens  from  fracture,  is 
trephining.  Enlarge  the  opening  by  the  rongeur,  pack  with  one  large  piece 
of  iodoform  gauze,  or  catch  the  rent  with  hemostatic  forceps,  leaving  them  in 
place  for  three  or  four  days,  or  apply  a  lateral  ligature  or  a  suture  ligature. 
Elevate  depressed  bone.  In  rupture  during  an  operation  control  hemorrhage 
by  packing. 

Fractures  of  the  skull  may  be  simple,  compound,  depressed,  non- 
depressed,  or  punctured.  They  are  divided  into  fractures  of  the  vault,  usually 
due  to  direct  force,  and  fractures  of  the  base,  due  to  extension  of  fractures  of  the 
vault,  to  indirect  violence  (a  fall  upon  the  feet,  the  buttocks,  or  the  vault),  to 
forcing  of  the  condyles  of  the  lower  jaw  against  or  through  the  base,  or  to 
foreign  bodies  breaking  through  the  orbit,  vault  of  the  pharynx,  the  ear,  or  the 
roof  of  the  nostrils.  Fracture  by  contre-coup,  which  occurs  on  the  side  op- 
posite the  application  of  the  violence,  is  very  rare.  Fractures  of  the  skull  are 
uncommon  in  early  youth,  but  they  are  much  more  frequent  in  the  aged. 
Usually  the  entire  thickness  of  the  bone  is  fractured,  but  either  the  outer  or  the 
inner  table  (Fig.  326)  may  be  broken  alone.  In  complete  fractures  the 
inner  table  is  broken  more  extensively  than   is  the  outer  table,  because  the 


Fractures   of  the   Vault 


609 


inner  table  is  the  more  brittle,  because  the  force  diffuses,  and  also,  as  Agnew 
taught,  because  the  inner  table  is  part  of  a  smaller  curve  than  is  the  outer 
table,  and  violence  forces  bone-elements  together  at  the  outer  table,  but  tears 
them  asunder  at  the  inner  table  (Figs.  324,  325). 

Fractures  of  the  Vault. — A  fracture  of  the  vault  of  the  skull  may  be  simple 
and  undepressed,  or  it  may  be  depressed  (Figs.  320  and  326),  compound,  or 
comminuted.  A  mere  crack  may  exist  in  a  bone,  and  if  a  rent  exists  in  the  soft 
parts,  a  bit  of  dirt  or  a  hair  may  be  caught  in  the  crack.  Fractures  of  the 
vault  arise  from  direct  force.  A  fissure  may  escape  recognition,  although  in 
some  cases  percussion  gives  a  "cracked-pot"  sound.  Any  considerable  de- 
pression can  be  detected.  In  a  simple  fracture  occasionally  the  cerebrospinal 
fluid  collects  under  the  scalp  and  forms  a  tumor  which  pulsates  and  becomes 
tense  on  forcible  expiration  (puffy  tumor  of  Pott).  Compound  fractures  can 
be  readily  recognized,  but  do 
not  mistake  a  suture,  a  Wor- 
mian bone,  or  a  tear  in  the 
pericranium  for  a  fracture. 
A  fissured  fracture  is 
marked  by  a  dark  line  of 
blood  which  sponging  will 
not  remove.  Fracture  of 
the  inner  table  alone  can 
only  be  suspected.  The 
prognosis  of  fractures  of 
the  vault  depends  upon 
the  extent  of  brain-injury 
rather  than  upon  the  ex- 
tent of  bone-injury.  Simple 
fractures  unite  by  bone; 
compound  fractures  with 
loss  of  bone  unite  only  by 
fibrous  tissue.  The  dan- 
gers    may     be     immediate 

(hemorrhage,  brain-injury,  and  septic  inflammation)  or  be  distant  (epilepsy, 
insanity,  and  persistent  headache). 

Treatment. — The  mortality  of  fracture  of  the  skull  used  to  be  much  greater 
than  at  present.  Before  the  days  of  antisepsis  it  was  51  per  cent.  (Harte). 
Trephining  is  performed  much  oftener  than  was  once  the  custom,  and  is  vastly 
.safer.  Out  of  26  trephined  cases,  3  died  (Harte).  In  any  case  of  fracture 
of  the  skull  endeavor  to  bring  about  reaction  before  operating,  unless  the  signs 
of  pressure  continuall\-  increase  or  the  evidences  of  shock  remain  unimproved 
or  become  graver.  A  simple  fracture  without  depression  and  without  brain- 
symptoms  is  treated  expectantly  (by  rest,  quiet,  low  diet,  purgation,  moderate 
ele\ation  of  and  cold  to  the  head,  and  arterial  sedatives).  A  simple  fracture 
with  moderate  depression  and  without  cerebral  symptoms  is  treated  expec- 
tantlv,  and  so  also  is  a  simple  fracture  in  which  symptoms  existed  but  are 
abating.  Simple  fracture  with  marked  depression  requires  immediate  tre- 
phining, even  when  brain-symptoms  are  absent.  Some  surgeons  make  an 
exception  in  voung  children,  and  wait  a  while  I)efore  tre|)hining,  in  the  expec- 
39 


Fig.  326. — Fracture  ot  the  vault  with  e.xtensive  depression  of 
the  inner  table  ("  American  Te.jct-book  of  Surgery  '"). 


6io 


Diseases  and   Injuries  of  the   Head 


tation  that  the  expansile  brain  will  lift  the  depressed  but  elastic  bone  up  to  the 
level.  Trephining  in  cases  where  no  symptoms  exist,  although  there  is  marked 
depression,  often  prevents  disastrous  consequences  arising  in  the  future,  and  is 
known  as  "preventive  trephining"  (Agnew,  Keen,  Horsley,  Macewen,  v. 
Bergmann,  and  others).  In  all  compound  fractures,  shave  and  asepticize  the 
entire  scalp,  enlarge  the  incision,  and  explore  the  bone.  If  a  fissure  exists  it 
must  be  asepticized,  and  if  a  hair  or  other  foreign  body  is  found  in  it,  in  order 
to  effect  removal  and  secure  asepsis  the  outer  table  of  the  skull  must  be  cut 
away  with  a  chisel,  the  fissure  being  thus  converted  into  a  broad  groove.  In  a 
compound  fracture  with  much  depression,  trephine,  elevate,  and  irrigate.  In 
any  fracture,  trephine  if  distinct  symptoms  exist.  In  punctured  wounds  of  the 
brain  (punctured  fractures),  always  trephine,  open  the  dura,  and  disinfect 


F'K-  327.— Extensive  fracture  of  the  base  of  the  skull  ("  American  Text-book  of  Surgery"). 


(Keen).     In  any  case  of  fracture  of  the  vault  where  trephining  has  been  per- 
formed, it  is  wise  to  open  the  dura  and  e.xamine  the  brain. 

Fractures  of  the  Base. — A  fracture  of  the  base  of  the  skull  may  exist  in 
only  one  of  the  three  fossae,  in  two  of  them,  or  it  may  involve  all.  Figure  327 
shows  an  extensive  fracture  of  the  base  of  the  skull.  The  middle  fossa 
is  oftenest  involved.  Fracture  of  the  posterior  fossa  is  the  most  fatal. 
These  fractures  may  be  due  to  direct  violence,  to  indirect  force,  and  to  ex- 
tension of  a  fracture  of  the  vault.  Extension  from  the  vault  is  always  by  the 
shortest  rmite.  Fracture  by  direct  violence  may  arise  from  the  penetration  of 
the  nasal  rocjf,  the  orbital  roof,  or  the  pharyngeal  roof  by  a  foreign  body.  The 
posterior  fossa  may  sufTer  from  a  fracture  by  direct  violence  applied  to  the  neck. 
Fractures  by  indirect  force  may  arise  from  blows  upon  the  frontal  jjone  (the 


Fractures  of  the   Base  6ii 

orbital  portion  of  the  frontal  or  the  cribriform  process  of  the  ethmoid  break- 
ing), from  falls  upon  the  chin  (the  condyle  of  the  jaw  breaking  the  middle 
fossa),  or  from  falls  upon  the  buttocks,  the  knees,  or  the  feet  (fracture  occurring 
in  the  posterior  fossa).  The  base  is  very  rarely  broken  by  contre-coup 
(Treves). 

Symptoms. — Fractures  of  the  base  of  the  skull  are  apt  to  be  compound.  A 
.solution  of  continuity  in  the  pharynx,  roof  of  the  nares,  orbit,  or  ear  permits 
access  of  air  to  the  seat  of  fracture  and  allows  blood  and  cerebrospinal  fluid  to 
flow  externally.  In  fracture  of  the  anterior  fossa  the  fracture  may  be  com- 
pound, because  of  laceration  of  the  mucous  membrane  of  the  nares  or  of  the 
conjunctiva.  Blood  may  run  from  the  nose,  its  source  being  the  vessels  of  the 
mucous  membrane  or  the  dura,  the  fracture  being  compound.  Epistaxis  does 
not  prove  the  fracture  to  be  compound,  but  only  suggests  it;  but  if  the  epis- 
taxis is  prolonged,  the  probability  is  greatly  increased;  and  if  the  flow  of  blood 
is  succeeded  by  a  flow  of  cerebrospinal  fluid  the  diagnosis  of  compound  frac- 
ture is  positive.  Cerebrospinal  fluid  only  appears  when  the  mucous  mem- 
brane, the  dura,  and  the  arachnoid  are  each  lacerated  (Treves).  In  fractures 
of  the  anterior  fossa  blood  is  apt  to  flow  into  the  orbit,  producing  subcon- 
junctival ecchymosis,  and  some  blood  is  often  swallowed  and  vomited.  In 
fractures  of  the  middle  fossa  blood  may  flow  from  the  ear  through  a  tear  in  the 
tympanum,  its  source  being  the  vessels  of  the  tympanum,  the  meningeal 
vessels,  or  a  sinus.  Blood  may  flow  through  the  Eustachian  tube  and  come 
from  the  nose,  may  be  spit  up,  or  may  be  swallowed  and  vomited.  In  many 
cases  a  quantity  of  cerebrospinal  fluid  flows  from  the  ear,  the  discharge  being 
increased  by  expiratory  effort  and  a  position  which  favors  gravity.  The 
cerebrospinal  fluid  must  not  be  confused  with  either  blood-serum  or  liquor 
Cotunnii.  The  cerebrospinal  fluid  is  always  present  in  large  amount;  the 
liquor  Cotunnii  can  only  be  present  in  minute  amount.  Blood-serum  is  highly 
albuminous;  cerebrospinal  fluid  is  a  serous  fluid  of  very  low  specific  gravity, 
never  shows  more  than  a  trace  of  albumin,  and  contains  considerable  chlorid 
of  sodium  and  in  some  instances  sugar,  which,  when  present,  reacts  to  Trom- 
mer's  and  to  Moore's  tests,  but  does  not  reflect  polarized  light  nor  ferment  with 
yeast  (Keetley,  from  Collins).  Treves  states  *  that  cerebrospinal  fluid  cannot 
flow  from  the  ear  in  fractures  of  the  middle  fossa  (i)  unless  the  line  of  fracture 
crosses  the  internal  meatus,  (2)  unless  the  prolongation  of  the  membranes  into 
the  meatus  is  torn,  (3)  unless  a  communication  exists  between  the  internal  ear 
and  tympanum,  and  (4)  unless  the  drum-membrane  is  torn.  Miles,  of  Edin- 
burgh,! claims  that  bleeding  from  the  ear  followed  by  a  flow  of  cerebrospinal 
fluid  is  not  pathognomonic  of  fracture  of  the  middle  fossa  of  the  base.  He 
maintains  that  when  the  drum  is  ruptured  we  may  have  these  signs,  when  bone 
is  not  broken,  the  chief  source  of  the  blood  being  the  vessels  of  the  pia  and 
temporosphenoidal  lobe,  the  blood  and  cerebrospinal  fluid  flowing  inside  the 
sheath  of  the  auditory  nerve,  passing  into  the  vestibule,  through  the  lamina 
cribrosa,  and  from  the  vestibule  into  the  middle  ear,  finding  exits  from  this 
space  by  way  of  the  Eustachian  tube,  and  also  through  the  rent  in  the  drum- 
^  membrane.  Profuse  serous  discharge  may  flow  from  the  ear  after  an  injury 
without  fracture  when  the  drum  is  ruptured,  the  fluid  coming  from  the  cells  of 
the  mastoid.     It  must  be  understood  that  fracture  of  the  base  may  exist  when 

*  "Applied  Anatomy."  f  Edinburgh  Med.  Jour.,  Nov,   1S95. 


6i2  Diseases  and   Injuries   of  the   Head 

there  is  no  How  of  blood  or  of  serous  fluid.  A  fracture  of  the  middle  fossa  is 
usually  compound,  made  so,  even  when  the  drum  is  not  ruptured,  by  the 
Eustachian  tube,  and  there  is  often  paralysis  of  the  seventh  or  eighth  nerve  or  of 
both  of  them.  In  fracture  of  the  posterior  fossa  there  is  usually  respiratory 
derangement  and  blood  accumulates  beneath  the  deep  fascia  and  produces 
discoloration  in  the  line  of  the  posterior  auricular  artery  (Battle's  sign),  the 
discoloration  first  appearing  near  the  tip  of  the  mastoid.  The  discoloration 
appears  in  the  line  of  nerves  and  vessels  which  emerge  from  the  deep  fascia,  the 
vessels  passing  through  openings  and  the  extravasated  blood  emerging  from 
the  same  openings.  Fractures  of  the  posterior  fossa  are  apt  to  be  compound 
through  the  pharynx,  and  in  such  cases  the  patient  spits  or  vomits  blood. 
Compound  fractures  of  the  posterior  fossa  are  more  fatal  than  fractures  in 
either  of  the  other  fossae.  Fractures  of  the  base  are  apt  to  be  associated  with 
paralvsis  of  cranial  nerves.  Optic  neuritis  often  arises  after  the  first  week. 
In  fractures  of  the  base  the  temperature  is  subnormal  during  the  shock,  rises 
to  ioo°  to"  ioi°,  falls  again  to  about  normal,  and  remains  normal  or  subnormal 
unless  there  be  inflammation  or  sepsis.  Lumbar  puncture  may  obtain  bloody 
fluid.  Such  a  finding  means  subarachnoid  bleeding  and  indicates  fracture. 
Harte  (''Annals  of  Surgery,"  Oct.,  1901)  has  collected  46  positive  cases  of 
fracture  of  the  base  of  the  skull  from  the  records  of  the  Pennsylvania  Hospital; 
35.5  per  cent,  recovered. 

Treatment. — In  treating  a  compound  fracture  of  the  base  of  the  skull, 
coflect  any  serous  discharge  and  analyze  it,  and  disinfect  any  cavity  involved. 
In  fractures  of  the  middle  fossa  with  ruptured  drum  clean  the  ear  mechanically, 
wash  it  out  with  hydrogen  peroxid  and  with  a  stream  of  warm  corrosive  subli- 
mate solution  of  a  strength  of  i :  2000  (turn  the  head  toward  the  affected  side 
while  washing,  so  that  the  mercurial  solution  will  not  run  down  the  Eustachian 
tube),  in.sufiiate  iodoform,  pack  with  iodoform  gauze,  and  apply  an  antiseptic 
dressing.  Several  times  daily  the  ear  is  to  be  irrigated,  and  insufflated  with 
iodoform.  The  nasopharynx  must  be  frequently  irrigated  with  normal  salt 
solution  or  boric-acid  solution,  and  insufflated  with  iodoform.  The  con- 
junctival sac  is  frequently  irrigated  with  boric-acid  solution.  If  after  a  head- 
injury  blood  accumulates  back  of  the  drum,  this  membrane  should  be  incised 
to  permit  of  drainage  and  disinfection.  In  fractures  of  both  the  middle  and 
anterior  fossae  and  in  fractures  of  the  posterior  fossa  communicating  with  the 
pharynx  the  nasopharynx  must  always  be  cleaned.  The  exact  method  depends 
on  the  choice  of  the  surgeon.  We  may  wash  out  these  cavities  frequently  with 
hot  water,  next  with  peroxid  of  hydrogen,  and  finally  with  boric-acid  solution, 
or  can  use  normal  salt  solution.  After  washing  insufflate  the  nasopharynx  with 
iodofcjrm,  and  pack  the  nose  with  iodoform  gauze  (Keen,  Dennis) ;  also  cleanse 
the  conjunctival  sac  frequently.  In  some  cases  drainage  has  been  obtained 
from  the  anterior  fossa  by  breaking  through  the  cribriform  plate  and  introduc- 
ing a  tube  by  way  of  the  nostril  (Allis),  and  from  the  middle  fossa  by  trephin- 
ing above  and  behinfl  the  external  auditory  meatus.  In  a  compound  fracture 
of  the  (jrbit  disinfect  and  drain.  It  may  be  necessary  to  trephine  the  roof  of 
the  orbit  to  secure  drainage.  In  fracture  of  the  posterior  fossa  examine  to  see 
if  the  fracture  is  compound,  into  the  pharynx,  and  if  it  is  cleanse  with  great 
care  the  nasopharynx,  and  mouth,  as  previously  flirected.  In  a  very  extensive 
fracture  of  the  Ijase,  besides  use  of  the  methods  set  forth  above,  the  entire  head 


Wounds  of  the  Brain 


613 


Fig.  328.— Extensively  comminuted  gunshot-fracture  of  the  skull 
(after  v.  Bergniann). 


should  be  shaved  and  a  plaster-of-Paris  cap  be  apphed.  Cases  of  fracture  of 
the  base  must  be  put 
into  a  quiet  and  dark- 
ened room  and  be  kept 
upon  a  low  diet,  sleep 
being  secured,  and  the 
bowels  and  bladder  be- 
ing attended  to.  If  we 
are  uncertain  as  to 
whether  a  fracture  ex- 
ists or  not,  keep  the  pa- 
tient quiet  and  in  a 
darkened  room,  and  on 
a  low  diet.  Attend  to 
the  bladder,  keep  the 
bowels  loose,  examine 
the  nasopharynx  with 
mirrors  and  the  drum 
through  a  speculum. 

Wounds    of    the 

brain  are  produced  by 

violence  and  by  foreign 

bodies  (knives,  bullets, 

etc.).    Except  when  due 

to  penetration  of  a  fon- 

tanelle  in  a  child  or  of  a  parietal  foramen   in  adults,  wounds  of  the  brain 

are  accompanied  by  fracture  of  the 
skull.  These  wounds  are  very  danger- 
ous: foreign  bodies  (bone.  hair,  cloth- 
ing, etc.)  are  often  lodged  in  the  brain, 
hemorrhage  is  usually  severe,  and  sep- 
sis is  almost  inevitable  without  proper 
treatment.  Such  cases  are  very  fatal, 
though  some  astonishing  recoveries 
are  on  record.  Figures  3 28  and  329 
show  gunshot-fractures  of  the  skull. 

The  symptoras  of  brain-wounds 
may  be  slight  and  long-deferred  or 
may  be  immediate  and  overwhelm- 
ing; they  depend  upon  the  site  and 
extent  of  the  injury.  Locahzing 
symptoms  may  exist,  and  encephalitis 
with  coma  is  apt  to  arise.  Abscess 
not  unusually  follows. 

In  treating  wounds  of  the  brain 
always  shave  the  entire  scalp  and  ex- 
amine the  weapon,  if  possible,  to  see 
if  a  piece  were  broken  off.    Asepticize, 

enlarge  the  wound,  trephine,  arrest  bleeding,  elevate  any  depression,  remove 

foreign  bodies,  irrigate  the  wound,  suture  the  dura,  drain,  and  dress. 


Fig.  329. — Gunshot-fracture  of   internal  table  of 
the  skull  (after  v.  Bergniann). 


6 14  Diseases  and   Injuries  of  the   Head 

Qunshot=VVOUnds  of  the  Head.— A  penetrating  wound  is  one  in  which 
the  bullet  enters  the  head,  but  does  not  emerge;  a  per/orating  wound  is  one  in 
which  the  bullet  passes  through  the  head  and  emerges.  The  bullet  of  the 
modern  rifle  will  rarely  lodge,  but  a  pistol-bullet  will  often  lodge.  The  wound 
of  entrance  is  small;  the  wound  of  exit  is  large.  At  the  wound  of  entrance  the 
inner  table  is  more  extensively  fractured  than  the  outer  table;  at  the  wound  of 
exit,  the  outer  table  is  more  widely  broken  than  the  inner  table.  In  these 
cases  there  is  always  great  concussion,  and  concussion-symptoms  exist  even 
when  the  bullet  has  not  entered  the  brain.  In  moderate  concussion  the  action 
of  the  heart  is  retarded;  in  severe  concussion  it  is  accelerated.*  A  bullet  may 
be  lodged  within  the  cranium  when  merely  a  fracture  without  a  bullet-hole 
can  be  detected.  In  these  cases  the  bullet  produces  a  fracture  and  enters  the 
cranium,  and  then  the  depressed  bone  flies  back  into  place  (v.  Bergmann). 
In  such  cases,  if  complete  perforation  occurs,  the  one  existing  opening  is  the 
opening  of  exit.  A  bullet  may  lodge  in  the  bone,  between  the  dura  and  the 
bone,  in  the  brain,  between  the  dura  and  bone  of  the  opposite  side,  or  in  the 
bone  of  the  opposite  side,  in  the  nasal  fossa,  maxillary  antrum,  or  orbit.  Al- 
ways examine  the  side  of  the  head  opposite  to  the  wound  of  entrance  to  deter- 
mine if  there  is  any  bulging  or  fracture.  A  bullet  may  pass  across  the  brain 
and  be  deflected  from  the  inner  surface  of  the  skull  (Fluhrer).  Ruth  does  not 
believe  the  bullet  can  rebound  from  the  opposite  wall.j  The  secondary 
symptoms  of  gunshot-wounds  of  the  head  are  varied  and  uncertain,  and  may 
not  be  observed  at  all  before  death.  Fowler  wisely  points  out  that  a  patient 
with  a  gunshot-wound  of  the  head  may  have  also  received  other  injuries,  and 
the  other  injuries  may  be  in  part,  at  least,  responsible  for  cerebral  symptoms. 

Treatment. — Bring  about  reaction  (see  Concussion).  In  severe  cases 
apply  heat  to  the  head,  and  make  artificial  respiration.  It  will  sometimes  be 
necessary  to  operate  while  artificial  respiration  is  being  made.  In  treating 
gunshot-wounds  of  the  head  shave  and  asepticize  the  whole  scalp,  disinfect  the 
entire  track  of  the  ball,  and  arrest  hemorrhage  at  the  wounds  of  entrance  and 
exit,  using  the  rongeur  to  expose  the  bleeding  points  if  the  bullet  be  large, 
employing  the  trephine  if  it  be  small.  If  the  bullet  has  emerged  and  has  been 
picked  up,  examine  it  to  see  if  it  is  entire.  The  bullet,  if  retained,  is  to  be 
sought  for.  Place  the  head  in  such  a  position  that  the  track  of  the  ball  will  be 
vertical,  then  introduce  Fluhrer's  aluminum  probe  and  let  it  find  its  way  by 
gravity.  The  probe  may  find  the  ball  near  the  wound  of  entrance,  in  which 
case  extract  the  ball  with  forceps;  or  the  probe  may  find  the  ball  near  the 
opposite  side  of  the  head,  in  which  case  make  a  counter-opening  through  the 
bone  at  a  point  the  probe  would  touch  if  it  were  pushed  entirely  across.  Take 
a  new  and  c/ean  rubber  catheter  (No.  9,  French),  insert  a  stylet,  and  carry  the 
catheter  through  the  wound  (Keen).  Knowing  the  depth  of  the  ball,  search  for 
it  around  the  catheter-tube  as  an  axis,  and  when  found  extract  it.  After  ex- 
traction drain  the  wound  by  means  of  a  tube.  When  a  counter-opening  exists, 
drain  through  and  through.  If  the  ball  cannot  be  detected,  drain  by  a  tube 
carried  to  the  flcj^ths  of  the  wound.  After  dressing  always  place  the  head  in  a 
position  favorable  for  drainage.  Fluhrer  tells  us  that  when  a  counter-opening 
fails  to  disclose  the  bullet,  use  the  new  opening  as  a  doorway  through  which  to 

*  Fowler,  in  Annals  of  Surgery,  Nov.,  1895. 

I  See  the  instructive  article  by  Fowler,  in  AnnaLs  of  Surgery,  Nov.,  1895. 


Pachymeningitis  615 

search  for  the  ball.  He  believes  the  bullet  is  not  unusually  deflected.  The 
angle  of  deflection  is  somewhat  greater  than  the  angle  of  incidence,  and  the 
bullet  is  apt  to  fall  a  little  toward  the  base.  Splinters  of  bone  are  often  driven 
into  the  brain  by  a  bullet,  and  these  are  removed  whether  the  ball  is  found  or 
not.  Several  varieties  of  probes  have  been  commended.  Fluhrer  uses  a  large- 
sized  aluminum  probe.  Senn  uses  an  instrument  shaped  like  the  Nelaton  probe, 
but  of  the  same  diameter  as  the  bullet  (Fig.  330).  (Of  course,  the  porcelain 
probe  will  not  show  a  black  mark  from  contact  with  a  modern  bullet.)  Fowler 
uses  a  graduated  pressure-probe;  so  long  as  the  pressure  is  within  the  limits  of 
the  spring,  as  shown  by  the  scale,  the  probe  is  in  the  bullet-track.     Girdner's 


Fig.  330. — Senn's  bullet-probe. 


telephonic  probe  is  a  valuable  aid  to  diagnosis.  Recently  bullets  have  been 
located  by  the  Rontgen  rays.  There  can  be  no  doubt  that  many  gunshot- 
wounds  have  been  recovered  from  without  operation,  and  it  is  beyond  question 
that  many  deaths  follow  operation  (about  ^^^  per  cent.,  according  to  Hahn). 
Von  Bergmann  is  so  impressed  with  these  facts  that  he  does  not  operate  when 
cerebral  symptoms  are  absent. 

Fungus  cerebri  (hernia  of  the  brain)  rarely  contains  true  brain-sub- 
stance. It  is  in  most  instances  a  growth  from  the  neuroglia.  Hernia  cerebri 
cannot  occur  if  the  dura  is  not  opened ;  it  is  rare  in  any  case  unless  the  brain  is 
damaged,  and  is  most  frequent  after  septic  wounds.  In  any  brain-operation 
if  the  dura  is  opened  suture  it;  or,  if  there  be  a  great  gap  in  the  dura,  turn 
in  a  flap  of  pericranium,  its  bone-forming  surface  being  upward,  and  stitch 
this  membrane  to  the  dura  (Keen).  The  evidence  of  brain-hernia  is  a  pro- 
truding mass  which  is  soft,  lobulated,  of  a  dirty  white  color,  pulsating,  painless 
to  the  touch,  often  bleeding,  and  sometimes  discharging  cerebrospinal  fluid. 
In  treating  a  brain-hernia  employ  antiseptic  dressings.  Skin-grafting  benefits 
some  cases.  Pressure  is  dangerous.  Excision  by  the  knife  or  cautery  does  no 
good.     After  healing,  a  depression  marks  the  site  of  the  hernia. 

Traumatic   inflammation  of  the  brain  and  its  membranes  is 

divided  into  encephalitis  or  cerebritis,  inflammation  of  the  cerebrum;  cere- 
bellitis,  inflammation  of  the  cerebellum;  uieniugifis,  inflammation  of  the 
meninges;  arachnitis,  inflammation  of  the  arachnoid;  pachymeningitis,  in- 
flammation of  the  dura;  and  leptomeningitis,  inflammation  of  the  arachnoid 
and  pia. 

Pachymeningitis. — Inflammation  of  the  e.xternal  layer  of  the  dura  is 
called  pachymeningitis  externa.  It  may  arise  from  tumor,  caries,  necrosis, 
middle-ear  disease,  sunstroke,  or  traumatism.  Syphilis  is  a  not  unusual  cause. 
The  other  membranes  may  become  involved.  Suppuration  may  arise,  having 
extended  by  contiguity  from  neighboring  parts.  The  symptoms  of  pachy- 
meningitis externa  are  uncertain.     They  resemble  often  those  of  leptt)menin- 


6i6  Diseases  and   Injuries  of  the   Head 

gitis  (page  617).  Pressure-symptoms  may  arise.  Headache  is  always  pres- 
ent. Paralysis  may  or  may  not  exist.  If  pus  forms,  the  ordinary  constitu- 
tional symptoms  of  suppuration  are  evident  (high  temperature  and  sweats), 
not  the  symptoms  of  abscess  in  the  brain.  In  a  severe  case  the  other  mem- 
branes become  involved. 

The  treatment  consists  in  removing  the  cause  (carious  bone,  pus,  middle- 
ear  disease).  In  pachymeningitis  from  traumatism  it  is  sometimes  advisable  to 
trephine  in  order  to  drain  inflammatory  products;  in  a  case  with  localizing 
symptoms  always  trephine;  in  an  ordinary  case,  without  pus  and  with  no 
evidences  of  traumatism,  use  wet  cups  back  of  the  mastoid  processes,  apply  an 
ice-bag  to  the  head,  and  purge  by  means  of  calomel.  Administer  iodid  of 
potassium  in  most  cases.  If  sunstroke  is  the  cause,  treat  according  to  ordi- 
nary medical  rules. 

Pachymeningitis  interna  may  extend  from  the  pia,  or  may  extend 
from  the  outer  layer  of  the  dura.  The  form  known  as  hematoma  of  the  dura 
mater,  or  pachymeningitis  interna  hsemorrhagica,  may  arise  during  infectious 
diseases  (typhoid  fever  and  rheumatism),  in  persons  of  the  hemorrhagic 
diathesis,  in  diseases  causing  atrophy  of  the  brain,  in  chronic  diseases  of  the 
heart  and  kidneys,  and  in  syphilitics.  Among  the  exciting  causes  are  trau- 
matism, inflammation  in  adjacent  parts,  and,  especially,  the  abuse  of  alcohol. 
In  this  disease  blood  is  extravasated  on  the  inner  surface  of  the  dura.  Many 
observers  do  not  class  hemorrhagic  pachymeningitis  as  inflammation,  but 
regard  the  hemorrhage  as  primary. 

The  symptoms  of  internal  pachymeningitis  are  very  chronic,  are  not 
characteristic,  and  may  be  absent.  They  consist  usually  of  persistent  head- 
ache and  apoplectiform  attacks,  with  contraction  of  the  pupil,  slow  pulse,  and 
vomiting.  Choked  disk  is  not  infrequent,  localizing  symptoms  may  be  made 
out,  and  coma  is  apt  to  arise. 

The  treatment  is  the  same  as  thi^t  for  external  pachymeningitis. 

Acute  leptomeningitis  is  a  purulent  inflammation  of  the  soft  mem- 
branes of  the  brain.  The  pathological  changes  can  be  noted  in  the  pia  and  in 
the  brain-substance.  The  brain  is  edematous,  the  pia  purulent,  the  convolu- 
tions are  flattened,  the  ventricles  are  distended  with  fluid,  and  hemorrhages 
occur  into  the  brain-substance.  Pus  may  be  localized  upon  the  pia,  but  it  is 
usually  diffused  o\'er  one  hemisphere  or  over  both.  Various  organisms  may 
be  found,  especially  .streptococci,  staphylococci,  and  diplococci.  In  some 
cases  we  find  the  bacillus  pyocyaneus  or  the  bacillus  pyocyaneus  foetidus,  which 
is  identical  with  the  colon  bacillus  and  with  the  bacillus  meningitis  purulenta 
(Park).  Saprophytic  organisms  are  occasionally  present.  This  disease  may 
be  acute  or  chronic,  and  a  severe  case  is  spoken  of  as  encephalitis.  Secondary 
leptomeningitis  is  apt  to  affect  the  convexity;  primary  leptomeningitis  is  apt  to 
affect  the  base. 

The  causes  of  le])tomeningitis  are  ci)i(]emic  cerebrospinal  fever,  tuber- 
cul<isis,  acute  general  diseases  (pneumonia,  typhoid,  erysipelas,  and  rheu- 
matism), bone-di.seases,  traumatisms,  middle-car  disease,  syphilis,  and  sun- 
stroke. The  tissues  of  the  pia  and  the  cerebrosjjinal  lluid  cijntain  diplococci 
identical  with  pneumococci.  Infection  may  take  place  by  various  avenues. 
It  may  pass  from  the  nose  by  way  of  the  Eustachian  tube  to  the  ear,  or  from  the 
nose  to  the  frontal  sinus  or  ethmoid  sinuses  (Hirt),  and  from  these  situations 


Tuberculous   Meningitis  617 

to  the  brain.  It  may  pass  from  the  middle  ear  or  mastoid  to  the  membranes  of 
the  brain.  In  fractures  at  the  base  the  organisms  enter  by  way  of  the  pharynx 
and  the  Eustachian  tube,  or  the  ear.  The  symptoms  of  acute  leptomeningitis 
are  violent  headache  persisting  during  delirium,  flushing  of  the  face,  rigidity  of 
the  neck,  cerebral  vomiting,  a  slow  pulse,  elevated  temperature,  photophobia, 
contraction  of  the  pupils,  intolerance  of  sound,  hyperesthesia  of  the  skin  and 
muscles,  and  delirium  passing  into  stupor  and  coma.  A  chill  or  a  succession 
of  chills  may  occur.  Choked  disk,  strabismus,  and  nystagmus  are  not  un- 
usual. Convulsions  or  paralyses  may  occur.  Death  is  the  rule  within  one 
week.  The  treatment  usually  consists  of  purgation  with  calomel;  bleeding 
behind  the  mastoid  processes;  cold  to  the  head;  warm  baths  with  cold  affusions 
to  the  head;  iodid  of  potassium,  bromid  of  potassium,  or  morphin  for  vomiting 
and  headache.  A  patient  in  this  condition  should  be  trephined  in  order  to 
relieve  pressure  and  to  give  exit  to  inflammatory  products.  It  gives  some 
hope  of  recovery,  and  the  usually  adopted  medical  treatment  is  practically 
useless.  Should  the  patient  recover,  he  is  guarded  for  a  long  time  from 
physical  exertion,  mental  excitement,  worry,  irritation,  constipation,  and  in- 
somnia. 

Chronic  Leptomeningitis  (or  Encephahtis). — The  causes  of  chronic 
leptomeningitis  are  the  same  as  those  of  the  acute  form.  If  traumatism 
is  the  cause,  the  inflammation  arises  at  a  later  period  than  it  would  in 
acute  encephalitis.  The  symptoms  of  concussion  follow  a  head-injury. 
Days,  or  even  weeks,  after  the  accident,  a  series  of  symptoms  occur — namely: 
localized  pain  at  the  seat  of  injury,  often  accentuated  by  tapping;  listlessness; 
irritability;  apathy  regarding  business  affairs  and  home  obligations,  or  pro- 
found depression  and  hypochondria  with  inability  to  attend  to  business. 
Choked  disk  may  exist.  In  any  case  acute  encephalitis  may  arise,  with  or 
without  a  chill.  The  treatment  of  this  disease  is  symptomatic  unless  local 
symptoms  exist.  Always  operate  if  locahzing  symptoms  are  found.  Intense 
local  pain  justifies  trephining. 

Tuberculous  Meningitis  (Acute  Hydrocephalus;  Water  on  the  Brain). 
— This  inflammatory  condition  is  due  to  the  bacilli  of  tuberculosis.  In 
a  child  affected  with  tuberculous  meningitis  there  is  often  a  record  of  a  fall,  the 
injury  acting  as  an  exciting  cause  by  establishing  an  area  of  least  resistance. 
Prodromal  symptoms  are  common  (restlessness,  irritability,  anorexia,  change  of 
character).  The  disease  begins  with  a  convulsion  or  with  headache,  fever, 
and  vomiting  (Osier),  the  child  cries  out  from  pain  (the  hydren cephalic  cry),^ 
and  the  bowels  are  constipated.  The  pulse  is  rapid  in  the  beginning,  but 
later  becomes  slow  and  irregular.  The  pupils  are  contracted,  there  is  mus- 
cular twitching,  and  the  sleep  is  impaired.  The  temperature  is  about  103°. 
In  the  second  period  of  the  disease  the  vomiting  ceases,  constipation  becomes 
more  marked,  the  belly  retracts,  headache  is  not  so  violent,  and  the  patient 
lies  in  a  soporose  condition  interspersed  with  episodes  of  delirium.  In  this 
stage  the  pupils  dilate  and  are  often  unequal,  the  head  is  retracted,  convul- 
sions occur  or  limited  rigidity  is  noted,  the  respirations  are  sighing,  and  if  a 
finger-nail  is  drawn  along  the  skin,  a  red  line  develops  (the  tdcJie  cerebrale, 
due  to  vaso-motor  paresis).  Squint  and  consequent  double  vision  are  usual. 
In  the  last  stage  coma  becomes  absolute  and  general  convulsions  or  limited 
spasms  are  apt  to  occur.     Optic  neuritis  exists,  and  the  child  passes  \o  death 


6iS  Diseases  and   Injuries   of  the   Head 

along  a  road  identical  with  that  of  typhoid  collapse.  In  some  cases  the  ex- 
amination of  cerebrospinal  fluid  withdrawn  by  lumbar  puncture  throws  light 
upon  the  diagnosis.  In  children  the  base  is  usually  involved,  and  the  disease 
is  apt  to  last  from  two  to  four  weeks;  in  adults  the  convexity  of  the  brain  is 
usually  involved,  and  death  is  apt  to  occur  in  a  few  days. 

The  treatment  is  like  that  for  traumatic  meningitis. 

.Abscess  of  the  brain  is  a  localized  collection  of  pus.  The  organisms 
found  are  noted  upon  page  6i6  (Acute  Leptomeningitis).  The  causes  are 
suppurative  otitis  media  (in  half  of  all  the  cases),  fracture  of  the  skull,  con- 
cussion of  the  brain,  and  general  septic  diseases.  A  tuberculous  mass  may 
caseate  (tuberculous  abscess).  The  abscess  may  be  between  the  dura  and  skull 
(extradural),  adhesions  forming  and  preventing  a  general  leptomeningitis, 
between  the  dura  and  brain  (subdural),  or  in  the  brain-substance  (cerebral  or 
cerebellar).  Leptomeningitis  may  arise  because  no  adhesions  are  created,  be- 
cause septic  clots  form  in  veins  or  sinuses,  or  because  infected  blood  regurgitates 
into  the  sinuses  (Park).  A  traumatic  abscess  is  generally  beneath  the  area  to 
which  the  traumatism  was  applied,  but  it  may  be  on  the  opposite  side.  The 
infection  may  begin  in  the  nose,  the  orbit,  or  the  middle  ear  (page  6i6). 
Roswell  Park  says  infection  may  pass  along  blood-vessels,  lymph-vessels, 
nerve-sheaths,  or  the  prolongations  of  the  membranes  which  extend  outside 
of  the  skull.  An  acute  inflammation  of  the  middle  ear  rarely  causes  abscess, 
because  an  acute  inflammation  in  sound  tissues  causes  the  formation  of  granu- 
lation tissue,  which  acts  as  a  barrier  to  infection.  Chronic  inflammation  of 
the  middle  ear  is  the  most  frequent  cause  of  abscess.  Park  tells  us  if  the  roof 
of  the  tympanum  is  involved,  it  is  perforated  and  abscess  of  the  middle  fossa 
ensues;  if  the  tympanum  is  perforated  toward  the  mastoid  antrum,  the  abscess 
arises  in  the  temporosphenoidai  lobe;  if  the  perforation  is  toward  the  sigmoid 
groove,  the  abscess  forms  in  the  cerebellum.* 

Symptoms  of  Abscess  of  the  Cerebral  Substance  or  of  the  Cerebel- 
lum.— The  symptoms  due  to  pus-formation  are  as  follows:  There  maybe  an 
initial  rise  of  temperature,  but  (except  in  extradural  abscess)  the  tempera- 
ture quickly  becomes  normal  or  even  subnormal.  Subnormal  temperature 
is  not  nearly  so  common  as  is  usually  supposed.  It  has  been  present  in 
about  one-half  of  the  cases  I  have  seen.  Toward  the  end  of  the  case  the 
temperature  may  rise  and  the  fever  become  linked  with  delirium.  Surface 
elevation  of  temperature  over  the  seat  of  the  abscess  is  occasionally  observed. 
A  chill  may  or  may  not  occur.  Anorexia  and  vomiting  are  present.  Urinary 
chlorids  are  diminished  and  the  ])hosphates  are  increased  (Somerville). 
Symptoms  due  to  pressure  are:  headache  (which  at  first  is  general,  then 
local,  and  grows  worse  later  in  the  case,  and  exists  even  in  delirium;  this  fact 
distinguishes  it  from  the  headache  of  fever,  which  ceases  in  delirium);  pulse 
is  very  slow;  respiration  tends  to  the  Cheyne-Stokes  type;  drowsiness  lapses 
into  stupor  and  stupor  passes  into  coma;  paralysis  of  the  sphincters  takes 
place;  convulsions  are  common;  sensation  is  rarely  impaired;  and  [)aralysis 
of  the  basal  nerves  may  occur  (third  and  sixth  especially).  The  pupil  on  the 
same  side  as  the  abscess  is  dilated  and  fixed.  Choked  disk  is  not  invariably 
found;  if  it  is  unilateral,  it  is  on  the  same  side  as  the  abscess;  if  it  is  bilateral, 
it  is  more  marked  on  the  same  side  as  the  abscess.     Localizing  symptoms, 

*  Park,  in  Chicago  Med.  Record,  Feb.,  1895. 


Brain   Disease  from   Suppurati\-e   Ear   Disease  619 

spasmodic  and  paralytic,  depend  upon  the  center  which  is  irritated  or  de- 
stroyed. In  cerebellar  abscess  there  are  vertigo,  vomiting,  occipital  headache, 
rigidity  of  the  post-cervical  muscles,  incoordination,  but  choked  disk  is  often 
absent. 

Meningitis  arises  soon  after  an  accident;  an  abscess,  more  than  a  week,  and 
often  many  weeks,  after  an  accident.  Meningitis  presents  high  temperature 
and  the  general  symptoms  before  outlined.  Mastoid  disease  may  occasion 
cerebral  symptoms  without  abscess,  or  it  may  cause  abscess.  In  sinus- 
thrombosis  there  is  septic  temperature,  the  veins  of  the  face  and  neck  are  en- 
larged, and  a  clot  can  usually  be  felt  in  the  jugular.  A  tumor  grows  slowly, 
usuallv  presents  almost  from  the  start  localizing  symptoms,  and  double 
choked  disk  is  frequently  present.  In  tumor  the  temperature  is  apt  to  be 
normal. 

Treatment. — If  abscess  is  due  to  ear  disease  with  implication  of  the 
mastoid  cells,  at  once  open  and  clean  out  the  mastoid,  and  after  this  proceed 
to  trephine  the  skull  in  order  to  reach  the  abscess.  In  any  case,  if  symptoms 
of  abscess  exist,  trephine  the  skull  at  once.  If  localizing  symptoms  are  pres- 
ent, open  over  the  suspected  region.  If  localizing  symptoms  are  not  present 
and  the  cause  is  ear  disease,  trephine  at  Barker's  point  (Fig.  318).  If  no  pus 
is  found  between  the  bone  and  dura,  open  the  membrane.  When  the  dura 
is  opened,  if  the  abscess  is  subdural  pus  will  be  evacuated;  if  the  abscess 
is  in  the  brain-substance,  the  brain  will  bulge  very  much  and  will  not  be 
seen  to  pulsate.  A  grooved  director  is  plunged  into  the  brain,  in  the  direction 
of  the  abscess,  for  two  or  two  and  a  half  inches  (Keen).  If  pus  is  not  found, 
withdraw  the  director  and  introduce  it  at  another  point.  When  pus  is  dis- 
covered, incise  the  brain  with  a  knife,  enlarge  the  opening  by  inserting  a 
closed  pair  of  forceps  and  withdrawing  the  instrument  with  the  blades  open. 
Scrape  away  the  granulation  tissue  lining  the  abscess-cavity,  irrigate  with 
hot  salt  solution,  and  introduce  a  rubber  drainage-tube;  stitch  the  dura,  but 
leave  an  ample  opening  for  the  tube;  bring  the  tube  out  through  a  button- 
hole in  the  scalp,  and  after  the  first  two  days  pull  the  tube  out  a  little  every 
day  and  cut  off  a  piece.  If  the  first  trephining  does  not  find  pus,  trephine 
again  at  another  point.  In  cerebellar  abscess  make  a  flap  with  the  base 
up,  and  trephine  or  gouge  away  the  bone  just  below  the  line  of  the  lateral 
sinus.     Puncture  the  brain  as  for  cerebral  abscess. 

Brain  Disease  from  Suppurative  Ear  Disease. — Chronic  disease 
of  the  middle  ear  is  apt  to  destroy  the  bone  between  the  tympanum  and 
the  middle  fossa  of  the  skull,  and  thus  produce  meningitis,  thrombosis  of 
the  petrosal  or  lateral  sinuses,  abscess  of  the  temporosphenoidal  lobe  or  of 
the  cerebellum,  or  extradural  abscess.  Chronic  otitis  media  also  induces 
inflammation  or  suppuration  of  the  mastoid  cells  (empyema  of  the  mastoid). 
Pus  in  the  mastoid  may  discharge  itself  into  the  middle  ear,  and  from  this 
point  into  the  external  auditory  canal,  through  a  perforation  in  the  drum- 
membrane  (especially  in  acute  cases).  In  some  cases  the  pus  becomes 
blocked  up  within  the  mastoid  process.  Pus  in  the  mastoid  may  after  a 
time  break  into  the  cavity  of  the  cranium  or  into  the  lateral  sinus,  or  may 
find  its  way  externally  and  open  into  the  sheaths  of  muscles  arising  from 
the  mastoid.  It  not  unusually  opens  into  the  sheath  of  the  digastric  muscle 
(Bezold's  abscess).     These  facts  teach  the  surgeon  that  chronic  ear  disease 


620  Diseases   and   Injuries  of  the   Head 

should  never  be  neglected,  but  should,  if  possible,  receive  the  closest  atten- 
tion of  the  specialist.  If  no  perforation  exists  in  the  drum,  the  surgeon 
must  make  one.  In  ordinary  cases  cleanhness  and  antisepsis  are  sufficient, 
the  ear  being  syringed  every  day  with  a  warm  2  per  cent,  solution  of  common 
salt.  If  only  a  small  drum-perforation  exists,  10  drops  of  pure  alcohol  or 
of  corrosive  sublimate  solution  (i  :  5000)  are  dropped  into  the  ear  daily; 
but  if  a  large  drum-perforation  exists,  boric  acid  and  iodoform  (7  to  i)  are 
insuiiflated.  Never  inject  alum.  A  strong  silver  solution  is  not  safe;  if  it 
is  used,  wash  the  ear  out  afterward  with  warm  salt  water.  If  granulations 
or  polypi  exist,  they  must  be  removed.  Some  cases  require  the  removal 
of  the  drum-membrane  and  the  ossicles  of  the  ear.  Many  cases  of  mastoid 
necrosis  are  due  to  tuberculosis.  If  headache,  vomiting,  and  mastoid 
tenderness  exist,  open  the  mastoid  (see  Operations),  in  order  to  prevent 
abscess  of  the  brain.  In  acute  otitis  media  it  is  very  rarely  necessary  to 
open  the  mastoid.  The  middle  ear  is  on  a  lower  level  than  the  antrum  of 
the  mastoid,  and  in  most  acute  cases  both  the  middle  ear  and  mastoid  cells 
drain  safely  through  a  drum-perforation.  Because  a  man  has  chronic  otitis 
media  it  is  by  no  means  always  necessary  to  trephine  the  mastoid.  In  many 
cases  removal  of  the  ossicles  and  drum-membrane  effects  a  cure.  In  chronic 
otitis  media,  even  if  the  mastoid  is  trephined,  the  ossicles  and  membrane 
ought  to  be  removed. 

Cerebral  abscess  from  ear  disease  is  almost  always  in  the  temporo- 
sphenoidal  lobe,  but  may  arise  in  the  cerebellum.  The  symptoms  are  a 
transient  rise  of  temperature  followed  in  many  cases  by  a  normal  or  subnormal 
temperature;  vomiting;  mastoid,  frontal,  and  temporal  pain.  The  mind  is  dull, 
and  stupor  arises  which  passes  into  coma;  the  bowels  are  constipated;  choked 
disk  may  be  present;  and  convulsions  or  spasms  or  paralyses  may  exist. 
Trephine  and  clean  out  the  mastoid,  and  asepticize  (see  Operations  upon  the 
Skull  and  Brain).  Also  trephine  at  Barker's  point,  one  and  one-fourth 
inches  behind,  and  the  same  distance  above,  the  middle  of  the  external 
auditory  meatus,  open  the  dura  and  seek  for  pus.  If  pus  is  not  found,  open 
the  cerebellum. 

Extradural  Abscess. — The  eye-symptoms  and  pain  are  the  same  in 
this  as  in  cerebral  or  subdural  abscess,  but  the  temperature  is  different, 
rising  to  103°  or  104°  F.  There  is  often  considerable  tenderness  above  and 
behind  the  mastoid.  In  extradural  abscess  following  disease  of  the  middle 
ear,  trephine  and  clean  out  the  mastoid;  follow  up  a- bone-sinus  to  the  abscess, 
rongeur  away  the  bone,  being  careful  to  avoid  injuring  the  lateral  sinus; 
curet,  irrigate,  and  drain. 

Infective  Sinus=thrombosis.— Any  sinus  may  be  attacked.  The  dis- 
ea.se  may  result  from  scarlet  fever,  smallpox,  diphtheria,  influenza,  typhoid, 
or  any  acute  suppuration.  In  erysipelas  of  the  scalp,  septic  clots  may 
form  in  the  veins  which  pass  through  the  bone  and  reach  the  longitudinal 
sinus.  Infective  thrombosis  oi  the  superior  longitudinal  sinus  is  thus 
produced. 

In  carbuncle  of  the  lip  and  orbital  su|)]juration  the  cavernous  sinus  may 
become  i n vol  ved . 

In  caries  of  the  basilar  jjortion  of  flic  o((i|)ilal  bone  the  circular  sinus 
(jr  the  caverntjus  sinus  may  suffer.     In  caries  of  the  ];etrous  jjortion  of  the 


Infective   Sinus-thrombosis  621 

temporal  bone,  and  in  suppuration  of  the  middle  ear  and  mastoid  process, 
infective  thrombosis  of  the  lateral  sinus  may  occur. 

In  any  case  the  symptoms  are  those  of  pyemia.  The  lateral  sinus  is 
the  one  most  frequently  attacked.  In  infective  thrombosis  of  the  lateral 
sinus  there  is  usually  a  history  of  an  old  discharge  from  the  ear. 

Infective  thrombosis  of  the  lateral  sinus  may  result  from  a  specific  fever, 
but  is  usually  due  to  chronic  suppuration  of  the  middle  ear  associated  in 
most  cases  w^ith  carious  bone  and  pus  in  the  mastoid  process.  Thrombosis 
of  the  lateral  sinus  occasionally  follows  an  operation  upon  a  suppurating 
mastoid,  or  develops  in  an  individual  who  suffers  from  middle-ear  dis- 
ease who  has  been  struck  upon  the  head,  who  has  had  the  ear  syringed 
with  force,  or  who  has  had  injected  a  corrosive  or  very  irritant  fluid.  Tuber- 
culous bone  disease  is  an  occasional  cause. 

Symptoms.— In  most  cases  there  is  a  history  of  chronic  ear  disease. 
In  children  the  symptoms  are  more  acute  than  in  adults.  In  any  case  the 
symptoms  may  rapidly  become  violent.  In  some  cases  there  are  preliminary 
symptoms  of  extradural  abscess,  pus  being  lodged  in  the  groove  of  the  sinus. 
It  has  been  pointed  out  that  pus  in  the  jugular  foramen  may  make  pressure 
upon  the  pneumogastric,  spinal  accessory,  and  glossopharyngeal  nerves, 
producing  aphonia,  hoarseness,  dyspnea,  dysphagia,  and  slow  pulse  (Geo. 
F.  Cott*).  Marked  headache  ushers  in  sinus-thrombosis.  The  pain  is  apt 
to  be  localized  about  the  ear  and  mastoid  process,  but  may  become  general. 
There  is  usually  tenderness  of  the  mastoid.  There  is  high  fever  from  the  start, 
but  when  the  clot  begins  to  soften  and  break  down,  hard  rigors  develop  and 
the  temperature  fluctuates  violently.  The  temperature  varies  each  day  between 
subnormal  and  106°  to  107°.  A  chill  may  occur  once  or  even  twice  a  day, 
and  it  lasts  from  ten  to  twenty  minutes.  The  pulse  is  soft  and  usually 
rapid.  The  patient  is  nauseated,  labors  under  vertigo,  is  very  restless, 
is  dull  and  stupid,  sometimes  delirious,  and  the  muscles  of  the  neck  are 
stiff.  Tenderness  and  marked  edema  are  detected  over  the  mastoid.  When 
the  clot  extends  into  the  jugular  vein  there  is  pain  on  moving  the  head  and 
on  swallowing,  the  cervical  glands  are  swollen,  and  a  clot  may  be  felt  in 
the  neck.  Choked  disk  exi.sts  in  about  half  of  all  cases.  There  is  often 
a  profuse  discharge  of  pus  from  the  ear,  but  in  some  cases  the  discharge 
is  found  to  have  abated  or  ceased.  E.xophthalmos  and  swelling  of  the  eye- 
lids point  to  involvement  of  the  cavernous  sinus  in  the  process.  In  early 
cases  there  is  thrombosis  of  the  lateral  sinus  alone,  or  of  the  lateral  sinus 
and  jugular  vein.  The  internal  jugular  vein  may  be  felt  as  a  cord  in  the 
neck.  In  advanced  cases  other  sinuses  become  involved  (superior  petrosal, 
inferior  petrosal,  both  cavernous,  the  lateral  sinus  of  the  opposite  side,  the 
ophthalmic  veins,  and  the  torcular  Herophili).  A  j)atient  with  sinus-thrombosis 
is  in  great  danger  of  developing  pulmonary  metastasis  and  septic  meningitis 
(Jansen).  Septic  meningitis  is  accompanied  by  abscess  about  the  sinus.  Sinus- 
thrombosis  is  a  very  fatal  disease  and  usually  runs  its  course  in  from  seven  to 
ten  days,  but  occasionally  lasts  for  weeks.  It  is  a  form  of  pyemia  and  death 
arises  from  the  causes  which  have  been  referred  to  in  discussing  that  disease. 

Infective  thrombosis  of  the  cavernous  sinus  causes  the  general  svmptoms 
of  pyemia  and  also  edema  of  the  lids,  and  exophthalmos. 

*  Am.  Med.,  April  19,  1902. 


622  Diseases  and   Injuries  of  the   Head 

Injective  Thrombosis  oj  the  Petrosal  Sinus. — Produces  pyemic  symptoms, 
but  no  characteristic  signs. 

The  prognosis  largely  depends  upon  early  recognition.  The  surgeon 
should,  wheneyer  it  is  possible,  open  a  mastoid  before  sinus-thrombosis  arises, 
and  should  eyacuate  an  abscess  about  the  sinus  before  a  clot  forms  in  the 
yenous  channel,  or  at  least  before  that  clot  becomes  septic  (Jansen). 

Treatment. — In  1880  Zaufal  proposed  the  operation  now  practised, 
and  Horsley  did  it  in  1886.  (See  article  by  Geo.  F.  Cott,  in  "American 
Medicine,''  April  19,  1902.)  Infectiye  thrombosis  of  the  lateral  sinus  is 
treated  as  follows:  Open  and  clean  out  the  mastoid,  and  expose  the  sinus  by 
the  use  of  the  chisel  or  rongeur  (Fig.  336).  Open  the  yenous  channel,  and  if 
a  clot  is  found  to  exist  cut  away  the  wall  of  the  sinus.  Introduce  a  small 
spoon  into  the  lumen  and  carry  it  toward  the  torcular  Herophih,  and  scrape 
away  the  clot  until  blood  flows.  Arrest  hemorrhage  by  plugging  a  piece 
of  iodoform  gauze  into  the  wound  and  toward  the  torcular.  Jansen  opposes 
remoying  the  entire  clot  toward  the  jugular,  and  does  not  tie  the  jugular, 
beheying  that  to  do  so  increases  the  danger  of  thrombosis  of  the  inferior 
petrosal  and  cavernous  sinuses.  He  simply  removes  the  soft  clot,  but  does 
not  disturb  the  solid  clot  toward  the  heart.  Most  surgeons  differ  with 
him,  and  after  opening  the  sinus,  turning  out  the  clot,  and  packing,  pro- 
ceed to  ligate  the  jugular  vein  at  the  level  of  the  cricoid  cartilage.  If, 
after  this  operation,  the  clot  in  the  jugular  becomes  septic,  incise  the  vein 
up  to  the  base  of  the  skull  and  pack.  Surgeons  are  of  the  opinion  that 
it  is  futile  to  do  any  operation  if  pulmonary  metastasis  has  taken  place.  In 
a  recent  case  of  the  author's  in  the  Jefferson  Medical  College  Hospital  the 
patient  recovered  after  operation  in  spite  of  the  fact  that  endocarditis  had 
developed. 

Until  recently  it  was  thought  that  the  lateral  sinus  was  the  only  sinus 
which  should  be  attacked  surgically,  but  in  a  case  Knapp,  of  New  York, 
requested  Hartley  to  remove  from  the  cavernous  sinus  a  clot  which  was 
causing  blindness  and  was  due  to  sarcoma.  The  operation  was  success- 
fully executed  by  Hartley,  the  incision  being  the  same  as  is  employed  to 
reach  a  Gasserian  ganglion  in  the  Hartley  operation.  This  patient  lived 
several  months.  Another  case  was  operated  upon  by  incision  of  the  sinus 
by  Dwight  (E.  W.  Dwight  and  H.  H.  Germain,  "  Boston  Med.  and  Surg. 
Jour.,"  May  i,  1902).  Some  surgeons  advise  removal  of  the  eyeball  and 
curctment  (A  the  sinus. 

Intracranial  Tumors. — An  encephalic  tumor  may  originate  within  the 
skull.  It  may  have  arisen  from  an  external  growth  invading  the  cranial 
cavity,  or  may  be  metastatic.  A  tumor  that  arises  within  the  cranium  may 
take  origin  from  the  pericsteum,  from  one  of  the  membranes  of  the  brain, 
from  the  yessels,  from  the  neuroglia,  or  from  the  brain-substance. 

No  region  of  the  b(xJy  is  so  liable  to  tumors  as  the  brain.  During  the 
course  of  a  number  of  years,  the  autopsies  of  the  Munich  Pathological  In- 
stitute are  stated  by  Bollinger  to  have  shown  one  tumor  of  the  brain  in  every 
85  autopsies.  Hale  White's  experience  is  that  such  tumors  are  even  more 
common  than  this,  and  he  estimates  them  at  one  in  every  59  autopsies. 

In  endeavoring  to  determine  the  causes  of  intracranial  tumors,  wc  must 
accredit   heredity   with   consideraljle   influence   in   tuberculosis,   and   possibly 


Intracranial   Tumors  623 

with  some  force  in  sarcoma  and  carcinoma.  These  tumors  are  decidedly 
more  common  in  males  than  in  females,  probably  because  of  the  greater 
male  liability  to  injury,  syphilis,  and  alcoholism. 

The  majority  of  cases  of  tumor  of  the  brain  occur  between  the  ages  of 
twenty-five  and  fifty.  Children  are  particularly  prone  to  sufi'er  from  glioma 
and  from  tuberculous  growths.  In  aged  persons  a  tumor  of  the  brain  very 
rarely  develops. 

Injury  may  be  responsible  for  the  development  of  sarcoma,  of  fibroma, 
and  possibly  of  other  forms;  in  fact,  a  syphiloma  may  arise  in  a  syphilitic 
person  at  the  seat  of  an  injury. 

We  use  the  term  intracranial  or  encephalic  tumor  not  only  to  include 
true  neoplasms,  but  also  to  designate  growths  of  parasitic,  syphilitic,  or 
tuberculous  origin.  It  is  of  importance  to  attempt  to  make  a  diagnosis  as 
to  the  form  of  tumor  that  is  present;  and  this  may  be  possible,  on  account 
of  the  fact  that  in  many  cases  the  form  affects  the  symptoms.  A  useful 
classification  of  these  growths  has  been  made  by  Knapp,  and  is  as  follows: 
(i)  the  infective  granulomata.  including  tuberculous  growths,  gummata,  and 
actinomycotic  areas;  (2)  connective-tissue  growths;  (3)  epithelial  growths; 
(4)  aneurysms.  The  most  common  of  all  these  tumors  is  undoubtedly  that 
due  to  tubercle.  In  fact,  Gowers  estimates  that  if  we  exclude  syphiloma, 
tubercle  is  responsible  for  one-half  of  the  cases;  and  glioma  and  sarcoma 
together,  for  one-third. 

Tuberculous  Tumors. — Tuberculous  tumors  are  the  most  common  form 
met  with.  They  may  be  single,  but  are  often  "multiple;  and  multiple  growths 
may  be  very  widespread.  A  tuberculous  tumor  usually  arises  in  the  mem- 
branes or  in  an  arterial  distribution,  but  may  begin  in  a  ventricle,  or  even 
in  the  brain-substance.  The  tubercle  bacilh  responsible  for  the  condition 
are  carried  by  the  blood.  A  large  tuberculous  tumor  is  due  to  the  coalescence 
of  many  foci.  It  undergoes  caseation  in  the  center,  and  is  surrounded  by  a 
zone  of  softened  or  sclerotic  brain-substance. 

Gummatous  Tumors. — We  may  find  a  single  gumma,  but,  far  more  often, 
syphilitic  growths  are  multiple.  Such  a  growth  may  be  round,  or  may  be 
irregular  in  outline;  in  fact,  the  outline  is  frequently  blurred  and  indistinct. 
Some  of  these  growths  are  soft,  and  some,  which  contain  a  quantity  of  con- 
nective tissue,  are  hard.  A  syphiloma  usually  arises  from  the  membranes, 
and,  hence,  is  generally  on  the  surface  of  the  brain;  and  the  membranes  in 
the  region  of  the  growth  usually  show  distinct  inflammation. 

Actinomycosis. — This  is  a  very  rare  condition,  in  which  the  mass  may 
remain  solid  like  a  tumor,  but  is  far  more  apt  to  break  down  into  an  actino- 
mycotic abscess. 

Sarcomata. — Injury  seems  to  play  a  considerable  part  in  the  production 
of  intracranial  sarcoma.  Any  variety  of  sarcoma  may  arise.  As  a  rule,  at 
least  in  the  beginning,  the  growth  is  single;  but  it  may  be  multiple,  or  may 
become  so.  The  majority  of  sarcomata  arise  from  the  membranes  or  from 
the  periosteum,  but  some  cases  take  origin  from  beneath  the  corte.x.  Early 
in  their  progress  these  growths  are  encapsulated,  but  some  of  them,  from 
the  very  start,  are  infiltrating;  and  even  those  that  were  at  first  encapsulated 
later  infiltrate.  Endothelioma  is  sometimes  met  with.  What  is  called  angioma 
of  the  brain  is,  in  reality,  angiosarcoma.    A  psammoma  is  usually  sarcomatous. 


624  Diseases  and   Injuries  of  the   Head 

Gliomata. — A  glioma  is  a  growth  so  ill  defined  and  so  slightly  differen- 
tiated in  appearance  from  the  brain-substance  that  it  may  easily  be  over- 
looked in  an  exploratory  operation.  It  arises  much  more  frequently  from 
the  white  than  from  the  gray  matter,  and  develops  from  the  neuroglia  of 
the  cerebrum,  of  the  cerebellum,  of  the  pons,  or  of  the  medulla  oblongata. 
A  glioma  may  be  soft  or  may  be  hard;  and  soft  gliomata  are  probably,  in 
reality,  sarcomata.     Hemorrhage  is  very  apt  to  occur  in  these  growths. 

Fibromata. — Intracranial  fibroma  is  a  rare  growth.  It  is  of  firm  con- 
sistence, is  encapsulated,  and  may  grow  to  a  large  size.  Such  growths  can 
be  readily  enucleated.  Injury  seems  occasionally  to  be  responsible  for  their 
formation. 

Osteomata. — Osteophytic  growths  not  uncommonly  take  origin  from  the 
inner  surface  of  the  skull,  but  the  osteomata  arising  in  the  dura  or  in  the 
brain-substance  are  rare.     Such  growths,  however,  occasionally  occur. 

Cholesteatomata. — These  tumors  are  fibrous  growths  covered  with  endo- 
thelium and  containing  layers  of  cholesterin.  They  are  particularly  apt  to 
arise  in  the  pia  mater,  but  may  begin  in  either  of  the  other  membranes  or 
in  the  brain-substance.     A  cholesteatoma  is  commonly  called  a  pearl  tumor. 

Enchondromata  and  true  neuromata  are  rare,  and  Upomata  are  excessively 
uncommon. 

Adenomata. — An  adenoma  occasionally  springs  from  the  conarium,  or 
pituitary  body. 

Carcinomata. — Primary  intracerebral  carcinoma  is  rare,  but  does  occur. 
Secondary  carcinoma  is  more  common,  and  may  follow  cancer  of  any  part 
of  the  body,  although  it  is  most  apt  to  follow  cancerous  growths  about  the 
face  and  neck.  A  primary  growth  may  begin  in  the  meninges  or  in  the 
lining  of  the  ventricle.  Intracerebral  carcinomata  may  be  single  or  multiple. 
They  are  soft  and  non-encapsulated  growths. 

Cysts. — Mills  .says  that  cysts  arise  about  an  old  hemorrhage,  are  small 
retention-cysts  of  a  vascular  plexus,  or  are  porencephalic.  Dermoid  cysts 
are  extremely  rare. 

Symptoms. — The  .symptoms  are  diffuse  and  local,  and  are  similar  in 
many  particulars  to  the  symptoms  of  .some  other  lesions.  Among  the  symp- 
toms of  tumor  are  headache,  slow  speech,  stupor  or  coma,  slow  pulse,  pain 
on  percu.ssion  of  the  cranium,  vertigo,  vomiting,  epileptic  convulsions,  double 
choked  disk,  partial  or  complete  blindness,  extensive  or  limited  paralyses, 
paralysis  of  the  face,  the  eye-muscles,  or  the  limbs,  zones  of  anesthesia  and 
aphasia,  word-deafness,  word-blindness,  agraphia,  inco-ordination,  and 
mental  disturbances.  The  situation  of  a  tumor  is  determined  from  localizing 
symptoms,  their  mode  of  on.set  and  manner  of  combination.  In  some  ca.ses 
the  symptoms  are  not  characteristic,  and  in  some  cases  there  are  no  localizing 
symptoms.  The  nature  of  the  tumor,  its  depth,  and  whether  it  is  single, 
and  if  other  tumors  exist,  is,  if  possible,  determined.  Localizing  symjjtoms 
may  be  due  to  irritation  or  destruction  of  functionating  power.  Irritation 
causes  .spasm  and  destruction  induces  paralysis.  Convulsions  which  are 
local  or  which  begin  locally  are  known  as  Jacksonian  ei)ilepsy.  A  local 
convulsion  points  U)  an  irritative  lesion  of,  or  immediately  adjacent  to,  the 
center  which  presides  over  the  muscular  movements  of  the  ])art  convulsed. 
Local   paralysis  [joints  to  a  destructive  lesion  of  the  center  which   jjresides 


Tumors   of  the   Pons  625 

over  the  movements  of  the  paralyzed  part.  In  some  cases  a  center  is  dam- 
aged and  the  muscular  movements  it  controls  are  paralyzed,  but  the  adjacent 
brain-areas  are  irritated  and  the  muscles  they  represent  are  attacked  with 
spasms.  In  some  cases  an  apparently  paralyzed  part  becomes  convulsed, 
the  center  not  being  completely  destroyed  and  sudden  hyperemia  serving 
to  awaken  spasm.  Always  note  the  order  of  invasion  of  different  regions 
and  observe  if  spasm  is  followed  by  muscular  weakness  or  anesthesia. 

1.  Lesions  in  the  Cortical  Motor  Area. — An  irritative  lesion  of  the 
lower  third  of  this  area  causes  spasm  of  the  opposite  side  of  the  face,  angle 
of  mouth,  or  tongue;  and  this  condition  is  often  associated  with  tingling 
(Osier).  The  spasm  may  remain  limited  or  may  extend  widely,  and  may 
even  become  general.  Tumors  of  the  third  frontal  convolution  of  the  left 
side  cause  motor  aphasia.  An  irritative  lesion  of  the  middle  third  of  the 
cortical  area  causes  spasm,  which  is  limited  to  or  begins  in  the  fingers,  thumb, 
wrist,  or  shoulder  (Osier).  An  irritative  lesion  of  the  upper  third  of  the 
cortical  motor  area  causes  spasm,  which  is  limited  to  or  begins  in  the  toes, 
ankle,  leg,  or  hip.  If  such  lesions  exist  an  aura  is  occasionally  felt  in  the 
affected  region  before  the  spasm  begins,  and  there  is  often  numbness  after 
the  spasm.  Destructive  lesions  of  the  motor  area  cause  local  paralysis, 
which  may  be  preceded  by  local  spasm  of  the  same  parts,  and  is  often  a.sso- 
ciated  with  local  spasm  of  other  parts. 

2.  Tumors  of  the  prefrontal  region  give  no  localizing  symptoms,  but 
produce  general  symptoms.  Mental  disorders  are  apt  to  occur.  As  the 
tumor  grows  it  may  subsequently  involve  the  motor  region. 

3.  Tumors  of  the  parieto-occipital  lobe  may  occupy  a  silent  region 
of  this  lobe.  There  may  be  blindness  or  paraphasia  when  the  angular  gyrus 
is  affected. 

4.  Tumors  of  the  occipital  lobe  produce  homonymous  hemianopsia. 

5.  Tumors  of  the  temporosphenoidal  lobe  frequently  produce  no 
symptoms.     Tumors  in  the  left  lobe  may  cause  deafness. 

6.  Tumors  of  any  size  in  or  about  the  corpus  striatum  cause  hemi- 
plegia by  pressure  upon  the  internal  capsule.  Pressure  upon  the  optic  thala- 
mus produces  hemianopsia  and  hemianesthesia.  Growths  near  the  basal 
ganglia  produce  intense  optic  neuritis  and  early  pressure  because  of  dis- 
tention of  the  ventricles.  Osier  tells  us  that  tumors  of  the  corpora  quad- 
rigemina  are  apt  to  involve  the  crura,  and  later  the  third  nerve.  Ocular 
symptoms  are  always  present  (loss  of  pupillary  reflex  and  nystagmus).  If 
the  third  nerve  is  involved,  there  are  paralysis  of  the  motor  oculi  area  on 
the  side  of  the  lesion  (external  strabismus,  dilated  pupil,  and  drop-lid),  and 
hemiplegia  of  the  opposite  side  of  the  body  from  pressure  upon  the  crus. 
This  condition  is  a  form  of  cro.ssed  paralysis. 

7.  Tumors  of  the  Pons. — Pontine  lesions  produce  symptoms  by  pressure 
upon  the  particular  nerves  which  come  from  this  region,  with  or  without 
the  evidences  of  pressure  upon  the  motor  path.  Forms  of  crossed  paralysis 
may  exist.  Lesions  in  the  lower  half  of  the  pons  may  affect  the  fifth,  sixth, 
and  seventh  nerves  on  the  side  of  the  lesion,  and  the  limbs  on  the  opposite 
side.  The  auditory  nerve  ma}'  be  involved  in  the  lesion.  In  crossed  paralysis 
the  face  on  the  side  of  the  limb  paral}-zed  is  usually  not  affected,  but  in  ex- 
tensive tumors  it  may  be  paralyzed.     Conjugate  deviation  may  occur  away 

40  ■  ■  " 


626  Diseases  and   Injuries  of  the   Head 

from  the  facial  paralysis.  In  tumors  of  the  upper  part  of  the  pons  the  pupils 
may  be  first  contracted  from  irritation  of  the  third  nuclei,  and  later  dilated 
from  destruction  of  tliese  nuclei.  Anesthesia  as  a  result  of  pontine  tumors 
is  not  nearly  so  common  as  is  motor  paralysis,  and  convulsions  are  rare. 

8.  Tumors  of  the  Medulla. — An  extensive  lesion  inevitably  causes 
death.  Cranial  nerves  only  may  be  involved,  but  crossed  paralysis  may  take 
place.  Vomiting  is  common,  retraction  of  the  head  is  not  unusual,  respira- 
tory and  circulatory  disturbances  and  dysphagia  are  frequently  noted;  some- 
times there  is  numbness,  and  occasionally  there  are  convulsions;  usually  there 
is  inco-ordination,  because  of  pressure  upon  the  cerebellum. 

9.  Tumors  of  the  Cerebellum. — Tumors  of  the  middle  peduncle  cause 
sudden  uncontrollable  movements  of  the  trunk,  either  toward  the  side  of 
the  tumor  or  away  from  it.  Vertigo  and  nystagmus  are  common.  Symp- 
toms are  frequently  complicated  by  evidences  of  pontine  disease  proper. 

Tumors  oj  the  middle  lobe  0}  the  cerebellum  cause  a  sense  of  lost  equi- 
librium and  obvious  unsteadiness  in  attempting  to  walk,  or  even  to  stand 
(Gowers).  The  patient  has  a  tendency  to  fall;  there  are  giddiness  and 
vomiting. 

Tumors  oj  the  cerebellar  hemispheres  produce  no  localizing  symptoms. 
The  usual  unsteadiness  of  gait  is  due  to  pressure  upon  the  middle  lobe  (Noth- 
nagel).* 

Treatment. — If  any  doubt  exists  as  to  the  nature  of  a  brain  tumor, 
give  the  patient  a  course  of  iodid  of  potassium,  and  as  doubt  is  the  rule,  we 
almost  invariably  administer  it.  Give  the  drug  at  first  in  small  amounts,  but 
rapidly  increase  it  until  heroic  doses  are  taken  (100  or  more  grains  a  day). 
Mercury  should  also  be  given  hypodermatically.  If  iodid  of  potassium  and 
mercury  relieve  the  symptoms,  operation  is  unnecessary,  although  it  may 
be  demanded  later  in  order  to  remove  an  irritant  scar.  If  antisyphilitic 
treatment  fails,  the  question  of  operation  must  be  considered.  In  many 
cases  of  undoubted  tumor  excision  for  cure  is  not  attempted  because  of 
the  absence  of  localizing  symptoms  or  because  of  the  inaccessible  situation 
of  the  growth.  Tumors  at  the  base,  tumors  of  the  pons  and  medulla,  of 
the  corpus  callosum,  of  the  basal  ganglia,  and  of  the  deeper  parts  of  the  cen- 
trum ovale,  are  irremovable  (Byrom  Bramwell).  Most  tumors  of  the  cere- 
bellum should  not  be  attacked.  In  tumors  which  are  very  extensive  com- 
plete removal  is  usually  out  of  the  question.  There  is  no  use  in  removing 
.secondary  malignant  tumors.  It  often  happens  that  the  brain  itself  (as  in 
syphilis)  is  so  extensively  diseased,  or  that  other  organs  (as  in  tuberculosis) 
are  .so  involved,  as  to  render  attempts  at  removal  futile.  Bramwell  tells 
us  t  that  he  has  studied  eighty-two  cases  of  intracranial  tumor,  and  he 
considers  that  in  only  five  of  them  could  the  tumor  have  been  entirely  re- 
moved. The  conclusion  is  that  though  some  tumors  of  the  brain  may  be 
successfully  removed,  extirpation  is  only  to  be  decided  on  after  careful  study 
of  all  the  indications  and  contraindications  offered  by  the  case.  The  fibro- 
mata constitute  the  best  cases  for  operation.  In  ca.ses  not  operated  upon 
it  may  be  neces.sary  to  use  the  bromids  for  convulsions  and   morphin  for 

*  For  full  consideralioii  of  localizing  symptoms,  .see  the  works  of  Gowers,  Mills,  Der- 
cum,  and  Oslir,  which  have-  been  freelv  used  in  writmg  the  above  section. 
t  Kflinburgh  Mod.  jour.,  June,  1894. 


Operative   Treatment  of  Epilepsy  627 

headache.  The  headache  is  often  benefited  by  purgatives,  courses  of  potas- 
sium iodid,  the  ice-bag  to  the  head,  and  the  apphcation  of  a  hot  iron  to  the 
nape  of  the  neck.  Though  thorough  extirpation  is  feasible  in  but  few  cases, 
operation  should  often  be  performed  for  palliative  purposes.  Grainger 
Stewart,  Annandale,  Horsley,  Macewen,  and  Keen  have  advocated  palliative 
trephining  in  certain  cases. 

This  procedure  is  of  value  in  diminishing  excessive  intracranial  pressure, 
and  thus  relieving  headache  and  decreasing  the  tendency  to  sudden  death 
from  inhibition  of  the  heart  or  respiratory  failure  (Hughlings  Jackson  and 
Byrdm  Bramwell). 

Palliative  trephining  may  relieve  optic  neuritis,  and  thus  retard  or  prevent 
atrophy  and  blindness.  Bramwell  asserts  this  positively,  and  he  still  believes 
that  excessive  intracerebral  pressure  is  an  important  element,  though  not 
the  only  element  in  neuritis. 

Most  cases  of  tumor  should  be  trephined  for  exploration;  in  some  cases 
extirpation  may  be  performed;  in  most  cases  extirpation  is  impossible,  and 
the  surgeon  must  be  content  with  the  palliative  influence  of  trephining.  A 
tumor  of  the  brain  if  not  cured  by  antisyphilitic  treatment,  is  of  necessity 
fatal  if  unoperated  upon,  and  trephining  is  not  a  very  dangerous  operation. 
After  palliative  trephining,  make  an  attempt  to  obtain  prolonged  drainage 
of  cerebrospinal  fluid. 

Operative  Treatment  of  Epilepsy.^The  shock  of  an  accident  or 
a  general  concussion  may  establish  epilepsy,  especially  in  those  predisposed 
by  heredity  or  other  causes.  Traumatic  epilepsy,  Le  Dentu  tells  us,*  may 
be  due  to:  (i)  bone-fragments  from  skull-fracture;  (2)  outgrowths  of  bone 
due  to  tumor;  (3)  cicatrices  of  meninges  resulting  from  laceration  of  mem- 
branes by  bone-fragments;  (4)  chronic  meningitis  which  ends  in  sclerosis 
of  membranes;  (5)  cysts  resulting  from  intracranial  hemorrhage  at  the  point 
of  fracture;  (6)  arteriovenous  aneurysm.  We  refer  here,  in  speaking  of 
traumatic  epilepsy,  purely  to  the  condition  when  it  follows  a  head-injury, 
and  this  is  the  common  meaning  of  the  term.  Remember  that  epilepsy, 
as  shown  by  Sachs,  may  follow  a  long-forgotten  injury.  When  epilepsy 
has  followed  traumatism  and  a  scar  exists  upon  the  scalp,  excise  the  scar, 
especially  if  it  is  tender  or  is  the  seat  of  an  aura.  If,  on  lifting  the  scalp,  a 
depression  of  bone  or  a  disease  of  the  bone  is  manifest,  trephine  for  e.xplora- 
tion,  even  over  a  silent  area.  Trephining  in  epilepsy  may  disclose  a  cyst, 
a  dural  scar,  a  brain-scar,  a  depressed  portion  of  bone,  or  eburnation  of 
bone  from  osteitis  (Keen).  In  exploratory  operations  for  epilepsy  always 
open  the  dura.  When  the  injury  is  over  a  known  motor  center  it  is  im- 
portant to  trephine.  This  operation  is  especially  indicated  when  the  con- 
vulsions begin  in  the  muscles  of  this  center,  in  which  case  it  is  proper  to 
remove  the  center  after  trephining.  Remove  all  sources  of  peripheral  irri- 
tation (Briggs  reported  a  case  of  epilepsy  in  which  there  were  distinct  skull- 
depression  and  necrosis  of  the  tibia,  but  the  cure  of  the  necrosis  of  the  tibia 
arrested  the  convulsions).  If  epilepsy  arises  notwithstanding  primary  tre- 
phining, open  the  flap,  round  the  bony  edges  with  a  rongeur,  and  cut  out 
the  scar.f 

*  I^a  Presse  medicale.  June  9,  1S94. 

t  The  author,  in  Hare's  "  System  of  Practical  Therapeutics  " 


628  Diseases  and   Injuries  of  the   Head 

These  operations  sometimes  seem  to  cure  epilepsy,  but  so,  occasionally, 
does  any  operation.  White  records  *  ninety  trephinings  in  which,  though 
no  cause  was  found  for  the  epilepsy,  great  relief  followed,  and  two  cases 
were  apparently  cured;  he  mentions  benefit  or  apparent  cure  following  tra- 
cheotomy, ligation  of  the  carotid  artery,  incision  of  the  scalp,  etc.  The 
same  effect  may  be  obtained  by  a  great  shock,  high  fever,  the  administration 
of  an  anesthetic,  or  an  accident.  The  fact  seems  to  be  that  any  operation, 
by  means  of  nervous  shock,  may  interrupt  the  epileptic  habit;  but  in  ordinary 
operations  the  lits  tend  after  a  time  to  recur,  and  soon  reach  their  old  standard 
of  frequency.  In  the  special  brain-operations  with  excision  of  obvious  lesions 
or  discharging  centers  the  fits  usually  recur,  but  they  will  rarely  reach  the 
old  standard  of  frequency,  and  will  be  more  amenable  to  medical  treat- 
ment. Bramwell  says  that  when  traumatism  is  followed  by  epilepsy  and 
the  epileptic  discharge  starts  from  a  cortical  center  which  is  not  beneath 
the  scar,  trephine  first  at  the  seat  of  injury,  and  if  no  lesion  is  met  with  tre- 
phine over  the  discharging  center.  In  epilepsy  the  fits  are  to  be  studied 
by  a  competent  observer  and,  if  focal  epilepsy  or  Jacksonian  epilepsy  exist, 
and  treatment  by  drugs  has  failed,  trephining  is  to  be  performed  over 
the  diseased  center  and  the  explosive  focus  is  to  be  located  by  an  electric 
current  and  removed.  Keen,  Horsley,  Nancrede,  Macewen,  and  others 
practise  this,  but  hope  for  improvement  rather  than  expect  cure.  This 
operation  causes  paralysis,  but  the  paralysis  is  rarely  permanent,  except, 
perhaps,  of  the  finer  movements. 

In  non-traumatic  chronic  epilepsy  without  localizing  symptoms  trephining 
is  not  justifiable  unless  persistent  headache  calls  for  it  as  a  means  of  relief 
from  intracranial  pressure.  Annandale  has  recently  advised  us  to  consider 
experimental  operation  in  such  cases  when  the  drug-treatment  has  failed 
and  when  the  patient's  condition  seems  hopeless.  He  says  there  is  no  chance 
of  improvement  without  operation,  and  operation  may  possibly  disclose  a 
removable  lesion. f  After  trephining  for  epilepsy  five  years  should  elapse 
without  a  convulsion  before  cure  is  reasonably  assured;  and  if  convulsions 
arise,  they  must  at  once  be  met  by  medical  treatment.  A  man  having  once 
had  a  convulsion  may  at  any  time  have  others;  hence  he  should  always  be 
watched.  It  is  not  unusual  for  a  few  convulsions  to  occur  soon  after  an 
operation  for  epilepsy,  and  then  to  cease  for  a  considerable  time.  These 
early  fits  result  from  habit.  Among  the  operative  procedures  suggested  for 
the  treatment  of  epilepsy  may  be  mentioned  circumcision,  clitoridectomy, 
ocular  tenotomy,  ligation  of  the  vertebral  arteries,  removal  of  the  cervical 
gangha  of  the  sympathetic  (page  588)  (Alexander,  Jonnesco,  Jaboulay), 
and  the  actual  cautery  to  the  head  (Fere). 

Operations  on  the  Skull  and  Brain. — Trephining  (for  a  fracture  of 
the  .skull). — Shave  the  scalp,  scrub  it  with  ethereal  soap  and  sterile  water, 
wash  it  with  sterile  water  and  then  with  alcohol  or  ether,  scrub  with  a  brush 
wet  with  corrosive  sublimate  solution  (i  :  1000),  and  wrap  the  seal])  in  wet 
corrosive  sublimate  gauze  (i  :  2000).  The  instruments  required  are  a  scalpel, 
a  dissector,  hemostatic,  dissecting,  and  mouse-toothed  forceps,  trephines  of 

*  "The  Supposed  Curative  Effects  of  Operations  /;';-  .sr,"  Annals  of  Surgery,  Aug. 
and  Sept. ,  189 1. 

t  Edinburgh  Med.  Jour.,  April,  1894. 


Operations   on  the  Skull   and   Brain 


62Q 


Gait's  conical  irephine. 


several  sizes  (Figs.  331,  332),  a  periosteum-elevator,  Hey's  5av»-,  rongeur 
forceps,  a  bone-elevator,  scissors  straight  and  curved  on  the  flat,  a  dural 
separator,  a  tenaculum,  small  curved  and  large  curved  Hagedorn  needles, 
and  a  needle-holder;  catgut,  fine  silk,  silkworm-gut,  and  Horsley's  wax. 
Provide  a  sand  pillow.  The  patient  should  be  anesthetized  unless  he  is 
unconscious,  and  is  placed  upon  his  back  with  the  shoulders  a  httle  raised. 
A  sand  pillow  is  placed  under  the  neck,  and  his  head  is  turned  away  from 
the  side  to  be  operated  upon.  The  position  of  the  surgeon  is  such  that  the 
patient's  head  is  a  Httle  to  his  left.  A  large  semilunar  incision  is  made  with 
the  base  down,  which  incision  goes  through  the  periosteum,  and  the  flap  is 
lifted.  The  bleeding  vessels  of  the  flap  are  caught  with  forceps.  The 
fracture  is  sought  for  and  found. 
The  pin  of  the  trephine  is  pro- 
jected beyond  the  crown  and  is 
set  upon  sound  bone,  the  crown 
overhanging  the  line  or  edge  of 
the  fracture.  The  surgeon  fries 
to  avoid    the   region  of  a  sinus 

or  large  artery.  A  gutter  is  cut  in  the  bone,  the  pin  of  the  instrument 
is  withdrawn,  and  the  trephining  is  completed.  In  going  through  the 
diploe  bleeding  is  copious.  The  inner  table  feels  very  dense.  Stop  from 
time  to  time,  clean  out  the  gutter  in  the  bone  with  the  dissector,  and  try 
the  bone  with  an  elevator  to  see  if  it  is  loose.  When  the  fragment  is  loose 
enough,  pry  it  out.  If  the  surgeon  desires  to  replace  the  button,  hand  it 
to  an  assistant,  who  places  it  at  once  in  a  bowl  of  warm  normal  salt  solu- 
tion, kept  warm  by  standing  in  a  basin  of  water  at  105°  F.,  or  who  puts  it 
in  warm  carbolized  towels.  The  edges  of  the  opening  should  be  rounded 
with  a  rongeur  and  the  bone,  if  depressed,  must  be  elevated.  Sometimes 
it  may  be  necessary  to  remove  splinters  and  fragments  of  bone.  After  re- 
moving the  fragments  the  edges  of 
the  opening  should  be  smoothed  by 
the  use  of  the  rongeur  forceps.  The 
dura  should  be  examined  to  see  if 
injury  exists,  and  hemorrhage  must 
be  stopped.  Bleeding  from  the  dura 
is  arrested  by  passing  a  ligature  of 
silk  or  catgut  threaded  in  a  small  curved  needle  under  the  vessel  on  each  side 
of  the  wound,  and  tying  the  ligatures.  Bleeding  from  the  pia  is  arrested 
by  direct  ligation,  by  suture  ligature  or  by  gauze  packing.  Bleeding  from 
the  diploe  is  arre.sted  by  the  use  of  Horsley's  wax.  The  wound  is  cleansed, 
in  some  cases  the  button  of  bone  is  re-introduced,  in  other  cases  some  chips 
are  cut  from  the  bone  and  scattered  upon  the  dura,  but  in  most  cases  no 
attempt  is  made  to  fill  up  the  gap  in  the  bone.  The  scalp  is  sutured  with 
silkworm-gut  and  horse-hair  or  gauze  drainage  is  employed  for  a  day  or  two. 
Sterilized  gauze  dressings  are  put  on,  a  rubber-dam  is  laid  over  them,  and 
a  gauze  bandage  wet  with  bichlorid  of  mercury  is  applied. 

Instead  of  the  trephine  some  surgeons  use  the  chisel  or  gouge  and  hammer 
to  remove  a  portion  of  the  bone.  Other  operators,  believing  that  this  pro- 
cedure may  cause  concussion,  emplov  the  surgical  engine. 


F'gT-  332- — Crown  Irephine. 


630 


Diseases  and   Injuries   of  the   Head 


Osteoplastic  Resection  of  the  Skull. — Wolff  suggested  this  operation, 
and  in  iSSg  Wagner  performed  it.     It  is  employed  for  the  removal  of  tumors 

and  the  Gasserian  ganglion, 
and  for  exploration.  A 
horseshoe  incision  is  made 
through  the  scalp  and  peri- 
osteum, a  groove  correspond- 
ing to  this  incision  is  cut  in 
the  bone  by  special  gouges  or 
chisels.  The  bone  is  chiseled 
through,  but  is  left  attached 
to  the  scalp.  The  bone  is 
then  broken  outward,  the 
fracture  taking  place  at  the 
base  of  the  bone-flap.  After 
the  operation  the  bone  which 
is  still  adherent  to  the  peri- 
cranium is  restored  to  its 
proper  place.  Some  sur- 
geons use  the  surgical  eijgine 
instead  of  the  chisel,  and 
others  make  trephine-open- 
ings  and  cut  from  within  out- 
ward by  means  of  the  Gigii 
wire  saw  (Obalinski).  The  osteoplastic  method  of  opening  the  skull  is  em- 
ployed when  a  large  opening  is  necessary,  as  when  the  operation  is  first  of 


Fig  333. — Cranial  areas  for  osteoplastic  operations  with 
the  StelKvagen  trephine,  these  areas  corresponding  to  the 
regions  of  the  left  hemicerebrum,  with  definite  syndromes 
(Mills). 


Fig.  334. — The  motor  region  outlined  on 
the  skull  previous  to  osteoplastic  operation 
with  the  Stellwageii  trephine:  x,  Point  to  the 
insertion  of  the  pin  of  the  Stellwagen  trephine  ; 
y  z,  base  line  (Mills). 


Fig.  335 — Slellwagen's  trephine. 


all  for  diagnosis.     Krause,  Keen,  and  others  employ  this  plan  in  operating 
to  remove  the  Gasserian  ganglion. 

Besides  restoring  a  flap  (jf  bone  into  [)()siti(Hi,  or  re|jlacing  a  button  of 


Technique   of  Brain-operations  63  I 

bone,  or  strewing  the  dura  with  bone-fragments,  other  methods  of  closing 
the  opening  have  been  practised.  F"or  instance,  heteroplasty  with  a  decal- 
cified bone-plate  and  heteroplast}'  with  a  celluloid  plate  or  other  foreign 
material.* 

Osteoplastic  Resection  oj  the  Sliitll  by  the  Use  oj  Stellwagen  Trephine. — 
The  concussion  inflicted  by  the  mallet  I  believe  adds  to  shock,  may  increase 
or  cause  hemorrhage,  may  extend  a  line  of  fracture  or  produce  fracture, 
and  may  rupture  a  purulent  collection.  For  these  reasons  I  prefer  a  dif- 
ferent plan.  The  surgical  engine  gives  satisfaction  to  .some,  but  it  is  difficult 
to  render  it  sterile,  and  it  runs  at  such  a  high  rate  of  speed  that  regulation  is 
troublesome  and  the  instrument  is  dangerous.  The  trephine  shown  in  the  cut 
has  proved  satisfactory.  It  has  since  been  modified  by  substituting  screws 
for  spikes  in  the  pivot  plate.  Dr.  Park  suggested  putting  a  handle  to  the 
spiked  plate  to  keep  it  from  slipping.  The  area  of  bone  to  be  removed  is 
carefully  determined  as  suggested  by  Mills  (see  Figs.  333  and  334),  the 
plate  is  screwed  into  the  skull,  the  scalp  is  cut  with  the  knife-blade,  the  base 
of  the  flap  being  made  narrow;  the  saw  is  substituted  for  the  knife  in  the 
instrument.  The  bone  is  cut  by  short,  quick  cuts,  making  no  attempt  to 
swing  the  saw  through  the  entire  length  of  the  incision  at  each  turn  of  the 
wrist.  When  the  inner  plate  is  nearly  cut  through,  the  division  is  completed 
by  a  small  osteotome.  The  operation  can  be  completed  on  an  ordinarily 
thick  skull  in  from  eight  to  eighteen  minutes.  (See  article  by  author  in 
''Annals  of  Surgery,"  July,    1903.) 

Trephining  the  Frontal  Sinus. — This  operation  may  be  employed  for 
inflammation  of  the  lining  membrane  of  the  sinus  or  for  empyema.  Make 
a  vertical  incision  in  the  middle  of  the  forehead,  starting  one  and  one-half 
inches  above  the  nasion  and  terminating  at  the  root  of  the  nose.  The  button 
of  bone  is  removed  and  the  opening  is  enlarged  if  necessary.  The  mucous 
membrane  is  incised,  the  opening  into  the  nose  is  found  and  is  dilated,  and 
a  drainage-tube  is  passed  into  the  nose  from  the  sinus,  the  upper  end  being 
left  in  the  sinus.  In  some  severe  cases  Jacobson  advises  us  to  curet  the 
sinus,  to  disinfect  it  by  the  use  of  silver  nitrate  or  chlorid  of  zinc,  and  to 
insufflate  an  "aseptic  powder."'  In  some  cases  resect  the  mucous  membrane. 
I  prefer  an  o.steoplastic  resection  to  trephining  the  frontal  sinus. 

Trephining  the  Mastoid  (operation  for  mastoid  suppuration,  page  632). 

Technique  of  Brain-operations  (after  Horsley  and  Keen). — Instru- 
ments as  for  fractured  skull.  In  focal  epilepsy  a  faradic  battery  is  required. 
Always  shave  the  scalp,  and  always  antisepticize  it.  In  localizations,  mark 
out  the  fissure  upon  the  scalp  with  an  anilin  pencil  or  with  iodin.  Have 
the  patient  semi-recumbent.  Mark  three  points  upon  the  bone  with  the 
center-pin  of  the  trephine  before  incising  the  scalp  (both  ends  of  the  Rolandic 
fissure  and  the  point  at  which  the  trephine  will  be  applied).  Make  a  semi- 
lunar flap  three  inches  in  diameter,  with  the  base  below.  Control  bleeding 
in  the  flap  by  forceps  pressure.  The  one  and  a  half  inch  trephine  should 
be  employed,  but  if  a  smaller  trephine  is  used,  the  opening  must  be  enlarged 
with  a  rongeur.  Before  enlarging  the  opening,  separate  the  dura  from  the 
bone  by  a  dural  separator.  As  a  rule,  open  the  dura  and  examine  the  brain 
The  dura  is  lifted  by  mouse-toothed  forceps  and  is  opened  with  scissors  along 

*  See  Bretaiio,  in  Deutsche  med.  Woch.,  May  17,  1894. 


632  Diseases  and   Injuries   of  the   Head 

a  line  a  quarter  of  an  inch  from  the  bone-edge,  a  broad  pedicle  of  dura  being 
left  uncut.  Hemorrhage  is  arrested  by  pressure  and  hot  water,  or  by  passing 
a  thread  of  silk  or  catgut  around  any  bleeding  vessel  by  means  of  a  curved 
needle.  In  some  cases  packing  must  be  retained  or  forceps  must  be  kept  on. 
In  packing,  endeavor  to  use  but  one  piece  of  gauze,  so  as  to  avoid  leaving  in 
a  forgotten  piece.  Upon  opening  the  dura  cerebrospinal  fluid  flows  out,  the 
stream  being  increased  with  each  expiration.  Absence  of  pulsation  of  the  brain 
points  to  abscess  or  tumor,  and  a  livid  color  indicates  subcortical  growth.  An 
old  laceration  is  brownish.  If  the  brain  bulges  through  the  opening,  it  means 
increased  pressure  (tumor,  abscess,  effusion  into  the  ventricles,  etc.).  After 
opening  the  dura  employ  no  antiseptics,  especially  when  the  surgeon  intends 
using  electricity  to  locate  a  center.  Irrigate  only  whh  warm  salt  solution. 
In  operating  for  tumor  the  dura  is  opened  and  in  some  cases  the  brain  is 
incised.  The  tumor  is  turned  out  by  the  finger,  or,  if  this  is  impossible, 
by  the  dry  dissector,  the  scissors,  the  dull  knife,  or  the  sharp  spoon.  If 
the  entire  tumor  cannot  be  removed,  take  away  as  much  as  possible.  The 
removal  of  a  portion  often  retards  the  growth  of  the  remainder,  and  the 
trephining,  by  lessening  cerebral  pressure,  relieves  the  symptoms  and  pro- 
longs hfe.  After  removing  a  tumor  arrest  distinct  points  of  bleeding  with 
the  ligature  alone  or  the  ligature  passed  around  the  vessel  by  means  of  a 
needle.  Pack  the  tumor-cavity  with  gauze  and  bring  the  end  of  the  plug 
out  of  the  wound.  Stitch  the  dura  with  silk  and  suture  the  scalp  with  silk- 
worm-gut. In  electrifying  the  brain  faradism  is  employed  of  a  strength 
about  sufficient  to  move  the  thenar  muscles  when  applied  to  them.  The 
current  is  applied  to  the  motor  area  by  the  double  electrode.  A  careful 
observer  watches  the  muscular  movements.  If,  for  instance,  the  surgeon 
wishes  to  remove  the  thumb-center,  he  moves  the  electrode  from  point  to 
point  until  he  obtains  thumb-movements.  The  region  is  sliced  awa\'  bit 
by  bit  until  the  center  which  is  responsible  for  the  convulsive  movements 
is  removed.  It  will  be  found  impossible  to  remove  only  the  thumb-center. 
Adjacent  centers  are  sure  to  be  more  or  less  damaged,  and  a  certain  amount 
of  paralysis  follows  the  operation.  If  we  wish  to  tap  the  ventricles,  Keen 
directs  the  trephine-opening  to  be  one  and  one-fourth  inches  behind  the  ex- 
ternal auditory  meatus  and  the  same  distance  above  the  base-line  of  Reid 
(Fig.  336,  a).  A  grooved  director  or  metal  tube  is  passed  into  the  brain 
in  the  direction  of  a  point  "  two  and  one-half  to  three  inches  above  the  oppo- 
site meatus."  The  normal  ventricle  will  be  entered  at  a  depth  of  two  to 
two  and  one-fourth  inches,  but  the  dilated  ventricle  will  be  entered  sooner 
(Keen).  The  moment  of  entry  is  marked  by  lessened  resistance  and  a  flow 
of  cerebrospinal  fluid.  Drainage  can  be  maintained  by  introducing  a  rubber 
tube.  This  operation  has  been  employed  in  hydrocephalus.  After  an  aseptic 
cerebral  operation,  as  a  rule,  do  not  drain  unless  hemorrhage  has  been  con- 
siderable. In  many  ca.ses  replace  the  bone,  but  not  when  the  bone  is  dis- 
eased, is  infected,  or  is  very  compact,  or  if  it  is  desired  to  alter  pressure. 
The  dura  is  sutured  by  a  continuous  silk  suture;  the  scalp  is  sutured  by  inter- 
ru[^ted  silkworm-gut  sutures. 

Operation  for  Mastoid  Suppuration. — The  instruments  re(|uired  in 
this  operation  are  a  scalpel,  a  gouge,  a  chi,?el,  a  mallet,  curets,  a  probe,  a 
dissector,  di.s.secting  and  hemostatic  forceps,  and  needles.     Provide  a  sand- 


Operation  for   Mastoid  Suppuration 


633 


bag  to  place  under  the  neck.  An  incision  is  made  one-quarter  of  an  inch 
posterior  to  the  auricle  and  down  to  the  bone,  and  in  the  direction  of  the 
long  axis  of  the  mastoid.  The  bone  is  bared  and  examined,  especially  at 
a  point  in  the  line  of  the  incision  which  is  on  a  level  with  the  roof  of  the  meatus 
(Fig.  336,  c).  The  bone  will  usually  be  found  softened.  Gouge  it  away 
and  thus  open  the  mastoid  antrum.  The  bone-opening  is  within  the  Hmits 
of  Macewen's  suprameatal  triangle,  a  space  bounded  by  the  posterior  root 
of  the  zvgoma,  the  posterior  bony  wall  of  the  meatus,  and  an  imaginary 
line  joining  the  two.     If  the  mastoid  is  open.ed  in  this  triangle,  the  antrum 


Fig.  336. — Opening  the  mastoid  antrum  and  the  lateral  sinus ;  exposure  of  the  temporo- 
sphenoidal  lobe  and  puncture  of  the  descending  horn  of  the  lateral  ventricle  :  a,  Temporosphenoidal 
lobe  (descending  cornu  of  lateral  ventricle  is  i  cm.  deeper)  ;  b^  inner  surface  of  periosteum  ;  c,  mas- 
toid antrum  ;  d.  lateral  sinus  (Kocher). 


is  entered  directly  and  there  is  no  chance  of  wounding  the  lateral  sinus.  If, 
in  the  adult,  pus  is  not  found  on  opening  the  mastoid  antrum,  gouge  down- 
ward and  backward,  but  with  great  care,  so  as  to  avoid  the  lateral  sinus. 
If  there  be  any  possibility  of  the  e.xistence  of  pus  in  the  groove  of  the  sinus, 
the  sinus  should  be  unhesitatingly  e.xposed.  After  evacuating  the  pus  from 
the  mastoid  gouge  away  bony  septa,  enlarge  the  opening  between  the  mastoid 
and  the  middle  ear  with  the  gouge,  turn  the  head  toward  the  side  operated  upon, 
and  irrigate  the  mastoid  with  corrosive  sublimate  solution  (i  :  2000) ;  dust 
with  iodoform,  pack  with  iodoform  gauze  for  a  few  days,  and  then  introduce 
a  silver  drainage-tube.     Treat  the  causative  ear  disease.     A.  Marmaduke 


634  Diseases  and   Injuries  of  the   Head 

vSheild  and  Prof.  Macewen  operate  on  inveterate  cases  of  mastoid  disease  as 
follows:  A  thick  flap  is  raised  behind  the  auricle,  the  flap  including  the  orifice 
of  any  sinus  and  being  "left  attached  by  its  stalk."  The  auricle  is  ''de- 
tached forward  and  the  soft  parts  over  the  mastoid  are  turned  backward 
by  horizontal  incision."  The  "lining  membrane  of  the  canal  is  separated 
from  the  bone."  The  mastoid  is  opened  and  dead  bone  and  caseous  matter 
are  removed,  overhanging  edges  are  chiseled  down,  and  the  posterior  bony 
wall  of  the  external  auditory  meatus  is  gouged  away.  The  skin-flap  is 
pushed  into  the  cavity  and  is  held  in  place  with  pads  of  gauze.  The 
margins  of  the  flap  may  be  sutured,  but  this  is  not  necessary.  Macewen 
calls  this  procedure  "papering"  the  cavity  with  skin.* 

If  mastoid  suppuration  has  established  abscess  in  the  temporosphenoidal 
lobe,  trephine,  one  and  a  quarter  inches  behind  and  one  and  a  quarter  inches 
above  the  middle  of  the  external  meatus  (Barker's  point)  and  search  for 
pus  as  directed  on  page  619.  If  abscess  0}  the  cerebellum  exists,  trephine 
below  the  line  of  the  lateral  sinus.  "  The  position  of  the  lateral  sinus  is 
indicated  by  a  line  running  horizontally  outward  from  the  occipital  protu- 
berance to  within  about  an  inch  of  the  external  auditory  meatus,  and  thence 
downward  to  the  mastoid  process"  (Owen's  "Manual  of  Anatomy").  If 
infective  sinus-thrombosis  exists,  break  into  the  lateral  sinus  (Fig.  336,  d) 
from  the  mastoid  opening  and  proceed  as  directed  on  page  622. 

Linear  Craniotomy. — Instruments  as  for  any  brain  operation,  plus, 
however,  several  kinds  of  rongeur  forceps.  Make  a  large  flap.  Trephine 
the  skull  a  finger's  breadth  from  the  sagittal  suture,  and  the  same  distance 
back  of  the  coronal  suture.  Rongeur  the  bone  away  in  a  hne  parallel  with 
the  sagittal  suture  up  to  a  point  in  front  of  the  lambdoidal  suture.  Remove 
the  pericranium  which  covered  the  bone  excised.  Insert  the  dura)  separator, 
or  pass  it  along  the  margins.  In  some  cases  an  additional  portion  of  the 
bone  is  removed  over  the  fissure  of  Rolando.  Various  suggestions  have 
been  made  as  to  the  direction  and  situation  of  bone-sections.  Bleeding 
is  arrested  and  the  fla])  is  closed  without  drainage. 

Removal  of  Gasserian  Ganglion. — (See  page  591.) 

Operation  for  Infective  Sinus-thrombosis. — (See  page  622.) 

*  Lancet,  Feb.  8,   1S96. 


Sacrococcygeal   Tumors  63 ; 


XXIV.    SURGERY    OF   THE    SPINE. 

Congenital  Deformities. — Spina  bifida,  err  hydrorrhachitis,  is  a  con- 
genital cystic  tumor  due  to  vertebral  deficiency,  permitting  protrusion  of 
the  contents  of  the  spinal  canal  in  the  median  line.  The  laminae  or  spines  of 
one  vertebra  or  of  several  vertebrae  may  be  deficient,  most  frequently  in  the 
lumbosacral  region.  Meningocele  is  a  protrusion  of  dura  mater  and  arachnoid, 
the  sac  containing  cerebrospinal  fluid,  but  no  nerves  and  no  cord-substance. 
Meningomyelocele  (the  commonest  form)  is  a  protrusion  of  dura  mater  and 
arachnoid,  the  sac  containing  cerebrospinal  fluid,  nerves,  and  cord -substance. 
The  cord  may  spread  upon  the  sac-wall  or  it  may  pass  through  the  sac  and  re- 
enter the  canal.  Syringomyelocele  is  great  distention  of  the  central  canal,  the 
sac-wall  being  formed  of  the  thinned  cord.  A  spina  bifida  varies  in  size  from 
that  of  a  walnut  to  that  of  an  infant's  head;  it  grows  rapidly  during  the  early 
weeks  of  life;  it  is  usually  sessile,  but  may  present  where  it  joins  the  body  a 
definite  constriction,  or  even  a  pedicle;  the  base  of  the  sac  is  covered  with 
healthy  skin,  and  the  fundus  is  covered  only  by  thin  epidermis  or  by  the  spinal 
membranes  themselves.  Pressure  upon  the  tumor  is  found  to  diminish  its 
size  and  to  increase  the  tension  of  the  anterior  fontanel,  and  possibly  to  cause 
convulsions  or  stupor.  The  cyst  is  translucent,  and  the  margins  of  the  bony 
aperture  are  distinct.  Crying,  coughing,  or  pressure  upon  the  anterior 
fontanel  makes  the  tumor  more  tense.  Spina  bifida  is  apt  to  be  associated 
with  club-foot,  with  hydrocephalus,  and  with  rectal  or  vesical  paralysis. 
Spina  bifida  usually  causes  death.  A  few  meningoceles  and  a  very  few  menin- 
gomyeloceles undergo  spontaneous  cure  by  the  shrinking  of  the  sac.  Syrin- 
gomyelocele is  invariably  fatal.  The  cause  of  death  may  be  rupture  of  the  sac 
or  marasmus. 

Treatment. — \'ery  small  protrusions  which  grow  slowly  and  are  covered 
with  sound  skin  may  be  treated  by  the  use  of  a  compress  and  bandage,  by  an 
elastic  bandage,  or  by  apphcations  of  contractile  collodion.  It  was  formerlv 
regarded  as  proper  to  tap  and  drain  the  sac.  Injection  was  used  by  many. 
The  sac  being  cleaned,  the  child  was  placed  on  its  side  and  a  little  chloroform 
was  given.  A  fine  trocar  was  plunged  obliquely  in  at  the  side  through  sound 
skin,  little  or  no  fluid  being  drawn  off,  and  3j  of  Morton's  fluid  injected  (iodin, 
gr.  x;  iodid  of  potassium,  gr.  xxx;  glycerin,  5j).  The  trocar  was  withdrawn 
and  the  puncture  was  sealed  with  a  bit  of  gauze  and  iodoform  collodion.  The 
child  was  put  to  bed.  If  injection  proved  successful,  the  sac  was  found  to 
shrink;  if  the  injection  failed,  it  was  the  custom  to  repeat  it  at  intervals  of  from 
seven  to  ten  days  (Jacobson,  White).  Surgeons  now  prefer  excision  of  the  sac. 
Bayer  treats  it  as  he  would  "  hernia.  Robson  in  some  cases  excises  the  entire 
sac. 

Sacrococcygeal  Tumors.— Dermoids  external  to  the  sacrum  are  oc- 
casionally seen  in  this  region.  Dermoids  also  arise  between  the  rectum  and 
sacrum.  In  the  lower  sacral  or  coccygeal  region  the  cutaneous  structures 
sometimes  fail  of  complete  coalescence  and  a  post-anal  dimple  or  sinus  is  the 
result.  Such  a  sinus  is  lined  with  skin  and  its  wall  contains  numerous  glands 
and  often  hairs.     It  may  inflame  or  suppurate.     If  it  blocks  up  at  the  outlet 


636  Surgery  of  the   Spine 

a  form  of  dermoid  develops.  Teratomata,  lipomata,  and  hydatid  cysts  may 
develop  in  the  sacrococcygeal  region. 

Treatment. — Dermoids  require  extirpation.  If  a  post-anal  dimple  causes 
no  trouble,  it  is  let  alone;  otherwise  it  is  dissected  out.  It  may  or  may  not  be 
possible  to  remove  teratomata.     Lipomata  and  hydatids  are  extirpated. 

Anosacral  Cysts. — These  cysts  develop  between  the  sacrum  and  rectum 
and  originate  from  remnants  of  the  post-anal  gut  and  neurenteric  canal.  Such 
cvsts  may  be  multilocular  or  unilocular.  They  can  be  detected  by  a  finger  in 
the  rectum. 

Treatment. — Some  of  these  growths  are  removed  after  osteoplastic  re- 
section of  a  portion  of  the  sacrum;  some  are  removed  by  incising  the  rectal 
wall. 

Tumors  of  the  Spinal  Cord. — Among  congenital  tumors  are  lipomata 
and  cysts  (dermoid,  congenital,  sacral,  and  fetal).  Tubercle,  gumma,  psam- 
moma,  and  fibroma  may  arise  from  the  cord  or  its  membranes.  Glioma  is  the 
most  usual  growth.  Primary  sarcoma  is  rare.  Angeioma  may  occur.  Pri- 
mary carcinoma  does  not  occur  in  this  region.  A  tumor  rarely  produces  ob- 
vious symptoms  until  it  is  as  large  as  a  hazel-nut. 

Symptoms. — Pain,  stiffness  of  the  back,  areas  of  anesthesia,  and  progres- 
sively advancing  motor  paralysis  are  symptoms  of  spinal  tumors.  A  tumor 
may  produce  the  symptoms  of  compression-myelitis,  locomotor  ataxia,  or 
mvehtis.  In  glioma  there  are  apt  to  be  loss  of  ability  to  recognize  variations 
of  temperature  (or  even  to  distinguish  between  heat  and  cold),  loss  of  the  sense 
of  pain,  and  paresis  and  atrophy  of  muscles.  Contractures  or  paraplegia  may 
arise  from  tumor.  The  location  of  the  growth  can  be  inferred  by  a  study 
of  the  territory  of  paralysis  and  the  zone  of  sensory  disturbance.  The  tumor 
is  always  situated  somewhat  above  the  upper  hmit  of  anesthesia.  In  many 
cases  the  diagnosis  is  impossible.  Gradually  increasing  painful  paraplegia 
with  pain  in  the  back,  and  with  sensory  paralysis  after  a  time  appearing  and 
ascending  from  the  feet  toward  the  trunk,  points  to  tumor  as  a  cause.  The 
reflexes  are  at  first  increased,  but  are  finally  lost  from  below  upward.  Spasms 
may  develop,  and  lateral  spinal  curvature  may  arise.  If  curvature  arises, 
the  concavity  of  the  curve  will  be  on  the  side  of  the  tumor.  Growths  outside 
the  membranes  produce  particularly  pain  and  spasm;  growths  within  the 
membranes  produce  especially  motor  paralysis  and  anesthesia. 

Treatment. — If  syphilis  is  suspected,  give  the  patient  a  course  of  heroic 
doses  of  iodid  of  potassium,  and  administer  mercury  hypodermatically.  In  a 
focal  lesion  not  due  to  dissemination  of  a  known  malignant  growth  perform  the 
operation  of  laminectomy  to  permit  of  exploration  and  possibly  of  removal. 
The  lamina;  of  at  least  three  vertebras  should  be  removed  and  the  tumor  is 
looked  for  distinctly  above  the  upper  level  of  the  zone  of  anesthesia.  It  is  not 
necessary  for  the  patient  to  wear  a  spinal  support  after  the  performance  of 
laminectomy.  McCosh  truly  says  that  operation  for  spinal-cord  tumor  is  de- 
cidedly more  hopeful  than  for  brain  tumor  because  localization  is  much  more 
accurate  and  removal  can  be  effected  with  less  permanent  damage.  Lloyd 
collected  51  operations:  10  per  cent,  died  and  31  percent,  actually  recovered. 
If  the  tumor  is  found  to  be  irremovable,  McCosh  suggests  division  of  several 
nerve-roots  to  relieve  the  f^ain. 

Acute  osteomyelitis  of  the  vertebra;  is  a  rare  disease;  it  may  be 


Spinal   Curvatures  637 

associated  with  osteomyelitis  of  other  hones,  but  may  occur  alone.  Infections 
of  the  viscera  not  unusually  accompany  it.  Any  part  of  a  vertebra  may  suffer 
from  it.  This  condition  may  follow  cold,  overexertion,  or  traumatism,  and  is 
more  common  in  the  young  than  in  the  old.  The  process  may  be  superficial, 
or  it  may  involve  the  bone  deeply  and  widely.  Suppuration  always  occurs; 
sequestra  generally  form;  and  phlebitis  is  a  dangerous  comphcation.  Any 
region  of  the  spine  may  be  attacked,  but  the  lumbar  region  is  particularly 
liable  to  invasion.  The  situation  of  the  abscess  varies  with  the  situation  of  the 
disease.  If  the  vertebral  bodies  are  diseased,  the  pus  passes  forward  (retro- 
pharyngeal, mediastinal,  psoas,  or  pelvic  abscess).  If  the  vertebral  arches 
suffer,  the  pus  passes  backward  (lumbar  or  dorsal  abscess).  The  membranes 
of  the  cord,  the  cord  itself,  the  nerves,  and  the  vertebral  articulations  are  fre- 
quently involved  in  the  process.  Staphylococci  or  streptococci  may  be  grown 
from  the  pus. 

Symptoms. — The  general  symptoms  are  those  of  osteomyelitis.  The 
local  symptoms  depend  on  the  seat  of  disease.  If  the  posterior  portion  of  the 
column  is  diseased,  there  is  a  hard  swelling,  which,  in  the  neck,  is  in  the  middle 
line;  in  the  dorsal  and  lumbar  regions,  in  the  middle  or  to  the  side;  and  in  the 
sacral  region,  invariably  to  one  side. 

Rigidity  of  the  spine  always  exists.  If  the  vertebral  bodies  are  affected, 
rigidity  is  noted,  the  spine  is  tender,  and  special  symptoms  appear,  their 
nature  dependent  on  the  region  affected  (retropharyngeal  abscess,  etc.).  Oc- 
casionally symptoms  of  meningomyelitis  are  noted.  The  constitutional 
symptoms  of  sepsis  are  marked.  The  condition  is  sudden  in  onset,  and 
purulent  collections  diffuse  widely  and  rapidly.  These  points  enable  the 
surgeon  to  make  a  diagnosis  between  osteomyelitis  and  Pott's  disease.  In 
osteomyelitis  angular  deformity  very  rarely  arises,  because  the  patient  is 
obliged  to  be  recumbent  and  because  hyperostosis  is  taking  place. 

Treatment. — The  patient  is  kept  recumbent.  His  constitutional  treat- 
ment is  such  as  will  combat  sepsis  (food,  stimulants,  etc.).  A  puriform  area 
must  be  incised  and  disinfected.  If  bone  denuded  of  periosteum  is  found,  it  is 
touched  with  a  solution  of  chlorid  of  zinc  or  with  the  actual  cautery.  If  a 
sequestrum  exists,  it  is  removed.  A  drainage-tube  is  inserted  and  dressings 
are  applied  (Miiller,  Makins,  Abbot,  and  Chipault). 

Typhoid  Spine. — It  was  pointed  out  by  Gibney  that  typhoid  fever 
may  leave  as  a  legacy  a  painful,  stiff,  and  weak  back.  The  muscles  of  the 
back  are  found  to  be  rigid  and  there  is  tenderness  of  one  or  more  vertebrae. 
The  pain  may  only  be  appreciated  on  motion,  but  in  some  cases  there  is 
aching  even  when  the  patient  is  at  rest.  The  pain  may  be  localized,  may 
run  into  one  or  both  thighs,  or  may  be  felt  in  the  abdomen.  The  symptoms 
arise  at  an  uncertain  period  after  the  fever,  develop  rapidly,  and  are  occa- 
sionally associated  with  transient  episodes  of  fever.  Kyphosis  or  lateral 
curvature  may  develop.  (See  L.  W.  Ely,  "Medical  Record,"  Dec.  20,  1902.) 
Usually  the  patient  is  hysterical.  The  condition  is  due  to  osteitis  and  peri- 
ostitis, or  osteomyelitis.     The  prognosis  is  excellent. 

Treatment. — The  use  of  a  plaster  or  leather  jacket;  counter-irritation  by 
the  hot  iron;  and  later  massage  and  electricitv. 

Spinal  Curvatures.— There  are  four  chief  forms  of  spinal  curvature: 
(i)  lateral  curvature  (the  scoliosis  of  the  older  surgeons);  (2)  posterior  cur- 


638  Surgen'  of  the  Spine 

vature  (the  excurvation,  gibbosity,  or  kyphosis  of  the  older  surgeons);  (3) 
anterior  curvature  (the  lordosis  of  the  older  surgeons) ;  and  (4)  angular  cur- 
vature (from  spinal  caries).  The  normal  spine  has  four  curves:  the  cervical 
curve,  the  convexity  of  which  is  forward;  the  dorsal  curve,  the  convexity  of 
which  is  backward;  the  lumbar  curve, which  is  convex  anteriorly;  and  the  pel- 
vic curve,  which  is  concave  anteriorly.  The  dorsal  and  the  pelvic  curves, 
which  are  primary,  are  due  to  the  formation  of  the  cavities  of  the  chest  and 
pehas,  and  depend  upon  the  shape  of  the  bones  (Treves).  The  cervical  and 
lumbar  curves,  which  are  compensatory,  depend  upon  the  shape  of  the  inter- 
vertebral disks,  and  only  appear  after  birth  when  the  erect  position  is  assumed. 
Lateral  curvature  (scoliosis)  is  a  lateral  deviation  of  the  spinal  column, 
often  accompanied  by  rotation  of  the  vertebrae  and  associated  with  increase  or 
with  diminution  of  the  normal  curves.  Lateral  curvature  is  predisposed  to  by 
weak  muscles  and  hgaments,  by  the  habitual  assumption  of  strained  and  un- 
natural attitudes,  by  unequal  length  of  the  legs,  and  by  paralysis  of  one  leg. 
This  distortion,  which  is  commonest  in  girls,  is  apt  to  arise  at  the  age  of  puberty 
(it  is  usually  corrected  in  boys  by  outdoor  exercise).  The 
bones  are  soft  and  the  muscles  are  weak,  and  this  condi- 
tion is  often  inherited.  Rickets  is  very  commonly  associ- 
ated with  lateral  curvature.  Any  condition  of  ill-health 
weakens  the  muscles;  hence  lateral  curvature  may  arise 
after  an  acute  sickness  or  in  a  person  who  oiitgrows  his 
strength.  An  empyema  with  adhesions,  by  pulhng  on 
the  chest-wall,  may  produce  a  curvature  the  concavity 
of  which  is  toward  the  diseased  side. 

The  weak  muscles  cease  to  sustain  the  spinal  column, 
and  the  ligaments  stretch,  relax,  or  lengthen.     The  com- 
Fig.  337— Lateral       monest   curve  is  toward  the  right  in  the  dorsal  region 
dorsal  curvature  to  the      (^gcause  most  people  use  the  right  hand  more  than  the 

right,    and     compensa-  '■        '■  ° 

tory  lumbar  curve  to  the       left).     As  soon   as  a  dorsal  curve  to  the   right  arises  a 
■eft-  compensatory  lumbar  curve  (Fig.  337)  takes  place  to  the 

left,  thus  enabhng  the  patient  still  to  sit  or  to  stand  erect. 
In  almost  all  cases  the  vertebrae  soon  rotate,  the  bodies  turning  to  the  convexity 
and  the  spines  turning  to  the  concavity  of  the  curve;  hence  the  transverse  pro- 
cesses toward  the  convexity  project.  The  ribs  follow  the  spinal  rotation;  the 
shoulder  is  elevated  on  the  side  of  the  convexity,  and  the  hip  on  the  opposite 
side  is  apparently,  but  not  in  reality,  raised.  As  a  matter  of  fact,  the  hip  be- 
comes prominent  rather  than  raised.  The  intervertebral  disks  are  apt  to 
flatten  out  on  the  concavity  of  the  curve.  In  very  rare  instances  lateral  cur- 
vature results  from  caries  of  a  half  of  one  or  of  several  vertebra;.  In  a  spinal 
tumor  lateral  curvature  may  occur,  the  concavity  of  the  bend  being  on  the  side 
of  the  growth. 

Symiploms. — An  ordinary  case  of  spinal  curvature  from  weak  muscles 
arises  gradually.  Stooping  is  noticed,  and  after  a  time  pain  is  com])lained  of  in 
the  dorsal  and  lumbar  regions,  and  weakness  in  the  back  is  detected  by  the 
sufferer.  The  pain  is  made  severe  by  sitting  long  in  one  attitude.  Anemia  is 
manifest,  and  walking  is  awkward  and  ungraceful.  When  the  shoes  and 
clothing  are  removed,  and  the  child  stands  with  its  back  toward  the  surgeon 
and  with  the  feel  symmetrically  together,  the  lower  angle  of  the  right  scapula 


Anteroposterior   Curvature  639 

(in  a  dorsal  curvature  to  the  right)  is  unduly  prominent  and  is  elevated  above 
the  left;  the  normal  prominence  of  the  right  iliac  crest  is  lost;  the  left  iliac  crest 
is  unduly  distinct;  on  marking  the  spinous  processes  with  an  anilin  pencil  the 
curve  becomes  manifest;  tenderness  is  developed  on  pressing  the  spines  only  if 
there  is  marked  neurasthenia;  the  normal  dorsal  anteroposterior  curve  is  ex- 
aggerated; the  abdomen  is  protuberant;  the  chest  is  flattened;  the  neck  juts 
forward;  and  the  breast  on  the  same  side  as  the  concavity  of  the  curve  is  more 
prominent  and  on  a  lower  level  than  the  other  breast.  Always  observe  if  the 
anterior  iliac  spines  are  on  a  level  or  not,  and  always  measure  the  length  of  the 
legs.  The  patient,  with  the  knees  extended,  bends  forward  with  the  arms 
hanging  loosely:  the  erector  spinas  muscle  between  the  iliac  crest  and  the  last 
rib  is  seen  to  be  more  prominent  on  the  convexity  of  the  lumbar  curve  than  on 
its  concavity  (Bernard  Roth),  and  the  angles  of  the  ribs  on  the  side  of  the  con- 
vexity of  the  dorsal  curve  are  on  a  higher  level  than  are  those  on  its  concavitv. 
Have  the  child  assume  what  it  supposes  to  be  an  erect  attitude,  and  let  the 
surgeon  correct  this  into  the  best  possible  position  (Roth),  and  see  how  long 
the  new  position  can  voluntarily  be  maintained.  A  large  percentage  of  these 
patients  labor  under  pes  planus.  When  there  is  no  osseous  deformity  (that  is, 
when  the  surgeon  may,  by  manipulation  and  traction,  correct  the  deformitv), 
and  when  the  spinal  muscles  are  not  paralyzed,  the  prognosis  is  good  for  com- 
plete cure.  Roth  states  that  cases  without  osseous  deformity  can  practicallv 
be  cured  in  one  month,  but  the  treatment  must  be  continued  for  one  year  to 
prevent  relapse.*  In  a  case  with  moderate  osseous  deformity  the  patient  can 
be  improved  vastly  by  three  months'  daily  treatment  (Roth).  Even  in  severe 
cases  of  bony  deformity  the  pain  may  be  relieved  and  the  deformitv  be  modi- 
fied. 

Treatment. — If  one  leg  is  too  short,  let  the  patient  wear  a  thick-soled  shoe. 
No  treatment  for  weak  muscles  has  ever  been  devised  so  utterlv  irrational 
and  absurd  as  the  prevention  of  all  movement;  and  neglect  of  all  treatment  for 
lateral  curvature  does  less  harm  in  the  vast  majority  of  cases  than  immobilizing 
the  spinal  muscles  by  braces  and  supports.  The  muscular  nutrition  in  these 
cases  is  to  be  restored,  as  is  muscular  nutrition  in  any  other  region,  by  scientific 
gymnastics,  electricity,  the  douche,  salt  baths,  frictions,  and  massage.  Bicv- 
cles  with  specially  constructed  seats  are  used  with  advantage  in  some  cases. 
The  mode  of  exercise  to  be  used  should  be  directed  by  some  one  skilled  in 
orthopedics,  and  the  instruction  in  the  details  must  be  thorough  and  persistent. 
Roth's  advice  is  to  so  re-educate  the  muscular  sense  that  a  patient  can  again 
know  whether  she  is  or  is  not  standing  straight;  to  maintain  an  improved 
position  in  sitting  and  standing;  to  use  such  clothing  as  will  not  interfere  with 
the  assumption  of  a  normal  attitude;  to  enforce  systematic  training  of  the 
muscles  of  the  spine  and  thorax;  and  to  give  attention  to  the  general  health.  In 
some  cases  where,  in  spite  of  all  attempts  at  correction,  deformitv  increases,  it 
may  be  necessary  to  immobilize  in  hope  of  obtaining  ankylosis  and  preventing 
further  deformity.  In  those  rare  lateral  curvatures  due  to  caries  a  supporting 
apparatus  must,  of  course,  be  applied. 

Anteroposterior  curvature  (not  from  spinal  caries  or  from  hip-joint 
disease)  is  an  increase  of  the  normal  anteroposterior  curves.  Increase  of  the 
dorsal  curve  is  posterior  curvature,  kyphosis,  or  excurvation  (Fig.  338,  x)\  in- 

"  Heath's  "  Dictionaiv  nf  Practical  Surcferv." 


640  Surgery  of  the   Spine 

crease  of  the  lumbar  curve  is  anterior  curvature,  lordosis,  or  saddle-back  (Fig. 
338,  b).  Both  lordosis  and  kyphosis  are  apt  to  be  present.  Scoliosis  has 
nearly  alwavs  some  anteroposterior  curvature  associated  with  it.  Lordosis  is 
apt  to  be  compensatory,  to  prevent  the  center  of  gravity  going  loo  far  forward. 
Lordosis  is  found  in  pregnant  women  and  in  very  fat  men.  In  an  old  man 
kvphosis  arises  from  flattening  out  of  the  vertebral  disks  from  pressure. 
Rheumatic  gout  may  cause  anteroposterior  curvature.  Anteroposterior  cur- 
vature is  often  due  to  paralysis  of  the  erector  spinas  mass  (from  infantile 
paralysis).     Pseudohypertrophic  paralysis  causes  lordosis. 

Symptoms  and  Treatment. — The  symptoms  of  anteroposterior  curvature 
are  as  folio w^s:  the  thorax  is  flattened  or  pigeon-breasted;  the  shoulder-blades 
are  widely  separated  and  the  scapular  angles  project;  the  abdomen  is  pro- 
tuberant; the  patient  complains  of  backache  and  soon  tires.  A  recent  ky- 
phosis disappears  when  the  patient  lies  upon  his  stomach.  The  facts  that 
the  erector  spinae  muscles  are  soft,  and  that  pain  is  absent  on  concussion 
transmitted  to  the  back,  separate  kyphosis  from  caries.  Lordosis  is  un- 
mistakable. When  the  spine  is  movable,  employ  the  same  plan  of  treatment 
as  in  lateral  curvature,  suiting  the  gymnastics  to  the  de- 
formity (Roth).  In  painful  kyphosis  with  partial  ankyl- 
osis endeavor  to  make  the  ankylosis  complete  in  order 
to  prevent  pain,  obtaining  this  result  by  applying  a  plaster 
jacket  which  laces  up  and  letting  the  patient  wear  it  for 
several  years. 

Angular  curvature  (spinal  caries;  spondylitis;  Pott's 
disease)  is  usually  due  to  tuberculous  caries  of  the  ver- 
tebral bodies,  and  occurs  particularly  in  children  who 
are  predisposed  to  tuberculosis,  but  it  may  arise  at  any 
^.      o    ..    ,     ■  ,  .      age.     Anv  portion  of  the  spinal  column  mav  be  attacked. 

Fig.  338. — kyphosis  (a)  o  .    I  ir 

and  lordosis  (b).  The  dorsolumbar  region  is  most  prone  to  suffer.     The 

chief  cause  is  tuberculosis,  but  syphilis,  secondary  cancer, 

and  acute  osteomyelitis  of  the  vertebrae  are  occasional  causes.     Blows  or 

strains  are  often  exciting  causes.     Angular  curvature  may  develop  after  an 

exanthematous  fever. 

The  cancellous  tissue  of  the  anterior  portion  of  the  vertebral  body  becomes 
primarily  carious,  or  the  inflammation  begins  in  an  intervertebral  disk. 
(The  changes  of  tuberculous  osteitis  have  previously  been  set  forth.)  The 
body  of  the  vertebra  and  the  vertebral  disk  are  destroyed,  and  the  process 
extends  to  adjacent  vertebra?.  The  weight  which  rests  upon  the  spinal 
c"olumn  causes  softened  bone  to  crumble,  compresses  the  diseased  vertebrae 
and  disks,  and. produces  angular  deformity  (the  anterior  part  of  the  spine 
formed  by  the  vertebral  bodies  is  shortened,  ,the  posterior  part  is  not,  and 
hence  the  .spines  project).  In  .some  ca.ses  the  disease  is  spontaneously  arrested 
by  organization  of  inflammatory  products,  and  ankylosis  (fibrous  or  bony) 
in  deformity  is  Nature's  cure.  In  most  ca.ses,  however,  the  disea.se  spreads 
and  ca.seous  pus  is  formed,  which,  according  to  the  route  it  takes,  causes 
lumbar  ab.scess,  dorsal  abscess,  psoas  abscess,  or  post-pharyngeal  abscess 
(page  124).  In  some  cases  the  spinal  cord  is  compressed,  but  in  most  cases 
it  is  not,  and  even  when  it  is  compressed  paraplegia  is  rare  and  is  usually 
temporary.     Com[)resjjon  of  the  con!  may  be  caused  ]jy  the  disi)laced  ver- 


Angular   Curvature  641 

tebrae  or  by  inflammatory  material  or  caseous  matter  between  the  bone  and 
dura  mater,  but  is  most  often  due  to  pachymeningitis.  Caries  of  the  cervical 
region  constitutes  a  more  dangerous  disease  than  caries  of  either  the  dorsal 
or  the  lumbar  region  (dangerous  pressure' occurs  more  easily).  Death  may 
be  caused  by  exhaustion,  sepsis,  hemorrhage,  amyloid  disease,  pneumonia, 
peritonitis,  pleuritis,  tuberculous  dissemination,  pressure  upon  the  cord,  or 
inflammation  of  the  cord  or  its  membranes. 

Symptoms. — The  suft'erer  from  Pott's  disease,  if  a  child,  grows  tired 
easily,  his  disposition  alters,  he  becomes  moody  and  irritable,  and  complains 
of  vague  pains  in  many  places,  is  disposed  to  lean,  rest,  or  lie  down,  and 
walks  with  the  back  rigid,  which  produces  a  peculiar  gait.  A  painful  spot 
is  found  by  pressing  upon  the  spines.  Faradism  to  the  back  causes  pain. 
Spasm  of  the  erector  spincT  mass  is  detected  (Hilton,  Golding-Bird).  It 
is  not  proper  to  seek  to  develop  pain  by  jarring  the  back  or  by  pressing  the 
head  downward.  The  posture  of  the  child  and  the  muscular  rigidity  prove 
the  existence  of  inflammation,  and  to  seek  to  develop  pain  by  the  methods 
referred  to  may  do  harm,  and  at  best  can  only  call  attention  to  what  is  already 
known.  Pain  in  the  back,  which  is  increased  by  motion,  by  pressure,  and 
by  vertebral  jars,  may  be  absent  until  late  in  the  case.  Distinct  pain  and 
tenderness  in  the  back  often  mean  abscess-formation.  Neuralgic  pains  pass 
into  distant  parts  (sciatica,  intercostal  neuralgia)  and  are  often  linked  with 
muscular  spasm.  A  chronic  bilateral  pain  in  the  trunk  or  extremities  is 
suggestive  of  Pott's  disease.  "  Chronic  bilateral  belly-aches  in  children  are 
almost  diagnostic"  (Jordan  Lloyd).  The  pain  of  dorsal  caries  can  be  re- 
lieved by  lifting  the  shoulders;  the  pain  of  cervical  caries  by  traction  on 
the  head.  Cramp  in  the  legs  occurs  in  dorsal  and  in  lumbar  caries.  The 
presence  of  the  knuckle  due  to  bending  the  spine  at  an  acute  angle  is  a  very 
important  sign  of  the  disease.  In  many  cases  angular  deformity  appears 
late,  in  some  cases  it  does  not  appear  at  all.  An  angular  deformity  is  detected 
sooner  in  those  regions  where  the  normal  curves  are  posterior  than  where  the 
normal  curves  are  anterior  (Jordan  Lloyd).  The  deformity  appears  early 
in  the  dorsal  region,  but  late  in  the  cervical  and  lumbar  regions.  In  some 
rare  cases  lateral  deformity  occurs.  Rigidity  is  an  early  sign  of  great  impor- 
tance. It  is  always  present.  Rigidity  is  manifest  very  early  in  cervical 
caries,  tolerably  early  in  lumbar  caries,  late  in  dorsal  caries.  Lloyd  gives 
the  following  practical  rules  to  enable  us  to  detect  rigidity.*  In  the  cervical 
region:  seat  the  patient  in  a  chair  and  tell  him  to  nod  the  head  affirmatively. 
Stiffness  in  nodding  points  to  occipito-atloid  disease.  Tell  him  to  look  far 
to  the  right  and  then  far  to  the  left.  Stiffness  of  these  motions  suggests 
atlo-axoid  disease.  Tell  him  to  place  his  shoulders  against  the  back  of  the 
chair  and  carry  his  eyes  back  along  the  ceiling.  Stiffness  in  this  movement 
indicates  disease  below  the  second  cervical  vertebra.  It  is  practically  useless 
to  examine  the  dorsal  region  of  an  adult  for  rigidity,  but  such  an  examination 
can  be  made  in  a  child.  Place  the  patient  prone  on  an  adult's  lap,  mark 
the  tip  of  each  spinous  process  with  an  anilin  pencil,  make  the  child  stand 
up  straight,  and  observe  if  any  of  the  marks  fail  to  come  nearer  together. 
If  it  is  seen  that  two  or  more  marks  do  not  approach  each  other,  there  is 
rigidity  which  prevents  approximation.     To  test  for  rigidity  in  tlie  lumbar 

*  Birmingham  Med.  Review,  .\pril,   1897. 
41 


64: 


Surgery   of  the  Spine 


region  lay  the  naked  patient  prone  upon  a  couch.  Grasp  the  patient's  ankles 
and  raise  the  pelvis  from  the  couch.  If  the  lumbar  spine  is  flexible,  the 
pelvis  can  be  lifted  without  raising  the  chest  from  the  bed,  and  the  maneuver 
deepens  the  hollow  of  the  loin.  If  the  lumbar  spine  is  stiff,  the  maneuver 
hfts  the  trunk  and  produces  no  alteration  in  the  vertical  outline  of  the  lumbar 
spines.  If  a  child  with  Pott's  disease  is  asked  to  pick  up  something  from 
the  ground,  because  of  rigidity  or  pain  on  movement  he  will  not  bend  the 
back,  but  will  bend  the  knees  or  get  upon  the  knees.  Paralysis  may  exist, 
and  it  is  due  to  pachymeningitis  more  often  than  to  pressure  from  bone. 
Cervical  caries  causes  dyspnea  and  torticollis,  the  head  rec]uiring  support 
with  the  hands.  Dysphagia  indicates  abscess.  In  adults  the  first  signs  of 
Pott's  disease  to  attract  attention  are  headache,  backache,  neuralgia,  girdle- 
pain,  cramp,  or  even  paralysis.  In  abscess  due  to  caries  of  the  dorsolumbar 
vertebrae  the  pus  usually  enters  the  psoas  muscle  and  passes  out  of  the  pelvis 
below  the  junction  of  the  middle  and  outer  thirds  of  Poupart's  ligament. 


Fig.  339. — Plaster-of-Paris  jacket  (Sayre). 


Fig.  340. — Plasler-of-Paris  jacket  and  jury-mast 
applied  (Sayre). 


It  may  point  here  or  may  pass  to  the  inner  aspect  of  the  thigh  and  point 
a  little  below  the  spot  where  a  femoral  hernia  is  met  with  if  it  exists.  In 
a  psoas  abscess  a  mass  is  always  felt  in  the  iHac  fossa  above  Poupart's 
ligament  ;  in  a  hernia  no  such  mass  exists  (J.  T.  Rugh).  In  sacral  caries 
there  is  no  deformity  and  frequently  no  pain.  The  diagnosis  becomes  ap- 
parent when  bilateral  abscess  is  detected  in  the  buttocks  or  groins  (Jordan 
Lloyd).  If  an  abscess  due  to  spinal  caries  opens  spontaneously,  healing 
will  not  occur,  but  mixed  infection  takes  place  and  death,  as  a  rule,  soon 
follows. 

Treatment  oj  Caries  oj  the  Spine. — When  recent  caries  of  the  spine  is 
active  and  aff"ects  a  child,  when  it  is  accompanied  by  pain  and  fever,  and 
when  jjaralysis  threatens,  insist  upon  perfect  rest.  Place  the  child  supine 
on  a  hard  mattress,  and,  if  possible,  take  it,  while  in  a  rolling  bed,  out  of 
doors  daily.  Leeches,  blisters,  or  the  hot  iron  over  the  area  of  pain  may 
do  good.     When  the  activity  of  the  process  abates  aj)ply  a  fixation  apparatus. 


Spinal   Abscesses  643 

In  diseases  at  or  near  the  vertebro-occipital  articulation,  as  long  as  dyspnea 
persists,  keep  the  patient  supine  with  a  small  hard  pillow  under  the  nape 
of  the  neck  (Hilton)  and  a  sand-bag  on  each  side  of  the  head  and  neck.  After 
several  months  mechanical  support  can  be  given  by  Furneaux  Jordan's 
method.  Jordan  applies  his  support  as  follows:  The  patient  lies  on  a  flat, 
hard  table,  his  arms  are  raised  above  his  head,  and  traction  is  made  upon 
the  head  by  means  of  a  pulley  and  a  weight.  Cotton  pads  are  placed  over 
the  ears,  the  back  of  the  neck,  and  the  clavicles,  and  are  held  in  place  bv 
a  flannel  bandage  applied  as  a  figure-of-eight  of  the  head,  neck,  and  chest. 
The  flannel  bandage  is  overlaid  with  plaster-of-Paris  bandages.*  In  disease 
of  the  cervical  region  below  the  axis,  or  of  the  dorsal  region  above  the  seventh 
vertebra,  use  Sayre's  jury-mast  (Fig.  340),  or  some  other  form  of  head  support. 
Sayre's  appliance  relieves  the  spine  from  the  weight  of  the  head  and  acts 
admirably.  In  most  cases  of  dorsal  and  lumbar  caries  some  fixation  apparatus 
must  be  employed.  The  best  of  all  fixation  apparatus  is  Sayre's  plaster- 
of-Paris  jacket  applied  while  the  patient  is  suspended  (Fig.  339).  The 
Sayre  apparatus  apphed  in  this  manner  is  used  for  the  treatment  of  caries 
of  the  lumbar  region  and  the  lower  half  of  the  dorsal  region.  When  all 
subjective  signs  cease,  substitute  for  Sayre's  jacket  a  felt  or  sole-leather 
jacket  which  laces  down  the  front.  Caries  of  the  upper  half  of  the  dorsal 
region  is  often  treated  by  a  Sayre's  jury-mast  (Fig.  340) ;  but  if  the  jury-mast 
fails,  it  may  be  necessary  to  place  the  patient  horizontally  in  "an  open 
cuirass,  fitted  to  the  back  from  occiput  to  sacrum,  and  combined  with  pulley 
extension  to  the  head  and  pelvis."! 

During  the  course  of  caries  of  the  spine  have  the  patient  eat  fat-forming 
and  nutritious  food,  try  to  get  him  out  often  into  the  fresh  air,  and  administer 
tonics  and  antituberculous  drugs.  Sea-air  is  very  beneficial.  When  all  active 
disease  ceases,  and  only  angular  curvature  remains,  use  an  apparatus  to 
combine  extension  with  mechanical  support,  the  plaster  jacket  being  generally 
employed. 

Spinal  abscesses  are  treated  as  indicated  on  page  535.  Treves  opens 
the  abscess  in  the  loin,  employing  a  vertical  incision;  introduces  a  finger, 
and  examines  the  anterior  surface  of  the  vertebrae  (if  the  patient  be  young 
and  slender  and  if  the  disease  affects  the  dorsal  or  lumbar  region) ;  irrigates 
with  gallons  of  warm  corrosive  sublimate  solution  (i  :  5000);  scrapes  the  wall 
of  the  abscess  with  the  finger  or  rubs  it  with  a  sponge;  irrigates  again;  scrapes 
again,  and  so  on  until  the  wall  is  cleared  of  debris;  wipes  the  abscess  dry, 
and  sutures  without  drainage.  The  patient  remains  recumbent  for  months. 
It  may  be  necessary  to  repeat  the  operation.  If  mixed  infection  occurs, 
drainage-tubes  must  be  inserted.  Treves  formerly  removed  the  carious  bone, 
but  many  surgeons  do  not  approve  of  removing  bone.  Halsted  opens  the 
abscess-cavity  widely,  removes  as  much  of  the  wall  as  possible,  and  packs 
with  iodoform  gauze.  Barker  opens  the  abscess  at  its  lower  portion  and 
inserts  an  irrigating  curet.  This  instrument  is  a  hollow  gouge  through 
which  hot  water  flows.  He  scrapes  and  irrigates  the  abscess-wall  with  this 
instrument.  When  the  water  runs  clear  he  withdraws  the  instrument,  injects 
three  ounces  of  iodoform  emulsion,  and  sutures  the  wound. 

*  See  "Children's   Deformities,"  bv  Walter  Pve. 

f  Jordan  Lloytl,  in  Birmingham  Med.  Review,  April,  1897. 


644  Surgery  of  the  Spine 

Forcible  correction  of  angular  deformity  is  advocated  by  Chipault 
and  Calot  in  cases  of  Pott's  disease  without  abscess.  Forcible  correction  is 
only  used,  if  used  at  all,  in  angular  deformity  of  the  middle  and  lower  part 
of  the  dorsal  region.  It  is  not  used  in  the  cervical,  upper  dorsal,  or  lumbar 
regions.  Before  it  is  used  a  skiagraph  should  be  taken,  to  show  if  bony 
ankylosis  exists  or  if  there  is  an  abscess.  If  there  is  an  abscess,  it  must  be 
treated  surgically,  and  must  heal  before  forcible  correction  is  attempted.  If 
bony  ankylosis  exists,  it  must  not  be  broken  down.  Only  recent  cases  are 
suited  for  this  treatment,  and  only  cases  in  which  very  few  vertebras  are 
involved  (Gabaert).  The  operation  is  unjustifiable  if  any  organs  are  tuber- 
culous, and  if  a  patient  is  in  very  poor  health.  It  is  particularly  indicated 
when  the  deformity  interferes  with  respiration  or  digestion,  or  when  there 
is  paraplegia.  The  operation  does  not  injure  the  cord  or  its  membranes. 
The  operation  is  not  entirely  safe,  and  a  number  of  deaths  have  been 
reported.  Chloroform  must  not  be  given,  as  it  seems  to  possess  special 
dangers  in  this  condition.  Gabaert*  points  out  certain  disasters  which  may 
follow  forcible  correction.  They  are:  death  during  anesthesia;  rupture  of 
an  abscess;  subsequent  paralysis  of  the  legs  and  bladder;  disseminated  tuber- 
culosis; and  shock  with  convulsions  and  death.  Forcible  correction  can  be 
carried  out  as  follows:  the  patient  is  anesthetized  with  ether,  and  is  placed 
face  down;  one  assistant  holds  the  feet,  another  the  head,  another  sup- 
ports the  abdomen,  and  another  the  pelvis.  While  strong  traction  is  made 
on  the  head  and  feet,  the  surgeon  makes  forcible  pressure  on  the  projection. 
After  the  correction  of  the  deformity  a  plaster-of-Paris  support  is  applied  so 
as  to  include  the  neck,  trunk,  and  pelvis,  the  gibbosity  being  left  exposed 
in  order  to  avoid  ulceration.  A  plaster-of-Paris  support  is  used  for  at 
least  six  months.  After  forcible  correction  a  large  gap  exists,  and  this  does 
not  fill  up  with  bone,  but  with  dense  fibrous  tissue,  and  in  some  cases  the 
spines  and  laminae  ankylose.  When  the  support  is  first  removed,  there  is 
usually  a  reappearance  of  the  deformity  to  some  degree.  In  some  cases 
Calot  resects  the  spines  and  laminae  of  the  diseased  vertebrae,  and  performs 
osteotomy  of  the  ankylosed  vertebral  bodies. f 

If  paraplegia  is  due  to  disease  of  the  mid-dorsal  region,  forcible  correction 
should  be  attempted. 

Laminectomy  is  warmly  advocated  by  some  surgeons  in  paraplegia 
from  spinal  caries.  This  operation  is  rarely  necessary,  but  in  some  few 
cases  is  imperatively  demanded.  Many  cases  recover  from  paraplegia  with- 
out operation — operation  has  a  very  heavy  mortality;  many  are  not  bene- 
fited at  all  by  it,  but  in  some  cases  it  has  certainly  saved  life. 

Laminectomy  should  not  be  undertaken  until  treatment  by  rest  and  fixa- 
tion and  exten.sion  has  been  applied  for  at  least  one  year.  Laminectomy  is 
necessary  in  cervical  caries  to  prevent  asphyxia.  The  operation  enables  the 
surgeon  to  remove  ma.s.ses  of  inflammatory  material  which  make  pressure 
on  the  cord.  The  dura  should  not  be  opened  unless  there  is  evidently 
trouble  beneath  it,  in  which  case  it  is  incised  and  any  tuberculous 
area  removed,  the  dura  being  sub.sequently  sutured.  Menard  removes 
the  transverse  processes  of  the  diseased  vertebrae  and  the  heads  and  necks 

*  Ann,  de  la  Soc.  Beige,  July  15,  1898. 

f  F.  Calot,  in  Archiv  Prov.  de  Cliiruigie,  Feb.,  1897. 


Injuries  of  Spinal   Ligaments  and   Muscles  645 

of  the  associated  ribs  in  order  to  give  the  surgeon  access  to  the  diseased 
vertebral  bodies. 

Spondylitis  Deformans. — This  is  the  name  usually  applied  to  osteo- 
arthritis of  the  spine.  In  this  disease'  osteophytic  formation  takes  place 
at  the  vertebral  borders,  and  the  vertebras  become  ankylosed.  The  vertebral 
bodies  as  a  rule  are  most  affected  by  the  disease,  but  any  portion  of  a  vertebra 
may  be  attacked,  and  often  the  heads  of  the  ribs  are  anchored  to  the  spine 
by  bone. 

The  disease  may  begin  in  infancy,  childhood,  youth,  adult  life,  or  old  age. 

Symptoms. — There  are  decided  and  persistent  pain  and  tenderness  of 
the  spine,  and  occasionally  evidence  of  pressure  on  the  nerve-roots.  Early 
in  the  case  deformity  is  apt  to  occur,  because  at  this  period  there  is  inflam- 
matory softening.*  The  deformity  is  not  angular,  but  is  usually  a  total 
kyphosis^  the  column  being  bent  forward  from  above  and  made  into  a  single 
curve.     Lateral  curvature  may  occur. 

Treatment. — Cure  is  impossible,  but  amelioration  can  be  obtained. 

The  local  and  constitutional  treatment  is  as  for  osteo-arthritis  in  any 
region.     If  curvature  begins,  a  mechanical  support  must  be  applied. 

Injuries  of  spinal  ligaments  and  muscles,  which  may  comphcate 

more  serious  injuries  or  may  exist  alone,  are  caused  by  wrenches,  twists, 
and  violent  muscular  efforts  (as  in  lifting).  Railway  accidents  may  be  re- 
sponsible for  these  sprains  and  strains. 

Symptoms. — Injuries  of  the  back,  even  without  cord-injurv,  are  fre- 
quently linked  with  very  deceptive  nervous  symptoms.  Symptoms  are  often 
severe,  but  are  usually  temporary.  In  some  few  cases  the  symptoms  are 
persistent.  Secondary  disease  of  the  cord  is  extremely  rare.  xA.ny  region 
may  be  affected,  but  the  lumbar  is  most  usually  injured,  and  the  entire  spine 
may  suffer.  The  three  marked  symptoms  are  pain,  tenderness,  and  stiffness 
of  the  back.  At  the  time  of  injury,  and  for  a  while  after,  there  is  often  marked 
shock,  and  hysterical  excitement  is  occasionally  observed.  The  cardinal 
symptoms  may  arise  very  soon,  but  may  not  become  severe  for  a  day  or 
two.  The  pain  is  not  acute  when  at  rest,  but  becomes  acute  on  movement. f 
The  pain  is  felt  in  the  back,  and  sometimes  darts  into  the  extremities.  The 
muscles  of  the  back  are  rigid,  the  spasm  being  due  to  pain.  The  patient 
is  very  careful  not  to  twist  or  bend  the  spine,  because  to  do  so  increases 
pain.  In  a  one-sided  injury  the  rigidity  is  unilateral,  and  this  symptom 
cannot  be  simulated.  Often,  but  by  no  means  always,  the  region  of  the 
back  is  swollen  and  the  skin  is  discolored.  The  tenderness  is  not  of  the 
skin,  but  of  the  muscles.  Firm  pressure  on  a  spot  of  real  tenderness  causes 
rapid  pulse  (^lannkopff).  The  vertebral  spines  are  regular  and  are  not 
mobile.  There  is  no  distant  paralysis  or  hyperesthesia  unless  the  cord  is 
damaged  (though  in  some  rare  cases  the  bladder  and  the  rectum  are  paralyzed 
when  no  cord-lesion  can  be  detected,  and  hyperesthesia  may  exist  over  the 
spines).  Moullin  tells  us  that  the  extremities  feel  weak  because  they  are 
deprived  of  proper  supj)ort  on  account  of  the  immobility  of  the  muscles 
of  the  back.  For  the  same  reason  the  action  of  the  abdominal  muscles 
is  interfered  with,  and  the  ]>ower  of  micturition  and  of  defecation  is  impaired 
(there  are  constipation  and  difficulty  in  emptying  the  bladder). 

*  J.  Jackson  Clarke's  book  on  "  CJrthopedic  Suigeiy."  f  Moullin  on  ''Sprains." 


646  Surgen-  of  the  Spine 

The  treatment  of  recent  injuries  comprises  rest;  the  application  of  an 
ice-bag  and  leeching  over  the  painful  area.  After  a  day  or  two  hot  fomenta- 
tions, tincture  of  iodin,  and  inunctions  of  ichthyol  and  lanolin  are  used; 
and,  later  still,  massage,  douches,  and  frictions  with  a  stimulating  liniment 
are  employed.  Phenacetin  helps  to  relieve  pain,  though  in  some  cases  opium 
is  necessarv.  The  injury  is  called  "railway  spine"  when  it  is  caused  by 
a  railway  accident. 

After  the  i?nmediate  eSects  of  the  accident  subside  traumatic  neurasthenia 
is  apt  to  arise.  In  this  condition  the  patient  grows  tired  easily  and  com- 
plains of  pains  and  aches  in  the  back  and  loins,  interfering  with  or  preventing 
work;  paresthesia  and  numbness  exist  in  the  extremities;  in  many  cases 
sexual  intercourse  is  impossible  because  of  premature  ejaculation  or  of  in- 
capacity for  erection;  there  are  dyspepsia,  eye-strain,  insomnia,  loss  of 
m.emorv,  rapid  and  irregular  pulse,  cardiac  palpitation,  and  mental  depres- 
sion or  confusion.  The  reflexes  are  usually  exaggerated,  but  they  can  be 
exhausted  more  easily  than  can  the  exaggerated  reflexes  of  organic  cord 
disease  (because  of  irritable  weakness).  Some  rigidity  and  tenderness  exist 
in  the  back,  and  the  skin  over  this  region  is  often  hyperesthetic.  Attacks 
of  retention  of  urine  may  occur.     Hypochondria  is  not  unusual. 

Treatment  0}  Traumatic  Neurasthenia. — Employ  rest,  tonics,  massage, 
douches,  and  frictions  to  the  back.  Secure  sleep,  and  endeavor  to  bring 
about  a  gain  in  weight.  If  sexual  incapacity  or  seminal  emissions  worry 
the  patient,  dilate  the  urethra  with  steel  sounds. 

Traumatic  hysteria  develops  only  in  those  predisposed  by  a  neuropathic 
hereditary  tendency;  traumatic  neurasthenia  may  arise  in  anybody.  In  the 
first  disease  the  accident  is  only  the  exciting  cause;  in  the  second  disorder 
it  is  the  cause.  Many  cases  of  so-called  "railway  spine"  are  really  examples 
of  traumatic  hysteria.  Traumatic  hysteria  and  neurasthenia  may  be  asso- 
ciated. Neurasthenia  is  a  condition  of  exhaustion  associated  with  a  number 
of  chronic  disorders;  it  forms  a  foundation  on  which  hysteria  is  apt  to  build 
its  structure.  The  structure  of  hysteria  is  made  up  of  morbid  impression- 
ability, hyperesthesia  of  centers,  lowered  self-control,  and  sensitiveness  of 
the  peripheral  nervous  .system.  The  accident  plays  a  double  part  in  pro- 
ducing traumatic  hysteria:  first,  by  its  effect  on  the  mind  (psychical  trau- 
matism); second,  by  its  effect  on  the  body,  which  anchors  the  attention  to 
one  point.  An  area  of  pain  or  stiffness  often  serves  as  an  autosuggestion 
which  undergoes  morbid  magnification  when  viewed  through  the  distorting 
medium  of  hysteria.  Erichsen  taught  that  the  symptoms  of  what  he  named 
"railway  spine"  arose  from  inflammation  of  the  cord  and  its  membranes, 
a  view  now  abandoned.  A  blow  given  to  a  hysterical  person  causes  a  feeling 
of  numbness,  and  thus  negative  .sensation  from  local  .shock  may  establish 
the  idea  of  paralysis,  or  the  traumatism,  acting  as  a  suggestion,  may  inhibit 
motor  representations  and  destroy  the  normal  ideas  of  motion  and  feeling 
(Charcot  and  Pitre).  Terror  always  causes  a  feeling  of  loss  of  power  in 
the  legs,  and  the  terror  of  the  accident  may  thus  develop  the  idea  of  para- 
plegia. The  site  of  a  traumatism  may  localize  symf)toms;  for  instance,  a  blow 
upon  tne  eye  may  cause  amaurosis  or  blepharospasm.  It  is  important  to 
remember  Charcot's  saying  that  a  hysteria  long  latent  and  unrecognized 
may  be  awakened   into  obvious  activity  by  a   blow  or  an   accident.     Pitre 


Contusion  of  the  Spinal   Cord  647 

shows  the  same  to  be  true  of  epilepsy.  A  not  unusual  lesion  is  hysterical 
traumatic  monoplegia,  not  coming  on  at  once  after  the  accident,  but  usually 
some  days  afterward,  and  presenting  flaccid  muscles,  the  electrical  reactions 
and  reflexes  remaining  normal,  but  the  muscular  sense  being  lost  (Pitre). 
The  muscles  usually  waste.  The  skin  of  the  paralyzed  limb  is  anesthetic 
or  analgesic.  There  may  be  anesthesia  limited  to  a  limb,  hemianesthesia, 
or  general  anesthesia.*  Hysterical  paralysis  is  usually  associated  with  the 
permanent  stigmata  of  hysteria — concentric  contraction  of  the  visual  field, 
pharyngeal  anesthesia,  convulsive  seizures,  and  hysterogenic  zones  (Clarke 
and  Pitre).  The  permanent  stigmata  may  be  latent.  Hysterical  phenomena 
lack  regularity  of  evolution,  and  they  may  be  produced,  altered,  or  abolished 
by  mental  influences  or  by  physical  forces  which  produce  no  eftect  on  organic 
disease.  In  most  hysterical  conditions  the  general  health  is  not  profoundly 
impaired. t 

Treatment. — By  moral  means  chiefly.  Gain  the  confidence  of  the  patient. 
In  many  cases  separation  from  family  and  friends  is  necessary  and  isolation 
is  desirable.  The  Weir  Mitchell  rest-cure  is  the  best  plan  of  treatment, 
and  all  its  details  should  be  carried  out  faithfully. 

Malingering. — Persons  often  pretend  to  suft'er  from  maladies  as  a  result 
of  accident,  which  diseases  do  not  exist  in  them.  Some  get  well  upon  the 
rendering  of  a  favorable  verdict  by  a  jury.  In  any  case  always  examine 
carefully,  so  as  to  be  able  to  exclude  malingering.  Note  the  patient's  behavior 
and  motions  when  his  attention  is  diverted  from  his  disease.  Meningomye- 
litis  can  be  excluded  if  there  be  no  spasm,  paralysis,  hyperesthesia,  pares- 
thesia, or  anesthesia  at  a  distance  (A.  Pearce  Gould).  If  pain  has  lasted 
for  months,  if  pressure  downward  upon  the  head  or  shoulders  does  not  in- 
crease pain,  if  the  vertebras  are  movable,  and  there  is  no  angular  displace- 
ment, exclude  caries.  Gould  states  that  when  there  are  wasted  muscles, 
when  moderate  spine-movement  is  painless,  but  effort  in  bringing  the  body 
erect  causes  pain  in  the  erector  spinas  region,  the  trouble  is  a  strain  of  the 
erector  spinas  muscle.  If  the  muscle  is  not  wasted,  and  the  pain  is  in  bending 
forward  rather  than  in  straightening  up,  the  vertebral  ligaments  are  the 
seat  of  trouble.  Unilateral  spasm  cannot  be  simulated.  The  administration 
of  ether  may  dispose  of  a  pretended  paralysis,  the  patient  moving  the  sus- 
pected extremity  while  drunk  from  the  anesthetic. 

Concussion  of  the  Spinal  Cord. — This  term  has  no  definite  patho- 
logical meaning.  It  is  probable  that  the  condition  is  one  of  laceration  of 
capillaries  and  of  cord-substance. 

The  symptoms  are  shock,  intense  pallor,  nausea,  often  vomiting,  and 
sometimes  syncope.  With  this  condition  special  symptoms  may  be  linked — 
as  temporary  paralysis,  a  girdle-sensation,  numbness  and  loss  of  power  in 
the  limbs,  hiccough,  torticolHs,  coarse  tremors,  pains  in  the  back  and  limbs, 
areas  of  anesthesia  and  analgesia — depending  on  the  portion  of  cord  lacerated. 

Treatment. — The  treatment  in  concussion  of  the  spinal  cord  is  the  same 
as  that  for  sprains.  Traumatic  neurasthenia  and  hysteria  or  organic  cord- 
disease  may  follow  this  injury. 

Contusion  of  the  spinal  cord  may  arise  from  a  blow  or  a  sprain,  but 
it  is  usually  due  to  extreme  flexion  of  the  spine.     It  causes  hemorrhage  into 

*  J.  Mitchell  Clarke,  in  Brain.  f  Read  the  works  of  Thorburn  and  Pitre. 


648  Surgery  of  the  Spine 

the  gray  matter  of  the  cord  (hematomyeha).  The  symptoms  are  motor  and 
sensory  palsy  and  diminished  reflexes.  Some  cases  recover,  but  others  end 
in  myehtis. 

Wounds  of  the  spinal  cord  are  rare,  and  are  usually  fatal.  Wounds 
above  the  origin  of  the  phrenic  nerves  cause  almost  instant  death.  Gunshot- 
wounds  are  the  most  usual  form,  the  cord  being  damaged  by  the  bullet  and 
bv  bone-fragments.  A  knife  is  sometimes  thrust  in  between  the  occiput  and 
atlas. 

Treatment. — In  a  suspected  wound  of  the  cord  do  an  exploratory  laminec- 
tomv,  arrest  hemorrhage,  and  if  the  cord  is  divided,  suture  it. 

Compression  of  the  spinal  cord  may  be  due  to  blood  or  to  inflammatory 
exudate.  Compression  jrom  blood  may  be  due  to  extramediiUary  hemorrhage 
or  to  intramedullary  hemorrhage.  ExtrameduUary  hemorrhage  causes  sudden 
pain  in  the  back,  the  pain  radiating  from  compressed  nerve-roots;  hyperes- 
thesia and  paresthesia  in  the  area  of  the  radiated  pain;  spasm  of  vertebral 
muscles  suppHed  by  the  compressed  nerves,  sometimes  of  muscles  whose 
nervous  supply  is  below  the  lesion;  tremors;  convulsions;  retention  of  urine; 
paralytic  symptoms  following  the  signs  of  irritation,  but  no  absolute  paralysis 
(Mills).  A  girdle-sensation  is  usual.  Intramedullary  hemorrhage  causes 
pain,  a  girdle-sensation,  aboHtion  of  reflexes,  and  paralysis.  Spasms,  rigidity, 
and  paralysis  come  on  early.  Bed-sores  may  form,  and  retention  of  urine 
and  incontinence  of  feces  may  be  observed.  Paralysis  from  hemorrhage 
is  rapidly  progressive  from  below  upward  (crawling  paralysis). 

Treatment.- — If  paralysis  from  spinal-cord  bleeding  extends  rapidly,  and 
life  is  endangered  through  the  probable  involvement  of  a  vital  center,  per- 
form a  laminectomy,  remove  the  clot,  and  arrest  the  hemorrhage.  It  is 
wise  to  always  open  the  dura  and  inspect  the  cord.  ExtrameduUary  hemor- 
rhage may  be  arrested  by  sutures  or  by  packing.  Intramedullary  hemorrhage 
may  be  arrested  by  suture-ligatures  or  by  packing.  If  an  extramedullary 
clot  is  extensive,  it  is  proper  to  make  a  second  laminectomy  near  the  lower 
end  of  the  spinal  column  in  order  to  permit  the  surgeon  to  thoroughly  wash 
it  out.  The  dura  must  be  sutured  and  drainage  is  to  be  employed.  If 
there  is  paraplegia,  complete  anesthesia  of  the  paralyzed  parts  and  entire 
abolition  of  the  deep  reflexes,  operation  is  probably  useless,  but  it  is 
justifiable  to  try  it  because  of  a  possibility  that  the  cord  is  not  completely 
divided.  In  some  cases  with  persistent  paraplegia  the  operation  should  be 
undertaken.  If  operation  is  not  undertaken,  have  the  patient  lie  upon  his 
side  and  give  morphin  hypodermatically.  If  hemorrhage  continues  in  the 
cord  and  if  the  patient  be  plethoric,  perform  venesection.  Some  surgeons 
advise  hypodermatic  injections  of  ergotin.  To  promote  absorption  of  the 
clot  and  exudate  give  a  combination  of  carbonate  and  acetate  of  ammonium, 
order  pilocarpin,  and  employ  spinal  galvanism  and  hot  douches  (Bartholow). 

Fractures  and  dislocations  of  the  spine  are  very  rare.  The  spinal 
regions  most  liable  to  injury  are  the  atlo-axial,  the  cervicodorsal,  and  the 
dorsolumbar  (Treves).  A  vertebra  may  be  fractured  alone,  Init  dislocation 
without  fracture,  except  in  the  upper  cervical  region,  very  rarely  occurs. 
These  two  lesions,  dislocation  and  fracture,  are  so  often  associated  that  the 
term  jrarture-disloration  is  used  by  many  surgeons  to  include  them  both. 
The  causes  of  fracture  and  dislocation  are  direct  force  (seldom)  and  indirect 


Fractures  and  Dislocations  of  the  Spine 


649 


violence  (commonly).  Forced  flexion  or  overextension  is  the  commonest 
cause.  In  fractures  from  indirect  force  the  cord  generally  suffers.  In 
some  cases  the  displacement  of  the 
vertebra  lacerates  the  cord,  the 
vertebrae  return  into  place,  and  no 
deformity  is  detectable.  Fracture- 
dislocation  from  direct  force  may 
occur  at  any  part  of  the  col- 
umn, and  in  this  accident  the  pos- 
.  terior  vertebral  segments  are  driven 
together,  and  the  cord,  as  a  rule, 
escapes  injury.  Fracture-disloca- 
tions from  indirect  force  most  com- 
monly happen  in  the  cervical  and 
dorsal  regions.  In  the  cervical 
region  reduction  can  usually  be 
secured,  but  in  the  lumbar  region 
reduction  is  impossible. 

Symptoms. — In  fracture-dislo- 
cation great  displacement  is  un- 
usual, but  some  is  almost  always 
recognizable  (irregularity  of  the 
spines  or  angular  deformity) .  There 
are  pain  (which  is  increased  by 
motion),  tenderness,  ecchymosis, 
and  motor  and  sensory  paralysis. 
Priapism,  cystitis,  and  retention  of 
urine  often  occur.  Horsley  has 
pointed  out  that  in  many  cases  par- 
alysis passes  away  only  to  subse- 
quently recur,  the  recurrence  being 
due  to  edema  of  the  cord.  In  some 
cases  of  spinal  injury  there  is  tem- 
porary paralysis  due  to  shock.  Per- 
sistent paralysis  may  be  due  to  lacer- 
ation of  the  cord,  division  of  the 
cord,  or  compression  of  the  cord  by 
bone,  blood-clot,  or  products  of  in- 
flammation. The  extent  of  par- 
alysis depends  on  the  seat  of  the 
cord-injury.  When  the  symptoms 
are  not  immediate  in  onset;  when 
all  the  muscles  below  the  seat  of  in- 
jury are  not  completel}-  paralyzed ; 
when  there  is  some  retention  of  sen- 


Fig.  341.  —  Spine  sawed.  Fracture  of  the 
spinous  processes  of  the  seventh  cervical  and 
first  and  second  dorsal  vertebras.  Fracture  of  the 
bodies  of  the  fifth,  si.xth,  and  seventh  cervical  ver- 
tebra with  displacement  backwaid  of  the  upper 
fragment.  Total  crush  of  the  cord.  The  section 
passes  a  little  to  one  side  of  the  cord,  which  is  seen 
in  place,  and  the  staining  of  the  cord  by  hemor- 
rhage into  its  substance  shows  plainly  through  the 
membranes  even  in  photograph.  The  spinous 
processes  of  the  second  and  third  dorsal  \ertebra? 
were  found  fractured  at  the  operation,  and  were 
removed  (Thomas). 


sation;    when   reflexes  are   present 

and  muscular  rigidity  exists,  we  may  be  sure  that  the  cord  is  not  completely 
divided.  When  the  cord  is  completely  divided  the  symptoms  are  immediate, 
there  is  absolute  motor  and  .sensory  paralysis,  the  muscles  are  relaxed,  and  the 


650 


Surgery  of  the  Spine 


reflexes  are  absent.  Whereas  this  latter  symptom-group  is  present  when  the 
cord  is  completely  divided,  it  may  also  be  due  to  shock,  when  it  will  usually 
be  temporary,  but  occasionally  it  persists  some  time  even  when  the  cord  is  not 
completely  divided. 

A.  J.  McCosh  ("Jour.  Amer.  Med.  Assoc,"  Aug.  31  and  Sept.  7,  1901) 
points  out  that  definite  pressure  is  indicated  by  marked  symptoms  and  ab- 
sence of  reflexes.     When  there  is  not  definite  pressure,  the  symptoms  are 
irregular;  there  is  incomplete  palsy,  or  muscles  of  the  same  group  show  differ- 
ent degrees  of  paralysis;  anesthesia  is 
partial;  signs  of  irritation  are  not  dis- 
tinct and  there  are  patches  of  hyper- 
esthesia and  zones  of  paresthesia.     If 
in  doubt,  at  the  end  of  twelve  hours 
perform  an  exploratory  operation. 

The  prognosis  depends  on  the 
amount  of  damage  done  to  the  cord 
Fracture-dislocations  in  the  cervical 
region  produce  obvious  deformity, 
stiffness  of  the  neck,  and  irregularity 
of  the  spines,  and  a  displaced  vertebra 
may  occasionally  be  detected  by  a  fin- 
ger in  the  pharynx.  Crepitus  can  rarely 
be  detected  unless  a  spinous  process  is 
fractured.  The  Rontgen  rays  aid  diag- 
nosis. The  seat  of  cord-injury  may  be 
determined  by  a  study  of  the  palsy  and 
other  symptoms. 


Fig.  342. — Fracture  of  the  cervical 
spine  ;  cord  compressed  by  bone  and  blood. 
Hemorrhage  into  the  cord  at  the  seat  of  the 
lesion  and  below  the  lesion  (Warren  Muse- 
um). (From  Scudder's  "Treatment  of 
Fractures."    Drawn  by  Byrnes.) 


Fig.  343. — Lesion  of  spine  between  fifth  and 
sixth  cervical  vertebrce.  Note  position  of  arms, 
due  to  paralysis  of  subscapularis.  Biceps  anticus, 
supinator  longus,  and  deltoid  muscles  intact.  El- 
bow flexed,  shoulders  abducted  and  rotated  out- 
ward (after  Thorburn). 


Fracture-dislocation  of  the  atlas  or  axis  usually  causes  instant  death. 
When  the  rlis[)lacement  is  only  trivial,  the  patient  may  actually  recover, 
Ijut  will  i^robably  die  of  secondary  cord-disease.  In  injury  of  the  third 
cervical  vertebra  the  j)hrenic  nerve  is  involved,  the  diaphragm  is  paralyzed, 
and  death  soon  occurs.  In  fracture-dislocation  of  the  fifth  cervical  vertebra 
the  subscapularis  muscles  are  paralyzed,  but  the  biceps,  brachialis  anticus, 
supinator  longus,  and  deltoid  escape,  and  the  patient  assumes  a  charac- 
teristic attitude  (Fig.  343).     If  the  sixth  vertebra  is  dislocated  there  is  palsy 


Treatment  of  Fracture-dislocations  651 

of  the  muscles  of  the  hand.  In  injuries  below  the  sixth  vertebra  no  muscle 
of  the  arm,  forearm,  or  hand  is  paralyzed  at  first,  although  after  some  days 
paralysis  may  develop.  Damage  to  the  cord  above  the  sixth  cervical  vertebra 
produces  anesthesia  of  the  body  below  the  injury  and  of  the  entire  upper 
extremity  except  the  shoulder.  In  injury  just  above  the  upper  level  of  the 
seventh  cervical  there  is  body-anesthesia  and  anesthesia  of  the  outer  sur- 
faces of  the  arms  and  ulnar  margins  of  the  forearms  and  hands.  In  any 
cervical  injury  there  is  body-anesthesia  and  diaphragmatic  respiration,  and 
in  cases  without  paralysis  of  the  arms  there  is  sure  to  be  pain.  Injuries  of 
the  dorsal  spine  can  be  accurately  located.  There  is  paralysis  of  motion  and 
sensation  up  to,  or  almost  up  to,  the  seat  of  injury.  The  arms  are  not  par- 
alyzed. Very  great  pain  in  the  legs  occurs  if  the  lumbar  enlargement  is  in- 
volved. In  injury  of  the  twelfth  dorsal  or  upper  lumbar  vertebra  there  is 
paralysis  of  the  bladder  and  rectum,  an  incomplete  anesthesia,  and  a  partial 
motor  paralysis  of  the  limbs. 

Treatment  of  Fracture-dislocations. — When  dislocation  of  the  body 
of  a  vertebra  obviously  exists,  the  surgeon  may  attempt  reduction  by  exten- 
sion and  rotation.  The  maneuver  is  very  dangerous  in  the  cervical  region, 
and,  as  deaths  have  happened,  some  eminent  surgeons  advise  against  re- 
duction when  the  injury  affects  that  region.  In  fracture-dislocation  the 
traditional  plan  is  to  straighten  the  spine,  gently  if  possible,  and  to  put  the 
patient  upon  his  back  upon  a  water-bed  or  upon  air-cushions.  In  fractures 
in  the  cervical  region  support  the  head  and  neck  with  sand-bags.  Empty 
the  bladder  every  six  hours  with  a  soft  catheter,  which  is  kept  strictly  aseptic. 
Take  every  precaution  to  prevent  bed-sores.  Some  surgeons  advocate  reduc- 
tion of  the  deformity  by  extension  and  counter-extension,  and  the  application 
of  a  firmly  fitting  but  removable  jacket  with  the  suspension  collar  (as  used 
in  Pott's  disease).  If  this  plan  is  employed,  the  head  of  the  bed  is  raised 
and  the  collar  is  fastened  to  it.  Every  day  extension  is  made  gently  from 
the  shoulders  in  dorsolumbar  fracture,  and  from  the  chin  and  occiput  in 
cervical  fractures.  Extension  may  be  maintained  permanently  until  cure. 
Surgeons  have  come  rather  slowly  to  a  belief  in  laminectomy.  One  deterrent 
factor  has  been  the  high  mortality:  Lloyd  collected  the  records  of  159 
operations  and  found  that  59  patients  died  almost  at  once  and  39 
died  later.  White  says  laminectomy  should  be  performed  for  fracture 
or  for  dislocation  when  there  is  obvious  depression  of  the  vertebral 
arches;  in  all  cases  of  pressure  upon  the  cauda  equina;  when  there  are 
characteristic  symptoms  of  spinal  hemorrhage;  and  in  some  cases  where 
rapid  degeneration  becomes  manifest.  Surgeons,  as  a  rule,  until  recently 
agreed  that  operation  is  useless  when  there  are  motor  paralysis,  com- 
plete persistent  anesthesia,  and  entire  loss  of  deep  reflexes,  because  these 
symptoms  indicate  the  strong  probability  that  total  division  of  the  cord  has 
taken  place.  It  is  useless  to  operate  for  fracture-dislocation  of  the  atlas  or 
axis.  In  ordinary  cases  of  fracture-dislocation  below  the  axis  in  which  the 
cord  is  not  completely  divided  treat  by  extension  for  six  or  eight  weeks, 
and  then  operate  if  the  case  is  not  imj:)roving.  In  hemorrhagic  cases,  or 
cases  with  marked  depression  of  the  arches,  operate  early.  If  signs  of 
degeneration  begin  within  six  or  eight  weeks,  operate  at  once.  "  In  com- 
pound  fractures,  in  injuries  of  the  lamin;e  and  spinous  processes  without  a 


652  Surgery  of  the  Spine 

complete  crush  of  the  cord,  when  symptoms  are  due  to  hemorrhage,  when 
pachymeningitis  arises,  if  the  cauda  equina  is  compressed,  operate"  (Thor- 
burn). 

My  own  convictions  are  that  we  should  explore,  as  soon  as  shock  has 
passed  away,  if  we  think  it  probable  that  the  cord  has  been  divided ;  and  if  it 
is  found  divided  it  should  be  sutured.  If  in  any  case  we  are  in  doubt  twelve 
hours  after  the  injury  as  to  whether  or  not  pressure  exists,  we  should  explore. 
If  soon  after  the  accident  we  think  pressure  by  bone  exists,  we  should  operate. 
If  the  case  is  improving,  we  should  not  operate  even  if  there  are  pressure- 
signs,  unless  there  is  a  chance  that  pressure  is  due  to  bone,  in  which  case 
we  should  operate.  As  McCosh  says,  pressure  by  blood  or  inflammatory 
exudate  may  pass  away;  pressure  by  bone  cannot.  Even  long  after  an 
injury,  laminectomy  may  be  productive  of  some  benefit. 

The  rather  radical  views  set  forth  above  arose  largely  from  a  knowledge 
of  the  well-known  case  operated  upon  by  Stewart  for  total  division  of  the 
cord.  In  a  recent  case  of  gunshot-wound  of  the  dorsal  spine  treated  at 
the  Pennsylvania  Hospital  by  Francis  T.  Stewart,  and  reported  by  Francis 
T.  Stewart  and  Richard  H.  Harte  ("Phila.  Med.  Jour.,"  June  7,  1902), 
an  exploratory  incision  showed  that  the  spinal  cord  was  completely  divided. 
There  was  a  fracture  of  the  lamina;  of  the  seventh  dorsal  vertebra.  The 
spines  and  laminae  of  the  seventh  and  eighth  dorsal  vertebras  were  removed. 
The  bullet-hole  was  recognizable  in  the  membranes,  and  the  bullet^  and 
some  bone-fragments  were  removed.  When  the  dura  was  opened,  the  ends 
of  the  completely  divided  dorsal  cord  were  found  to  be  three-quarters  of 
an  inch  apart.  Stewart  freshened  these  ends  and  brought  them  together 
with  two  sutures  of  chromicized  catgut.  In  this  case  a  considerable  degree 
of  restoration  of  function  took  place.  At  the  time  of  the  operation,  three 
hours  after  the  injury,  there  was  complete  paralysis  and  absence  of  reflexes 
below  the  seat  of  injury;  but  sixteen  months  later  the  patient  was  able  to 
voluntarily  flex  the  toes,  flex  and  extend  the  legs,  flex  and  extend  the  thighs, 
and,  while  sitting,  lift  an  extended  leg  from  the  floor.  The  movements  of 
the  lower  extremity  became  more  forcible  when  reinforced  by  contracting 
the  muscles  of  the  upper  extremity  while  making  them.  The  patient  could 
stand  with  one  hand  resting  on  the  back  of  a  chair,  and  could  get  herself 
from  her  bed  to  her  chair  by  sliding.  The  bowels  were  under  perfect  control; 
and  there  was  no  incontinence  of  urine  when  she  was  awake,  although  there 
was  occasionally  some  when  she  was  asleep.  There  were  occasional  cramp- 
like pains  in  the  lower  limbs.  The  sense  of  touch,  temperature,  pain,  and 
position  were  perfect  all  over  the  previously  paralyzed  parts.  Below  the 
knee  the  localization  of  sensation  was  not  so  accurate.  There  was  a  slight 
amount  of  muscular  rigidity;  and  on  each  side,  an  ankle  and  patellar  clonus, 
which  was  easily  exhausterl.  When  the  sole  of  the  foot  was  tickled,  the 
big  toe  flexed,  the  thigh  abducted,  and  there  was  slight  contraction  of  the 
anterior  tibial,  the  ham-string,  and  the  tensor  vagincC  femoris  muscles.  There 
were  no  reactions  of  degeneration  and  no  trophic  changes.  There  had  never 
been  any  bed-sores. 

In  the  light  of  this  positive  report,  we  must  conclude  that  the  spinal  cord 
is  able,  under  certain  circumstances,  to  undergo  a  considerable  amount  of 
regenerati(jn ;  and  we  must  make  our  treatment  more  radical,  in    accordance 


Laminectomy  653 

with  this  conviction.  It  is  often  impossible  to  tell  whether  the  spinal  cord  is 
completely  divided  or  seriously  damaged  without  examining  it;  it  can  be 
examined  only  by  exploratory  operation ;  if  the  serious  symptoms  already 
indicated  exist  after  shock  has  passed  away,  exploratory  operation  should 
be  performed;  if  pressure  exists,  it  should  be  removed;  and  if  the  spinal 
cord  is  found  to  be  completely  divided,  it  should  be  sutured.  It  is  well  to 
remember  that  Abbe's  experiments  have  shown  that  there  may  be  great 
difficulty  in  bringing  the  divided  ends  of  the  cord  into  apposition.  In  order 
to  effect  this,  it  may  be  necessary  to  resect  a  vertebra.  In  connection  with 
.the  foregoing  important  case,  we  would  note  that  Dr.  Estes,  of  Bethlehem, 
has  also  operated  upon  a  case  of  complete  division  of  the  spinal  cord,  in 
which  suturing  was  followed  by  some  restoration  of  function. 

Operations  on  the  Spine.— Operations  for  Spina  Bifida. — A.  W. 
Mayo  Robson  maintains  *  that  operation  is  not  demanded  when  the  sac  is  of 
small  size  and  is  well  protected  by  sound  integument ;  that  operation  is  im- 
proper when  a  large  portion  of  the  column  is  fissured,  or  when  paraplegia  or 
hydrocephalus  exists;  that  operation  is  advisable  only  in  meningocele,  in 
cases  in  which  the  integument  is  thin  and  translucent,  in  cases  in  which  the 
cord  is  flattened  out,  or  the  nerves  are  fused.  Robson  has  closed  the  osseous 
defect  by  transplanting  periosteum. 

Instruments  Required. — Scalpels,  dissecting  and  hemostatic  forceps,  scis- 
sors, mouse-toothed  forceps,  rongeur  forceps,  dural  separator,  Hagedorn 
needles  and  needle-holder,  silk,  silkworm-gut  or  catgut. 

Operation. — Surround  the  sac  by  elliptical  incisions.  Find  the  neck  of 
the  sac,  and  if  it  contains  no  visible  nerves  ligate  it  and  cut  off  the  protrusion. 
Push  the  stump  into  the  canal.  Freshen  the  bone-margins  and  spring  a 
piece  of  celluloid  beneath  them  to  close  the  gap  (Park).  Suture  over  the 
stump  with  small  sutures  of  catgut. f 

Treves's  Operation  for  Vertebral  Caries. — (See  page  643.) 

Laminectomy. — The  instruments  required  for  laminectomy  are  dissecting, 
mouse-toothed,  and  hemostatic  forceps;  scalpels; bone-cutting  forceps;  rongeur 
forceps;  a  dry  dissector;  a  periosteum-elevator;  sequestrum  forceps;  small 
scissors;  straight  and  curved  on  the  fiat;  a  chisel  and  mallet;  retractors; 
blunt  hooks;  a  probe;  tenaculum  forceps;  a  spoon-curet;  a  sand-pillow;  fine 
needles,  curved  and  straight,  large  needles,  and  a  needle-holder. 

In  the  operation  of  laminectomy  the  patient  lies  prone  and  a  sand-pillow 
is  placed  under  the  lower  ribs.  Make  a  vertical  incision  over  and  down 
to  the  vertebral  spines,  the  middle  of  the  incision  corresponding  to  the  seat 
of  injury  or  disease.  The  sides  of  the  spinous  processes  and  the  laminte 
are  cleared.  The  periosteum  is  incised  in  the  angle  between  the  laminae 
and  spines,  and  is  lifted  away  from  the  arches.  The  spinous  processes  are 
cut  off  close  to  their  bases  by  means  of  rongeur  forceps,  the  laminas  are  re- 
moved on  each  side  with  the  rongeur,  and  the  dura  is  exposed.  In  some 
cases  of  fracture  fragments  will  be  found  on  exposing  the  vertebra,  or  a 
blood-clot  will  be  seen  between  the  dura  and  the  bone;  in  other  cases  the 
dura  must  be  opened  with  scissors  vertically  in  the  middle  line  while  it  is 

*  Annals  of  Surgery,  vol.  xxii,  No.  I. 

t  A  full  consideration  of  the  various  plans  of  operating  will  be  found  in  an  article  by 
Marcy,  in  Annals  of  Surgery,  March,  1895. 


654  Surgery  of  the  Spine 

grasped  with  mouse-toothed  forceps.  After  reaching  and  removing  the  com- 
pressing cause,  or  after  faihng  to  find  or  remove  it,  close  the  dura  with  catgut, 
drain  the  length  of  the  wound  with  a  tube,  stitch  the  superficial  parts  with 
silkworm-gut,  and  dress  antiseptically. 

Puncture  of  the  spinal  meninges,  or  lumbar  puncture,  was  devised 
by  Quincke,  and  has  been  carefully  tested  by  many  surgeons  (Fiirbringer, 
Naunyn,  and  others).  It  is  employed  as  a  means  of  diminishing  cerebral 
pressure  in  hydrocephalus,  cerebral  tumor,  uremia,  and  tuberculous  menin- 
gitis. It  has  proved  of  little  therapeutic  value.  In  some  cases  the  examina- 
tion of  the  fluid  has  been  of  diagnostic  value.  Stadelmann  has  reported 
37  cases  in  which  tubercle  bacilli  were  found  in  the  fluid.*  Turbidity  of  the 
fluid  indicates  the  existence  of  meningitis.  Bloody  fluid  indicates  hemorrhage 
within  the  arachnoid.  The  back  is  steriHzed;  the  patient  may  he  prone,  with 
a  pillow  under  the  belly,  or  may  sit  in  a  chair,  with  the  body  bent  forward; 
no  anesthetic  is  required.  A  Pravaz  syringe  is  employed,  and  the  point  is 
inserted  at  the  under  surface  of  a  spinous  process.  In  some  cases  but  a 
few  drops  of  fluid  will  be  obtained,  in  other  cases  several  ounces  may  be 
removed.  It  is  not  wise  to  draw  over  2  c.c.  The  flow  should  be  spontaneous, 
and  suction  ought  not  to  be  used.  Sometimes  nausea,  vertigo,  and  severe 
headache  follow  the  operation,  and  sudden  deaths  have  been  reported.  For 
a  number  of  hours  after  tapping  the  patient  should  remain  recumbent 

*  Berliner  klinische  Wochenschrift,  July  8,  1895. 


Inflammation  and  Abscess  of  the  Antrum  of  Highmore       655 


XXV.    SURGERY    OF    THE    RESPIRATORY  ORGANS. 

I.   Diseases  and  In'juries  of  the   Nose  and  .\ntrum. 

Foreign  bodies  in  the  nose  are  usually  introduced  through  the 
anterior  nares,  but  in  rare  instances  they  enter  by  way  of  the  posterior  nares. 
Small  particles  are  often  expelled  spontaneously;  larger  pieces  collect  mucus 
and  epithelium  and  become  fixed.     Some  materials  swell  after  lodgment. 

Treatment. — In  many  cases  anesthesia  is  required.  Illuminate  the  nostril, 
and,  if  the  foreign  body  can  be  seen,  insert  a  hook  back  of  it  and  effect  its 
removal  by  means  of  forceps.  Some  foreign  bodies  require  to  be  pushed 
back  into  the  nasopharynx.  Occasionally  expulsion  may  be  effected  by 
inserting  a  rubber  tube  into  the  unblocked  nostril  and  telling  the  patient 
to  blow  forcibly  through  the  tube.  In  serious  cases  a  specialist  should  be 
summoned  to  remove  a  portion  of  the  turbinated  bone  or  to  perform  whatever 
operation  he  thinks  best. 

Inflammation  and  Abscess  of  the  Antrum  of  Highmore  (of  the 

Maxillary  Antrum). — The  source  of  this  disease  may  be  inflammation  of 
the  nose  or  periostitis  around  the  roots  of  the  teeth.  In  some  cases 
the  natural  opening  into  the  meatus  is  patent;  in  other  cases  it  is  partly 
or  completely  blocked.  Caries  and  necrosis  may  arise.  The  symptoms 
are  pain,  edematous  swelling  of  the  face,  and  thinning  of  the  bone  so 
that  it  may  crepitate  under  pressure.  When  pus  has  formed,  if  the 
antral  opening  is  patent,  certain  positions  of  the  head  will  cause  a  puru- 
lent flow  from  the  nose,  and  if  a  speculum  is  inserted  pus  may  be  seen 
as  it  flows  into  the  nose.  The  opening  of  the  maxillary  antrum  into 
the  nasal  channel  is  at  the  summit  of  the  antrum;  hence  the  antrum 
drains  when  the  head  is  inverted.  The  ethmoidal  cells  and  frontal  sinus 
drain  best  when  the  patient  is  upright.  Wipe  the  interior  of  the  nose  and 
place  the  patient  with  his  head  between  his  knees.  If  the  nostril  fills 
with  pus,  it  comes  from  the  antrum  (Cobb).  In  severe  cases  the  jaw  expands, 
the  eye  protrudes,  and  great  tenderness  of  the  alveolus  exists.  Percussion 
e.xhibits  a  dull  note.  In  making  a  diagnosis  it  is  well  to  take  the  patient 
into  a  dark  room,  insert  an  electric  light  into  the  mouth  and  note  the  diminu- 
tion of  light-transmission  on  the  diseased  side  as  contrasted  with  the  sound 
side.  Transillumination  may  be  easily  practised  by  the  use  of  a  cautery 
electrode,  protected  by  a  small  glass  vial.  Any  cautery  battery  may  be 
employed  (plan  suggested  by  Ohls).  Exploratory  puncture  will  settle  a 
doubtful  diagnosis.  This  may  be  by  way  of  the  lower  meatus,  the  canine 
fossa,  or  the  alveolar  process.* 

Treatment. — Before  pus  forms  order  the  use  of  hot  fomentations  and 
remove  any  diseased  teeth.  When  pus  has  formed,  evacuate  it  at  once. 
Before  performing  a  severe  operation  try  the  effect  of  opening  into 
the  antrum  from  the  nose,  by  means  of  Krause's  trocar,  followed  by 
insufflation  of  iodoform.  If  this  procedure  fails,  other  means  may  be  em- 
ployed. If  the  disease  arises  from  a  carious  tooth,  pull  the  tooth  and  push 
a  trocar  through  its  socket  into  the  antrum.  If  the  teeth  are  sound, 
*  Cobb,  in  Boston  Med.  and  Surg.  Jour.,  May  7.  1S96. 


656  Surgery  of  the   Respiratory   Organs 

bore  a  hole  with  a  large  gimlet  or  with  a  bone-drill  above  the  root  of  the 
second  bicuspid  tooth  and  one  inch  above  the  edge  of  the  gum.  A  counter- 
opening  should  be  made  into  the  inferior  nasal  meatus.  A  drainage-tube  is 
pulled  from  the  first  opening  into  the  nose  and  is  allowed  to  protrude  from 
the  nostril.  Irrigate  daily  with  normal  salt  solution.  In  three  or  four  days 
discontinue  through-and-through  drainage,  but  prevent  the  first  opening 
closing  until  the  discharge  ceases  to  be  purulent.  In  severe  cases  make  a 
free  incision  through  the  canine  fossa  by  means  of  a  chisel. 

Distention  and  Abscess  of  the  Frontal  Sinus.— The  usual  cause  is  an 

injury  which  may  long  antedate  the  symptoms.  This  injury  causes  or  leads 
to  blocking  of  the  infundibulum;  secretion  accumulates  and  distends  the  sinus; 
and  in  some  cases  pus  forms.  In  many  cases  the  fluid  slowly  accumulates,  and 
it  requires  years  to  produce  marked  symptoms.  In  other  cases  infection  takes 
place,  and  the  symptoms  are  positive  and  violent.  If  the  outlet  into  the  nose  is 
not  permanently  blocked,  the  fluid  may  discharge  itself  from  time  to  time.  In 
the  chronic  cases  there  is  rarely  much  pain.  The  chief  sign  is  a  swelling  of  the 
inner  or  upper  part  of  the  orbit,  which  swelling  progressively  increases  and 
finally  displaces  the  eye.  If  at  any  time  acute  symptoms  supervene,  there  will 
be  pulsatile  pain,  discoloration,  and  tenderness. 

Treatment. — In  some  cases  it  is  possible  to  pass  a  trocar  upward  from  the 
nose  into  the  sinus,  and  so  drain  and  irrigate.  In  most  ca.ses  an  incision  should 
be  made  through  the  soft  parts,  and  the  sinus  opened  by  a  trephine  or  chisel. 
After  the  sinus  has  been  opened  it  must  be  curetted.  The  opening  into  the 
meatus  should  be  restored  and  enlarged,  and  a  drainage-tube  must  be  passed 
from  the  forehead  incision  into  the  nostril.  I  usually  prefer  to  open  the 
sinus  by  making  an  osteoplastic  flap  in  the  anterior  wall. 

2.   Diseases  and  Injuries  of  the  Larynx  and  Trachea. 

Edema  of  the  Larynx  (Edema  of  the  Glottis).— The  causes  of  edema 
of  the  larynx  are:  acute  laryngitis;  chronic  diseases,  such  as  tuberculosis, 
malignant  disease,  or  syphilis;  inflammatory  disorders,  such  as  diphtheria  and 
erysipelas;  acute  infectious  diseases;  Bright's  disease;  aneurysm;  whooping- 
cough;  fjneumonia;  quinsy;  wounds  of  the  larynx;  wounds  of  the  neck;  scalds 
and  burns  of  the  larynx,  and  the  inhalation  of  irritating  vapors,  such  as  those 
of  ammonia  and  sulphur.  The  symptoms  are  sudden  and  rapidly  increasing 
dyspnea,  respiratory  stridor,  huskiness  of  the  voice,  and  finally  aphonia.  The 
swollen  epiglottis  may  be  felt  with  the  finger  and  may  be  seen  with  the  help  of 
a  mirror. 

Treatment. — In  cases  in  which  edema  of  the  larynx  is  not  excessively  acute, 
introduce  a  gag  between  the  teeth,  hold  the  mouth  open,  take  a  knife  wrapped 
to  within  one-quarter  of  an  inch  of  its  point,  make  multiple  punctures  into  the 
epiglottis,  and  favor  bleeding  by  the  inhalation  of  steam.  In  severe  cases  per- 
form intubation  or  tracheotomy. 

Wounds  and  Injuries  of  the  Larynx.— The  larynx  may  be  injured 
internally  by  foreign  bodies,  and  externally  by  blows  and  cuts.  A  condition 
often  met  with  is  cut  throat,  the  result  u.sually  of  a  .suicidal  attempt  on  the  part 
of  the  patient  or  a  homicidal  effort  on  the  part  of  an  assailant.  The  cut  of  the 
suicide  is  usually  in  front;  as  a  rule,  it  misses  the  great  vessels,  but  divides  the 


Foreign   Bodies  in   the  Air-passages  657 

cricothyroid  or  thyrohyoid  membrane.  The  epiglottis  may  be  incised,  or 
even  be  cut  off.  If  a  large  vessel  is  cut,  death  rapidly  occurs.  The  immediate 
dangers  of  cut  throat  are  hemorrhage,  suffocation  by  blood  in  the  windpipe 
and  bronchi,  or  by  displacement  of  parts,  and  entrance  of  air  into  veins.  The 
secondary  dangers  are  pneumonia,  infection  and  sepsis,  exhaustion,  and 
secondary  hemorrhage.  The  remote  dangers  are  stricture  and  fistula  (Keet- 
ley). 

Treatment. — In  wounds  of  the  throat  arrest  hemorrhage,  remove  clots 
from  the  larynx  and  trachea,  bring  about  reaction,  asepticize  the  parts  as  well 
as  possible,  suture  the  deeper  structures  with  silver  wire,  catgut,  or  kangaroo- 
tendon,  and  the  superficial  parts  with  silkworm-gut,  dress  antiseptically,  and 
place  a  bandage  around  the  head  and  chest  so  as  to  pull  the  chin  toward  the 
sternum.  If  laryngeal  breathing  is  much  interfered  with,  perform  tracheo- 
tomy. Feed  the  patient  through  a  tube  until  union  is  well  advanced.  The  old 
method  of  leaving  the  wound  open  is  to  be  condemned.  When  sutures  are 
used,  primary  union  may  be  obtained.    This  fact  was  proved  by  Henry  Morris. 

Scalds  of  the  Glottis. — (See  section  on  Burns  and  Scalds.) 

Foreign   Bodies  in   the  Air=passages.— The   lodgment   of  foreign 

bodies  in  the  air-passages  is  a  frequent  accident.  Small  solid  bodies  are 
usually  expelled  by  coughing.  Liquids  and  solids  rarely  pass  beyond  the 
larynx  (except  in  laryngeal  disease  or  palsy,  wounds  of  the  floor  of  the  mouth, 
cut  throat,  and  in  people  unconscious  or  very  drunk).  In  vomiting  during  or 
after  the  administration  of  an  anesthetic,  or  in  the  vomiting  of  drunkards,  the 
vomited  matter  may  find  its  way  into  the  larynx  or  lungs.  There  is  great 
danger  of  this  accident  in  an  operation  upon  a  patient  with  intestinal  obstruc- 
tion who  has  stercoraceous  vomiting.  In  most  instances  of  foreign  bodies 
lodged  in  the  air-passages  it  will  be  found  that  the  object  was  being  held  in  the 
mouth  when  a  sudden  deep  inspiration  was  taken  (often  during  laughter). 
The  symptoms  are  immediate,  due  to  obstruction  by  the  body  and  to  spasm, 
and  secondary,  due  to  the  situation  of  the  body  and  the  changes  it  undergoes 
or  induces. 

Lodgment  in  the  pharynx  causes  violent  dyspnea.  The  body  can  be  seen 
or  felt. 

Lodgment  in  the  Larynx. — In  a  severe  case  the  patient  fights  madly  for  air; 
his  face  becomes  livid  and  cyanotic;  his  veins  stand  out  prominently;  speech 
is  impossible,  though  he  may  make  noises  and  utter  harsh  cries;  violent  cough- 
ing begins,  and  then  vomiting;  he  tries  to  force  a  finger  down  his  throat  and 
clutches  at  his  neck;  sweat  pours  from  him;  he  feels  a  sense  of  impending  dis- 
solution, and  he  falls  unconscious,  with  incontinence  of  feces  and  urine.*  In  a 
less  severe  case  violent  dyspnea  gradually  departs  and  the  patient  lies  ex- 
hausted; but  dyspnea  and  cough  are  liable  to  recur  suddenly  at  any  time  be- 
cause of  spasm,  and  they  may  be  induced  by  a  change  of  position.  These 
attacks  of  fierce  spasmodic  cough  are  not  at  first  linked  with  expectoration,  but 
after  inflammation  begins  there  is  a  profuse  and  often  bloody  expectoration. 
Inflammation  follows  more  rapidly  the  lodgment  of  a  sharp  or  irregular  bod}- 
than  it  does  that  of  a  round  or  smooth  body.  Inflammation  is  apt  to  produce 
edema  of  the  glottis,  bronchopneumonia,  or  ulceration  and  necrosis  of  the 
larynx.     Any  sort  of  foreign  body  in  the  larynx  may  at  any  moment  produce 

*  See  Moullin's  graphic  description  in  his  "Treatise  on  Surgeiy." 
42 


658  Surgery  of  the  Respiratory   Organs 

spasmodic  dyspnea,  and  is  always  very  liable  to  cause  edema  of  the  glottis. 
The  body  if  bony  or  metallic  can  be  detected  by  the  x-rays. 

Lodgment  in  the  Trachea. — The  immediate  symptoms  of  a  foreign  body 
in  the  trachea  depend  on  the  shape  and  weight  of  the  body,  and  whether  it  be- 
comes fixed  in  the  mucous  membrane  or  moves  to  and  fro  with  the  air-current. 
A  smooth,  heavy  body  falls  to  the  tracheal  bifurcation,  and,  if  it  does  not  enter 
a  bronchus,  moves  with  every  breath,  and  b}-  its  movement  causes  violent  lar}n- 
geal  spasm,  cough,  and  whooping  inspiration  without  aphonia.  The  patient  is 
often  conscious  of  the  movements  of  the  foreign  body,  and  the  surgeon  may 
detect  them  with  the  stethoscope.  The  foreign  body  may  be  found  with  the 
Rontgen  rays.  A  foreign  body  in  the  trachea  is  hable  to  cause  death  by 
dyspnea,  or  it  may  ascend  so  as  to  be  caught  in  the  larynx,  or  may  even  be 
expelled.  Irregular  or  sharp  bodies  lodge  in  the  mucous  membrane,  produce 
inflammation,  frequent  cough,  and  expectoration,  and  finally  lead  to  ulcera- 
tion. Bodies  which  swell  from  heat  and  moisture  tend  to  lodge  and  to  become 
fixed  (seeds  may  sprout). 

Lodgment  in  a  Bronchus. — Foreign  bodies  in  the  bronchi  seriously  en- 
danger life.  They  usually  lodge  in  the  right  bronchus.  When  a  small  lung- 
area  is  obstructed  the  obstructed  side  shows  diminished  respiratory  movement 
and  murmur  with  occasional  whistling  sounds  and  large  moist  rales;  the  per- 
cussion-note is  normal.  When  an  entire  lobe  is  obstructed  all  respiratory 
sounds  are  absent  over  it,  and  over  the  unobstructed  lung  respiration  is  exag- 
gerated; the  percussion-note  over  the  obstructed  area  is  at  first  resonant,  but 
becomes  dull.  The  A-rays  will  enable  the  surgeon  to  detect  some  foreign 
bodies  in  a  bronchus.  Lodgment  in  a  bronchus  may  cause  bronchopneu- 
monia, abscess,  hemorrhage,  and  even  gangrene.  In  some  cases  the  body  has 
been  expelled  spontaneously.  In  rare  instances  people  have  lived  for  years 
with  lodged  foreign  bodies.  If  death  does  not  soon  follow  the  lodgment  of  a 
foreign  body,  an  abscess  is  very  apt  to  form. 

Treatment. — If  a  foreign  body  lodges  in  the  pharynx,  try  to  pull  it  for- 
ward ;  if  this  fails,  push  it  back  into  the  esophagus.  In  lodgment  in  the  larynx 
or  below,  if  the  symptoms  are  very  urgent,  at  once  perform  a  quick  laryn- 
gotomy.  If  the  symptoms  are  not  so  urgent,  get  a  complete  history  of  the  acci- 
dent and  find  out  the  nature  of  the  foreign  body.  Be  sure  a  foreign  body  is 
retained  in  the  respiratory  tract,  and  determine  what  its  situation  may  be. 
Often  a  laryngologist  can  remove  a  foreign  body  from  the  larynx  by  means  of 
forceps,  a  mirror  and  lamp  being  used  for  illumination.  The  fauces  and  upper 
portion  of  the  larynx  should  have  cocain  applied  to  them  to  lessen  pain  and 
spasm.  If  the  surgeon  fails  in  extraction  by  forceps,  and  laryngotomy  has 
been  performed,  continue  the  search  through  the  opening  in  the  cricothyroid 
membrane;  if  laryngotomy  has  not  been  performed,  let  the  larynx  be  opened 
by  thyrotomy  (a  vertical  incision  between  the  alas  of  the  thyroid  cartilage,  and 
the  separation  of  these  alas  to  permit  of  exploration).  After  a  thyrotomy 
suture  the  perichondrium  with  catgut.  If  the  foreign  body  is  in  the  trachea, 
perform  ordinary  tracheotomy;  if  it  is  in  a  bronchus,  perform  low  tracheotomy. 
Tracheotomy  prevents  suffocation  from  laryngeal  spasm  or  edema  of  the 
glottis.  It  may  be  pos.sible  to  remove  the  body  in  the  bronchus  through  the 
incision  of  a  low  tracheotomy,  and  this  ought  to  be  tried.  The  foreign  body 
mav  be  expelled  through  the  tracheotomy  wound;  if  it  is  not  expelled,  search 


Tracheotomy 


659 


the  trachea  and  bronchi  with  Gross's  forceps,  with  probes,  with  hooks,  or  with 
the  finger.  If  the  foreign  body  cannot  be  found,  put  the  patient  to  bed,  and 
maintain  a  moist  atmosphere  in  the  room.  As  a  rule,  when  the  foreign  body 
is  not  found  insert  a  tube.  If  the  foreign  body  be  extracted,  do  not  insert  a 
tube  (unless  edema  of  the  glottis  exists  or  is  likely  to  come  on),  do  not  suture  the 
wound,  but  cover  it  with  moist  gauze  and  let  it  heal  by  granulation.  Morphin 
and  sedative  cough-mixtures  are  given.  Gross  says  that  even  when  a  foreign 
body  has  long  been  retained  an  operation  should  be  performed  if  the  air- 
passages  are  not  seriously  diseased.  What  shall  be  done  when  a  foreign 
body  is  lodged  in  a  bronchus  and  we  are  unable  to  extract  it  through  a  trache- 
otomy-wound ?  True  said  if  "  the  patient  is  in  danger  of  death  "  go  through  the 
chest-wall  and  attempt  to  remove  the  body.  He  said  this  with  a  full  knowl- 
edge of  the  difficuky  of  locating  the  body.  This  difficulty  has  been  partly 
overcome  by  the  .v-rays,  and  it  seems  now  more  certainly  our  duty  to  operate 
than  it  was  a  short  time  ago.  Nasiloff  proposed  to  reach  the  obstruction  by 
the  posterior  route  after  rib  resection.  Curtis  attempted  this,  and  though  the 
patient  died,  his  operation  proves  that  the  method  is  feasible.  An  opera- 
tion by  the  posterior  route  should  be  performed  at  once,  if  low  tracheotomy 
fails. 


3.  Operations  on  the  Larynx  and  Trachea. 

Tracheotomy. — The  instruments  required  in  this  operation  are  scalpels, 
dissecting  forceps,  a  dry  dissector,  hemostatic  forceps,  scissors,  a  tenaculum, 
aneurysm-needle,  tubes,  tapes,  Paquelin  cautery,  needles,  needle-holder,  a 
mouth-gag,  tongue-forceps,  foreign-body  for- 
ceps, retractors,  and,  if  membrane  is  present, 
feathers  and  a  solution  of  bicarbonate  of 
sodium.  In  a  formal  operation  give  chloro- 
form, but  in  an  emergency  case  this  cannot  be 
done.  The  patient  may  be  placed  supine 
with  a  sand-pillow  under  the  neck  and  with 
the  head  thrown  over  the  end  of  the  table. 
If  a  child,  Liston  used  to  wrap  it  up  to  the 
neck  in  a  sheet  to  prevent  movements  of  the 
limbs,  would  seat  himself  on  a  chair,  place 
the  child  upon  the  nurse's  lap,  and  takes  its 
head  between  his  knees.  The  head  must 
be  exactly  in  the  middle  line,  and  extended 
(in  an  adult  this  gives  two  and  three-quarters 
inches  of  trachea  above  the  manubrium;  in  a 
child  of  ten,  two  and  a  quarter  inches;  in  a 
child  of  six,  about  two  inches) .  The  operator 
stands  to  the  right  side  when  the  patient  is 

supine.  If  bleeding  is  profuse  when  the  surgeon  is  ready  to  open  the  trachea, 
place  the  patient  in  the  Trendelenburg  position  with  the  neck  extended.  .The 
trachea  may  be  opened  above  or  below  the  isthmus  of  the  thyroid  gland. 
The  isthmus  in  an  adult  usually  lies  over  the  second  and  third  rings  (Fig.  345). 
The  isthmus  in  a  child  usually  lies  over  the  first  ring  or  even  over  the  space 
between  the  cricoid  cartilage  and  the  first  ring.     The  high  operation  is  always 


Fig.  344. — Blood-supply  of  the  lar- 
ynx and  trachea  (Esmarch  and  Kowal- 
zig). 


66o  Surgery  of  the   Respiratory  Organs 

chosen  except  in   cases  ^vhere  it  is  desired  to  search   for  a  foreign  body  in  a 
bronchus. 

High  Tracheotomy. — High  tracheotomy  is  preferred  because  in  this 
region  the  muscles  are  distinctly  separated  (Fig.  345),  the  main  vessels  of  the 
neck  and  the  inferior  thyroid  vessels  are  not  encountered,  the  anterior  jugular 
veins  are  small  and  have  very  few  transverse  branches,  and  the  trachea  is  near 
the  surface  (Treves).  The  surgeon  accurately  locates  the  cricoid  and  thyroid 
cartilages.  An  incision  is  begun  at  the  upper  border  of  the  cricoid  cartilage, 
and  is  carried  down  precisely  in  the  middle  line  for  about  one  and  a  half  inches. 
Treves  advises  the  operator  to  steady  the  skin  of  the  neck  with  the  fingers  of 
the  left  hand  and  to  cut  with  the  unsupported  right  hand  (if  the  hand  be  sup- 
ported, the  respirations  will  interfere  with  the  operation).  The  skin,  the 
superficial  fascia,  and  the  anterior  layer  of  the  cervical  fascia  are  incised,  the 
sternohyoid  and  sternothyroid  muscles  are  separated,  and  the  fascia  over  the 
trachea  is  divided.  This  fascia  is  attached  above  to  the  cricoid  cartilage,  and 
it  divides  below  into  two  layers  to  invest  the  thyroid  body  and  its  isthmus.  If 
veins  are  in  the  hne  of  the  incision,  they  are  pushed  aside,  but  it  is  not  necessary 
to  take  the  time  to  apply  double  ligatures.  Even  if 
bleeding  is  profuse,  as  soon  as  the  trachea  is  opened  and 
air  enters  freely  into  the  lungs,  venous  congestion  is  re- 
heved  and  bleeding  is  apt  to  cease.  If  hemorrhage  be 
violent  and  the  veins  are  not  at  once  caught  by  forceps, 
it  may  be  well  to  place  the  patient  in  the  Trendelenburg 
position  before  incising  the  windpi]:)e,  in  order  to  prevent 
the  entrance  of  blood  into  the  lungs.  Before  opening 
the  trachea  the  isthmus  of  the  thyroid  gland  is  pushed 
downward;  if  it  cannot  be  pushed  down  sufficiently,  a 
transverse  incision  is  made  through  the  fascia  at  the 
upper  border  of  the  cricoid  cartilage,  and  the  fascia,  and 
the   isthmus  with   it,  is  hfted   off  the  trachea  (Bose's 

method).     A  tenaculum  is  inserted  into  the  cricoid  car- 
Fig-.    345. — Parts    ex-  -' 

posed  in  tracheotomy  (Es-      tilage  iu  order  to  Steady  the  tube.     The  back  of  the  knife 
march  and  Kowaizig).  jg  turned  toward  the  sternum,  a  finger  being  held  upon 

the  blade  to  prevent  too  deep  a  cut  being  made.  The 
knife  is  plunged,  as  if  it  were  a  trocar,  into  the  mid-line  of  the  trachea  above 
the  isthmus,  and  two  or  three  rings  are  divided  from  below  upward.  The  hook 
is  not  removed  until  the  operation  is  completed.  If  a  foreign  body  is  present, 
an  attempt  is  made  to  remove  it;  if  success  attends  the  effort,  no  tube  need  be 
worn;  but  if  the  body  is  not  found,  a  tube  must  be  used.  In  croup  or  diphtheria 
remove  membrane  (by  means  of  a  feather  and  a  solution  composed  of  bicar- 
bonate of  sodium  §ij,  glycerin  .5j,  water  .5x — Parker)  and  insert  a  tube.  The 
edge  of  the  cut  is  grasped  with  the  dissecting  forceps,  the  mucous  metnbrane 
being  included  in  the  bite;  the  head  is  placed  erect,  the  tube  is  introduced,  and 
the  tenaculum  is  removed.  Secure  the  tube  by  tapes,  and  suture  the  wound 
below  the  tube.  Remove  the  tube  at  the  first  moment  consistent  with  safety. 
In  croup  or  diphtheria  put  a  screen  around  the  befl;  have  the  air  kept  moist 
by  steam;  remove  the  inner  tube  and  clean  it  every  two  or  three  hours  at  first; 
clean  the  outer  tube  whenever  required.  Clean  the  larynx  and  trachea  from 
time  to  time  by  means  of  a  feather  and  Parker's  solution.  A  steam  spray 
atomizer  may  be  used  with  advantage. 


Pleuritic   Effusion  66 1 

Quick  laryngotomy  must  never  be  attempted  upon  a  child  under  thirteen 
years  of  age,  because  of  the  small  size  of  the  cricothyroid  space  before  this  age 
(Treves).  In  view  of  the  diflSculty  of  introducing  a  tube  and  of  wearing  it  so 
near  the  vocal  cords,  laryngotomy  should  not  be  performed  for  croup,  diph- 
theria, or  for  any  condition  in  which  a  tube  must  be  long  worn.  The 
operation  is  performed  as  follows:  Make  an  incision  an  inch  and  a  quar- 
ter long  in  the  middle  line,  from  above  the  lower  edge  of  the  th}Toid  to 
below  the  lower  border  of  the  cricoid  cartilage.  Divide  the  skin,  superficial 
fascia,  and  deep  fascia,  separate  the  cricothyroid  and  sternothyroid  mus- 
cles, divide  the  deep  layer  of  fascia,  and  cut  the  cricothyroid  membrane  hori- 
zontally just  above  the  cricoid  cartilage.  The  tube  must  be  shorter  than  the 
ordinary  tracheotomy-tube.  An  operation  which  opens  vertically  the  crico- 
thyroid membrane,  the  cricoid  cartilage,  and  the  upper  rings  of  the  trachea  is 
called  "  laryngotracheotomy. " 

Intubation  of  the  Larynx  (O'Dwyer's  Operation). — Bouchot  con- 
ceived the  idea  of  intubation;  O'Dwyer  perfected  it  and  made  it  a  genuine 
scientific  proceeding.  The  instruments  required  for  the  performance  of  this 
operation  are  a  mouth-gag,  an  instrument  to  hold  the  tube  and  introduce 
it,  and  an  instrument  for  extracting  the  tube.  The  collar  of  the  tube  has  a 
perforation  through  which  a  piece  of  silk  is  fastened  to  draw  out  the  tube. 
The  child  is  wrapped  in  a  sheet  to  secure  the  limbs,  is  seated  in  a  nurse's 
lap,  and  its  head  is  held  by  an  assistant.  The  jaws  are  opened  and  held 
apart  by  the  self- retaining  mouth-gag.  The  surgeon  sits  in  front  of  the 
patient,  wraps  a  piece  of  rubber  plaster  about  the  index-finger  of  his  left  hand, 
and  passes  the  finger  into  the  child's  mouth  until  its  tip  touches  the  epiglottis. 
He  introduces  the  holder  and  tube  (observing  if  the  silk  is  free)  along  the  sur- 
face of  the  tongue  until  the  obturator  touches  the  epiglottis;  raises  the  epiglottis 
with  the  left  index-finger,  and  passes  the  tube  into  the  larvnx;  places  the  left 
index-finger  against  the  tube,  and  withdraws  the  holder  with  the  right  hand. 
The  silken  thread  is  tied  to  the  ear,  and  the  nurse  is  directed  to  employ  the 
thread  to  remove  the  obturator  if  it  becomes  obstructed  or  is  coughed  up.  The 
tube  is  removed  in  two  or  three  days;  if  breathing  is  easy,  it  is  not  reintroduced; 
but  if  dyspnea  recurs,  it  is  replaced  for  two  or  three  days  more.  If,  in  intro- 
ducing the  tube,  a  mass  of  false  membrane  is  pushed  before  it  into  the  trachea, 
breathing  ceases,  and,  if  the  mass  is  not  at  once  coughed  up,  tracheotomy  must 
be  performed.  Feed  these  patients  on  semisolids  rather  than  upon  liquids 
(mush,  soft  eggs,  and  corn-starch) ;  and  if  trouble  occurs  in  swallowing  these 
articles,  feed  by  the  rectum  or  by  means  of  a  nasal  or  an  oral  tube.  In  opium- 
poisoning,  in  asphyxia,  in  acute  traumatic  pneumothorax,  and  in  cerebral  inju- 
ries, intubation  may  be  associated  with  the  use  of  Fell's  apparatus  (page  666). 

4.  Diseases  and  Injuries  of  the  Chest,   Pleura,  and  Lungs. 

Pleuritic  effusion  may  arise  from  the  lodgment  of  foreign  bodies,  from 
injury  by  fragments  of  a  broken  rib,  from  tumors,  and  from  inflammation  of  the 
lung,  but  most  usually  is  due  to  pleuritis.  The  commonest  cause  of  primary 
pleuritis  is  tuberculosis.  Inflammatory  effusion  is  nearly  alwavs  unilateral 
(except  in  tuberculous  pleuritis,  but  even  this  form  is  often  one-sided  in 
origin). 


662  Surgery  of  the   Respiratory   Organs 

The  signs  of  pleuritic  effusion  are:  dulness  on  percussion  over  the  area  of 
effusion,  this  dulness,  when  the  patient  is  erect,  being  at  the  lower  part  of  the 
chest  and  ascending  higher  posteriorly  than  anteriorly  (alteration  of  position 
alters  the  situation  of  the  dulness) ;  the  intercostal  spaces  are  widened,  the 
intercostal  depressions  are  obhterated,  the  intercostal  muscles  are  rigid  and 
their  rigidity  lessens  the  mobility  of  the  ribs  (Przewalski).  No  breath-sounds 
can  be  detected  in  the  area  of  percussion  flatness  when  the  collection  of  fluid 
is  large,  but  in  small  eft'usions  deeply  situated  the  breath-sounds  are  often 
audible;  the  percussion-note  above  the  liquid  is  hyperresonant  or  tympanitic, 
and  is  often  associated,  at  the  edge  of  the  liquid,  with  a  friction-sound;  pos- 
teriorlv,  high  up  and  near  the  spine,  there  are  bronchial  respiration  and  bron- 
chophonv.  In  cases  of  pleurisy  with  effusion  pain  almost  or  quite  disappears 
with  the  advent  of  effusion,  dyspnea  comes  on,  and  the  patient  lies  upon  the 
diseased  side.  Cough  always  exists  if  there  is  pleuritic  effusion,  and  fever  is 
usually  present.  In  serous  eft'usions  the  diagnosis  may  be  confirmed  by  the 
aseptic  introduction  of  a  clean  aspirating-needle. 

The  treatment  in  this  stage  is  to  discontinue  arterial  sedatives  and  to 
stimulate  if  the  circulation  calls  for  it.  The  exudation  is  removed  by  the  ad- 
ministration of  sahnes,  compound  jalap  powder,  or  elaterium.  If  these  means 
fail,  if  the  effusion  is  excessive,  or  if  it  is  producing  dyspnea,  at  once  aspirate. 
Aspiration  should  be  performed  for  an  effusion  which  fills  the  whole  chest, 
which  produces  great  dyspnea,  or  which  has  lasted  for  three  weeks.  In  tuber- 
culous pleuritis  early  aspiration  is  not  advisable,  but  aspiration  should  be  per- 
formed if  the  fluid  becomes  purulent,  if  the  effusion  displaces  the  heart 
considerably,  and  if  it  adds  notably  to  the  dyspnea.  If  an  effusion  becomes 
purulent,  the  proper  procedure  is  incision,  resection  of  a  portion  of  a  rib, 
and  drainage. 

Empyema  is  a  collection  of  pus  in  the  pleural  cavity.  It  may  begin  sud- 
denly, but  rarely  does  .so.  Among  the  causes  of  empyema  are  those  of  serous 
effusion.  Empyema  is  due  to  infection  of  the  pleura,  and  in  every  case  a 
bacteriological  study  should  be  made  of  the  pus  to  discover  the  causative 
bacterium.  The  pneumococcus  is  the  causative  micro-organism  in  many  of 
the  cases  which  follow  pneumonia.  These  bacteria  hve  but  a  .short  time,  and 
in  empyema  due  to  pneumococci  these  micro-organisms  may  not  be  discov- 
erable when  the  pus  is  evacuated.  In  most  cases  of  empyema  streptococci  or 
staphylococci  can  be  found  in  the  pus.  These  micro-organisms  may  appear 
in  an  empyema  induced  originally  by  pneumococci  (Stephen  Paget).  In  em- 
jjvema  develoj)ing  during  or  after  typhoid  fever  the  typhoid  bacillus  may  be 
discovered.  In  putrid  empyema  various  bacteria  are  found.  Bouchard  thinks 
acute  empyema  has  a  .special  organism.  The  baciUi  of  tuberculosis  are  pres- 
ent in  tuberculous  empyema,  but  may  disappear  after  mixed  infection  with 
pyogenic  bacteria.  Empyema  may  be  due  to  a  wound  or  contusion,  an  attack 
of  pneumonia,  tubercuk)us  pleuritis,  phthisis,  influenza,  pyogenic  infection  of 
a  .serous  effusion,  caries  of  a  rib,  specific  fevers,  especially  typhoid,  peritoni- 
tis, abscess  of  the  liver,  suppurating  hydatid  cyst  of  the  hver,  subphrenic  ab- 
.sce.ss,  malignant  diseaseof  the  pleura, gangrene  of  the  lung, and  pneumothorax. 

Acute  Empyema. — The  signs  are  in  reality  those  of  pleuritis  with 
effusion — viz.,  dulness  on  percussion,  absent  breath-sounds  over  the  puru- 
lent matter,  bulging  of  the  intercostal  spaces,  and  sometimes  edema  of  the 


Treatment  of  Emp)'ema  663 

skin  of  the  chest.  The  symplo??is  of  acute  empyema  are  dyspnea,  pallor, 
cough,  sweats,  chills,  and  usually  irregular  fever,  but  fever  may  be  ab- 
sent. There  is  marked  leukocytosis.  The  fingers  may  become  clubbed. 
An  empyema  of  the  left  side  may  pulsate.  A  neglected  empyema  may  break 
into  the  lung,  esophagus,  or  pericardium,  through  an  intercostal  space,  or  may 
point  in  the  lumbar  region.  When  an  empyema  is  pointing  externally,  the 
condition  is  called  empyema  necessitatns.  A  total  empyema  is  a  condition 
involving  the  entire  pleural  sac.  In  a  partial  or  localized  empyema  the 
purulent  matter  is  encapsuled.  After  an  empyema  ruptures  spontaneously 
it  rarely  heals  without  surgical  interference,  a  pleural  fistula,  as  a  rule,  per- 
sisting. A  subphrenic  abscess  may  follow  an  empyema.  When  an  empyema 
ruptures  into  a  bronchus,  pneumothorax  arises  as  a  rule.  Empyema  may 
cause  death  by  compression  of  the  heart  and  lung,  pulmonary  embolism,  peri- 
carditis, peritonitis,  cerebral  embolism,  cerebral  abscess,  septicemia,  exhaus- 
tion, or  rupture  into  a  bronchus. 

A  small  empyema  due  to  pneumococci  occasionally,  though  very  rarely, 
undergoes  spontaneous  cure,  the  pus  being  absorbed  (Stephen  Paget). 
'    A  small  empyema  is  occasionally  cured  by  encapsulation  with  fibrous  tissue. 

Under  exceptional  circumstances,  even  a  large  empyema  may  be  cured  by 
breaking  externally  or  into  a  bronchus. 

Empyema  is  so  rarely  cured  spontaneously  that  it  does  not  do  to  trust  to 
Nature,  and  practically  almost  every  case  will  die  without  surgical  treatment. 

Double  empyema  is  a  rare  and  extremely  fatal  condition.  There  are  two 
forms  of  empyema,  the  acute,  which  comes  on  as  a  violent  inflammation,  and 
the  chronic. 

Chronic  empyema  may  follow  an  acute  empyema,  or  the  condition  may  be 
chronic  from  the  beginning.  In  chronic  empyema  the  lung  is  compressed, 
shrunken,  and  strongly  adherent,  and  the  pleura  is  very  thick.  In  some  cases 
the  pleura  is  over  an  inch  thick.  This  thickening  is  brought  about  by  the 
deposition  of  layer  after  layer  of  fibrin.  In  not  a  few  cases  a  chronic  empyema 
succeeds  an  acute  one  or  is  itself  maintained  because  a  drainage-tube  has 
slipped  into  the  pleural  cavity  and  remains  lodged. 

A  closed  empyema  is  one  in  which  no  opening  has  been  made  b\'  the  sur- 
geon and  no  opening  has  formed  spontaneously.  In  a  closed  empyema  the 
pus  is  rarely  putrid;  in  an  open  empyema  the  pus  is  often  putrid. 

Treatment  of  Empyema. — The  treatment  is  purely  surgical,  and  the 
earlier  it  is  applied  the  better.  To  delay  allows  the  pleura  to  thicken  and  per- 
mits adhesions  to  form,  conditions  which  prevent  lung  expansion  and  retard  or 
even  prevent  cure.  The  results  of  operation  are  better  in  children  than  in 
adults;  in  small  collections  than  in  large;  in  recent  than  in  advanced  cases;  in 
pneumococcus  empyema  than  in  empyema  due  to  other  organisms.  The 
surgical  methods  comprise  aspiration,  incision,  rib-resection,  the  operation  of 
Schede,  the  operation  of  Estlander,  and  the  operation  of  Fowler  (see 
pages  675  and  676). 

In  acute  empyema  general  practitioners  are  very  apt  to  aspirate,  and  yet 
aspiration  is  almost  never  curative.  It  may  cure  a  pneumococcus  empyema 
in  a  child,  and  an  encysted  empyema,  but  even  in  these  it  will  usually  fail. 
Aspiration  is  not  to  be  considered  a  method  of  curative  treatment.  It  is  to  be 
regarded  as  the  surgical  treatment  only  in  a  tuberculous  empyema  in  a  young 
person  with  rapidly  progressing  phthisis,  because  in  such  a  case  incision  will 


664  Surgery  of  the   Respiratory  Organs 

probably  prove  fatal  (Lockwood).  It  is  a  very  useful  diagnostic  expedient, 
and  enables  the  surgeon  to  prove  the  existence  of  pus,  and  the  pus  which  is  ob- 
tained can  be  examined  bacteriologically.  In  a  very  large  effusion  it  is  wise 
to  aspirate  and  withdraw  part  of  the  effusion  a  day  or  two  before  operating. 
This  enables  the  patient  to  take  an  anesthetic  with  greater  safety  and  obvi- 
ates the  danger  attending  the  rapid  evacuation  of  a  large  amount  of  pus. 

In  a  recent  empyema  incision  and  drainage  or  rib  resection  and  drainage 
will  often  cure  the  case,  and  yet  many  of  the  results  are  unsatisfactory.  In 
some  cases  the  discharge  ceases  and  yet  pulmonary  function  is  not  completely 
restored.  In  other  cases  a  pleural  fistula  persists.  If  a  profuse  discharge  is 
maintained,  amyloid  disease  may  arise.  An  acute  empyema  is  to  be  drained 
by  intercostal  incision  or  by  resection  of  a  rib  (page  674).  A  chronic  closed 
empyema  is  drained  in  the  same  manner,  and  if  the  lung  will  not  fully  expand 
and  remains  stationary  for  a  month  Schede's  or  Estlander's  operation  is  re- 
quired. An  open  chronic  empyema,  in  which  the  lung  will  not  expand,  re- 
quires the  operation  of  Schede,  Estlander,  or  Fowler  (pages  675  and  676). 
When  there  is  an  external  opening  which  persists,  and  which  joins  a  long, 
narrow  cavity,  the  condition  is  spoken  of  as  pleural  fistula,  and  pleural  fistula 
is  often  produced  by  the  prolonged  use  of  a  drainage-tube  and  sometimes  by 
caries  of  a  rib.  A  pleural  fistula  may  sometimes  be  cured  by  dilatation  of 
the  sinus,  but  in  most  cases  it  is  necessary  to  resect  one  or  more  ribs.  Even 
if  there  is  no  opening  on  the  cutaneous  surface,  there  may  be  one  into  a 
bronchus. 

Non=traumatic  Pneumothorax. — By  the  term  pneumothorax  is 
meant  the  presence  of  air  in  the  pleural  cavity.  As  a  rule,  besides  air  there  is 
serous  fluid  or  pus.  It  may  be  due  to  the  rupture  of  an  empyema  into  a 
bronchus;  to  the  rupture  of  a  tuberculous  area,  an  area  of  gangrene,  an  abscess 
of  the  lung,  an  air-cell  in  a  state  of  emphysema,  or  of  pulmonary  tissue  softened 
because  of  hemorrhagic  infarction.  The  immediate  effect  of  the  entrance  of 
air  into  the  pleural  sac  is  to  compress  the  lung,  the  degree  of  compression  being 
in  proportion  to  the  amount  of  gas  present.  In  severe  cases  the  lung  is 
squeezed  against  the  vertebral  column,  and  the  heart,  the  diaphragm,  and  even 
the  liver  are  displaced.  In  some  cases,  where  the  admission  of  air  does  not 
continue,  the  amount  set  free  in  the  pleural  sac  is  absorbed.  In  most  cases 
pyopneumothorax  (empyema)  follows. 

Symptoms. — The  symptoms  usually  arise  suddenly,  and  consist  of  dis- 
lres.sing  dyspnea,  pain  in  the  chest,  lividity,  and  rapidity  and  weakness  of  the 
pulse.  In  some  ca.ses  of  phthisis  the  symptoms  are  not  very  severe.  It  has 
been  pointed  out  that  occasionally  in  phthisis  pneumothorax  seems  to  actually 
benefit  the  tuberculous  area  in  the  lung.  The  physical  signs  of  pneumothorax 
are  as  follows:  The  affected  side  of  the  chest  is  bulged  and  immobile,  and  the 
heart  is  displaced,  especially  if  the  condition  affects  the  left  side.  Palpation 
fliscovers  that  vocal  fremitus  is  le.ssened  or  absent.  On  auscultation  it  is 
found  that  the  l^reath-sounds  are  very  feeble  or  absent.  The  voice  is  trans- 
mitted as  a  metallic  sound,  the  rales  .sound  metallic,  and  on  coughing  there 
may  be  metallic  tinkling.  The  percussion-note  is  tympanitic.  In  .some  rare 
cases  the  percussion-note  is  dull.  When  fluid  gathers  there  is  a  f)ositively 
dull  note  on  percussion  over  the  fluid. 

Treatment. — Osier  says  the  treatment  should  be  the  same  as  that  of 
pleurisy  with  effusion.     In  many  ca.ses  it  is  wise  to  perform  paracentesis 


Acute  Traumatic   Pneumothorax  665 

without  suction  to  remove  air  and  serous  elfusion.  If  pus  forms,  a  rib 
should  be  resected  and  a  tube  inserted  (see  Empyema).  In  pneumothorax 
occurring  during  chronic  phthisis  operation  is  of  great  service.  In  cases 
with  rapidly  progressive  phthisis  it  is  practically  useless. 

If  the  opening  into  a  bronchus  or  air-cell  remains  patent,  aspiration  will 
not  get  rid  of  air;  the  air  will  enter  into  the  pleura  as  rapidly  as  the  aspirator 
removes  it.  Incision  has  dangers  of  its  own :  the  diaphragm  is  flapping  dur- 
ing respiration  and  may  be  injured  (Fowler),  and  when  the  pleura  is  opened 
there  is  a  great  alteration  produced  in  the  air-pressure  in  the  chest,  and  the  pa- 
tient rnay  "  drown  in  his  own  secretions.  "  After  incision  irrigation  is  not  justi- 
fiable, because  the  fluid  may  enter  a  bronchus  and  produce  sutTocation  (Fowler). 

West's  rule  is  a  good  one  * — that  is,  early  incision  is  dangerous.  In  an 
early  stage  use  paracentesis  without  suction.  This  will  often  relieve  the 
patient.  If  paracentesis  does  reheve  him,  wait  a  while  and  perhaps  repeat  the 
operation  if  the  symptoms  again  become  severe.  If  paracentesis  does  not  re- 
lieve, incise,  resect  a  portion  of  a  rib,  and  drain.  If  pus  forms,  an  incision 
must  be  made  and  a  portion  of  a  rib  resected,  to  afford  exit  to  the  fluid. 

Fowler  points  out  that  if  the  lung  is  bound  down  by  adhesions,  incision  is 
dangerous  but  justifiable.  Operation  at  the  proper  time  often  prevents  the 
lung  being  bound  down  t)y  adhesions. 

Acute  Traumatic  Pneumothorax.— This  is  produced  by  the  sudden 
admission  of  a  quantity  of  air  into  the  pleural  cavity  as  a  result  of  a  wound  of 
the  chest-wall.  A  small  quantity  of  air,  or  the  gradual  introduction  of  con- 
siderable air  does  not,  as  a  rule,  produce  very  serious  symptoms.  The  sudden 
admission  of  a  quantity  of  air  causes  very  dangerous  symptoms,  and  even 
death.  A  quantity  of  air  mav  be  admitted  rather  suddenly  as  a  result  of  an 
accident  or  during  the  performance  of  a  surgical  operation  which  opens  the 
pleura.  It  sometimes  arises  during  the  removal  of  tumors  from  the  chest-wall, 
during  operations  upon  the  lung,  and  during  empyema  operations.  As  a  rule, 
when  pulmonary  adhesions  exist,  dangerous  symptoms  do  not  arise,  even  when 
the  pleura  is  widely  opened,  and  adhesions  exist  in  25  per  cent,  of  empyema 
cases  seen  by  the  surgeon. f 

It  used  to  be  taught  that  whenever  the  jjleura  is  opened  there  is  a  strong 
tendency  to  the  development  of  pneumothorax,  but  West  has  shown  that  the 
surfaces  of  the  pleura  often  cohere  with  a  force  superior  to  pulmonary  elas- 
ticity, and  in  such  cases  pneumothorax  does  not  arise. 

Symptoms. — ^When  the  pleura  is  opened  during  an  operation  or  by  an 
injury,  the  symptoms  may  be  trivial  and  transitory,  may  be  tolerably  severe, 
may  be  extremely  grave,  and  the  patient  may  quickly  die  (Qudnu  and  Longuet). 
Rudolph  Matas  sets  forth  the  symptoms  as  presented  by  the  French  observers :+ 

The  mild  symptoms  are  a  weak,  slow  pulse  and  irregular,  noisy  respiration. 

The  severe  symptoms  are  slow  pulse,  slow  and  irregular  respiration,  and 
dyspnea,  continuing  after  the  anesthetic  has  been  withdrawn. 

The  grave  symptoms  are  cyanosis;  collapse;  small,  weak  pulse;  shallow  and 
noisy  respiration;  and  spells  of  syncope.  Death  may  occur  suddenly  from 
inhibition,  or  later  from  mechanical  asphyxia  (Matas). 

Treatment. — Various  plans  have  l.^een  adopted:  suturing  the  opening  in 

*  Brit.  Med.  Jour.,  Nov.  27,  1897.  t  Rudolph  jMatas,  Annals  of  Surgery,  April,  1899. 

±  Annals  of  Surgery,  April,  1899. 


666 


Surgery  of  the   Respiratory  Organs 


the  pleura;  pkigging  the  opening;  pulhng  the  diaphragm  into  the  wound  in  the 
chest-wall  and  suturing  it;  and  grasping  the  lung  and  suturing  it  to  the  wound. 
Whenever  the  pleura  is  widely  opened,  follow  the  advice  of  Matas  and  use  the 
Fell-O'Dwyer  apparatus,  and  when  the  operation  is  completed,  suture  the  lung 
to  the  margin  of  the  opening  in  the  pleura  with  a  continuous  catgut  suture. 
Parham  and  Keen  have  followed  this  plan  and  the  lung  was  kept  from  col- 
lapsing.* 

The  Fell-O'Dwyer  apparatus  is  shown  in  Fig.  346. 

O'Dwyer's  tube  is  introduced  into  the 
glottis  and  is  attached  to  a  bellows,  the 
lung  is  inflated,  respiration  is  maintained 
by  the  use  of  the  bellows,  and  collapse 
with  all  its  dangers  is  avoided. 

Contusions  and  Wounds  of  the 
Chest. — Contusions. — A  contusion  may 
be  trivial  and  limited  to  the  superficial 
parts  of  the  chest-wall;  it  may  involve  the 
muscles;  it  may  be  associated  with  frac- 
ture of  the  ribs  or  sternum  or  with  vis- 
ceral injury. 

Symptoms. — In  an  ordinary  contu- 
sion without  visceral  injury  there  are  con- 
siderable pain,  discoloration,  and  often 
much  swelling.  The  patient  prefers  to  lie 
upon  the  back  and  the  respiration  is  ab- 
dominal. After  a  severe  blow  upon  the 
chest  there  is  great  shock  and  may  even  be 
instant  death.  The  condition  of  shock  so 
produced  is  called  concussion  of  the  chest. 
Broken  ribs  may  injure  the  pleura  or  lung. 
After  a  severe  blow  upon  the  chest  a 
limited  area  of  inflammation  may  arise 
in  the  pleura  (traumatic  pleuritis).  Severe 
visceral  injury  is  announced  by  positive 
symptoms.  A  contusion  of  the  lung  causes 
pain,  cough,  expectoration  of  bloody  mu- 
cus, dyspnea,  and  possibly  distinct  hem- 
optysis. Over  the  contused  region  the 
percus-sion-note  is  dull  and  on  au.scultation 
crepitus  is  audible.  A  hmited  pneumonia 
always  follows,  but  genuine  croupous  pneumonia  may  ari.se. 

In  rupture  of  the  lung,  besides  the  symptoms  above  noted,  there  are 
hemothorax  and  pneumothorax. 

Rupture  of  the  diaphragm  causes  pain  and  dyspnea,  and  often  vomiting. 
The  stomach  or  intestine  may  pass  into  the  pleural  sac.  If  this  happens,  there 
will  be  a  tympanitic  percussion-note  over  the  displaced  viscus  and  symptoms 

*  F.  W.  Parham's  paper  on  "Thoracic  Resection  for  Tumors  Growing  from  the  Bony 
Walls  of  the  Chest."  Read  before  the  Southern  Surgical  and  Gyniiecological  Association, 
November,  1898. 


Fig.  346. —  The  Fell-O'Dwyer  appa- 
ratus. This  illustration  shows  an  early 
model ;  since  then  the  bellows  has  been 
improved  by  the  addition  of  a  strong 
wooden  frame,  which  holds  it  steadily,  and 
is  provided  with  a  long  arm  that  acts  as  a 
powerful  foot-piece  for  compressing  the 
machine  with  the  least  amount  of  muscular 
effort. 


Wounds  of  the   Chest  667 

will  vary  with  the  viscus  involved.  In  a  case  in  the  Jefferson  Medical  College 
Hospital,  in  which  the  stomach  passed  into  the  left  pleural  sac,  there  were 
persistent  vomiting,  violent  pain  in  the  chest  and  upper  abdomen,  great  thirst, 
and  displacement  of  the  apex-beat.  Such  a  diaphragmatic  hernia  may  be- 
come strangulated.     (See  page  842.) 

Treatment  of  Contusions  of  the  Chest. — An  ordinary  contusion  is  treated 
as  directed  in  the  section  on  Contusions  (page  192),  and  the  chest  is  strapped 
v/ith  adhesive  plaster,  as  in  the  treatment  of  fractured  ribs.  In  concussion  of 
the  chest  the  treatment  for  shock  is  applied.  It  may  be  necessary  to  employ 
artificial  respiration  for  a  time.  If  a  diaphragmatic  hernia  is  diagnosticated, 
the  abdomen  should  be  opened,  the  displaced  viscera  restored  to  their  proper 
abode,  and  the  diaphragm  sutured.  The  diaphragm  may  also  be  reached  by 
resecting  several  ribs  and  opening  the  pleural  sac.  In  contusions  of  the  lung 
cold  is  applied  to  the  chest,  and  any  inflammation  which  arises  is  treated 
according  to  general  rules.  In  rupture  of  the  lung  the  case  may  be  treated 
expectant!}',  but  dangerous  and  continued  bleeding  or  pneumothorax  may 
render  surgical  interference  necessary. 

Wounds  of  the  Chest. — Non-penetrating  wounds  are  not  particularly 
grave,  and  are  treated  according  to  general  principles,  the  chest  being  immo- 
bilized. Penetrating  wounds  are  extremely  grave,  as  viscera  are  apt  to  be 
injured.  In  such  a  wound  an  intercostal  artery  may  be  severed  or  the  internal 
mammary  artery  may  be  divided.  An  intercostal  artery  is  rarely  divided  un- 
less a  rib  is  broken.  The  surgeon  should  always  examine  carefully  in  order  to 
determine  whether  an  intercostal  artery  or  the  internal  mammary  artery  has 
been  divided,  and,  in  doing  so.  should  bear  in  mind  the  admonition  of  Matas — 
that  is,  the  bleeding  from  these  vessels  may  be  internal,  the  blood  collect- 
ing in  the  pleural  sac.  The  pericardium  or  heart  may  be  injured  (page  284). 
A  wound  of  the  pleura  is  usualh',  but  not  always,  associated  with  a  wound  of 
the  lung.  If  the  lung  is  injured,  there  are  usually  great  shock,  pain  in  the 
chest,  dyspnea,  and  cough.  In  a  large  wound,  damage  to  the  lung  will  be 
indicated  if  air  is  sucked  into  the  wound  during  inspiration  and  expelled  during 
expiration,  and  blood  is  forced  out  of  the  wound  by  coughing.  The  lung  may 
be  visible  or  may  protrude  {hernia  of  the  lung).  In  a  small  wound  it  is  often 
difficult  and  sometimes  impossible  to  determine  whether  the  lung  has  been 
injured.  Pneumothorax  with  pulmonary  collapse  proves  it  has.  Severe 
hemothorax  strongly  suggests  it.  Spitting  blood  does  not  prove  it.  In  some 
severe  cases  there  is  no  hemoptysis;  in  some  slight  bruises  the  amount  of  blood 
coughed  up  is  large.  Emphysema  about  the  wound  does  not  prove  lung 
injury.  An  incised  wound  of  the  lung  is  apt  to  produce  rapid  death  from 
hemorrhage,  especially  if  the  wound  is  at  the  root  of  the  lung.  A  pistol-bullet 
or  a  sporting-rifle  bullet  is  not  usually  productive  of  great  primary  hemorrhage; 
but  infection  probably  follows,  and  secondary  hemorrhage  is  apt  to  occur.  The 
modern  mihtary-rifie  ball  passes  through,  rarely  lodges,  is  aseptic,  and  often 
produces  astonishingly  httle  trouble.  A  pistol-bullet  and  an  old-time  rifle 
bullet  may  lodge  or  may  perforate. 

Treatment. — Bring  about  reaction  as  pointed  out  on  page  192. 

In  an  incised  wound  of  the  chest,  if  large,  carefully  inspect  it.  If  the 
wound  is  small,  cut  down  layer  by  layer  until  the  depths  of  the  wound  are 
reached.     Disinfect  the  wound  -dwi  arrest  hemorrhage.     If  the  pleura  is  not 


668  Surgery  of  the   Respiratory  Organs 

open,  proceed  according  to  general  rules  (page  197).  If  the  pleura  is  found  to 
have  been  opened,  suture  it  with  catgut,  close  the  superficial  wound,  dress  with 
gauze,  and  immobihze  the  chest-wall. 

The  above  proceedings  should  be  carried  out  whether  it  is  or  is  not  believed 
that  the  lung  has  been  damaged,  provided  there  is  no  pneumothorax  and  no 
violent  hemorrhage.  What  course  shall  be  pursued  if  the  lung  has  been  in- 
jured bv  a  stab  ?  If  hemorrhage  does  not  threaten  life  and  there  is  no  pneu- 
mothorax, the  patient  is  kept  at  rest  and  observed.  If  pneumothorax  occurs, 
the  pleural  sac  must  be  drained  by  means  of  a  tube,  because  clots  must  be 
evacuated  and  infection  should  be  anticipated.  If  hemorrhage  into  the  pleural 
sac  persists,  active  measures  become  necessary.  The  use  of  ice-bags  and  drugs 
is  but  waste  of  time.  Some  surgeons  believe  that  the  mere  closure  of  the 
external  wound  leads  to  arrest  of  hemorrhage,  blood  accumulating  and  making 
pressure.  It  is  true  that  hemorrhage  often  ceases  after  suturing  or  plugging  a 
wound  and  strapping  the  chest,  but  it  is  not  probable  that  it  ceases  because  of 
these  measures.  Blood  in  the  pleura  will  not  clot  for  many  days.  Further, 
as  Le  Conte  shows,  as'the  blood  is  forced  against  the  root  of  the  lung,  the  right 
heart  is  engorged,  the  blood-pressure  is  raised,  and  the  bleeding  continues.* 

Bleeding  from  the  lung  can  often  be  arrested  by  inserting  the  end  of  a 
drainage-tube  into  the  pleural  sac.  In  cases  where  a  drainage-tube  is  inserted 
into  the  pleural  cavity  and  free  drainage  estabhshed,  the  pleura  is  immediately 
filled  with  air,  and  the  muscles  of  respiration  are  kept  from  acting  on  the  lung. 
The  lung  contracts  by  its  own  elastic  tissue,  as  well  as  by  the  pressure  e.xerted 
by  the  pneumothorax,  and  at  the  same  time  the  presence  of  the  air  favors 
clotting  in  the  severed  vessels. f  If  the  insertion  of  a  tube  fails,  or  if  the  bleed- 
ing is  rapid  and  obviously  seriously  threatens  life,  several  ribs  must  be  rapidly 
resected  and  the  bleeding  part  explored.  In  some  cases  the  bleeding  may  be 
arrested  by  hgation,  in  some  cases  by  packing  a  small  wound  with  gauze,  in 
some  cases  by  the  suture  ligature.  In  a  violent  secondary  hemorrhage  follow- 
ing a  gunshot-wound  of  the  lung  the  author  packed  the  entire  pleural  cavity 
with  sterile  gauze  to  obtain  a  base  of  support,  and  arrested  the  bleeding 
by  carrying  iodoform  gauze  directly  against  the  oozing  surface.  J  After 
directly  arresting  hemorrhage  from  the  lung,  turn  clots  out  of  the  pleural  sac 
and  insert  a  drainage-tube.  In  a  perforating  wound  inflicted  by  a  bullet,  re- 
action must  be  brought  about,  the  wound  dressed  antiseptically,  the  chest 
strapped,  and  the  patient  kept  quiet.  If  pneumothorax  occurs,  the  pleura 
should  be  drained  with  a  tube.  If  hemorrhage  occurs,  it  should  be  met  as 
directed  above.  In  a  wound  in  which  the  bullet  has  lodged  an  exammation 
should  be  made  to  see  if  the  bullet  is  under  the  skin  and  if  it  is,  it  is 
removed  after  the  patient  has  reacted.  It  should  always  be  borne  in  mind 
that  a  pistol-bullet  may  be  deflected  by  a  rib  or  may  pass  from  the  front  to  the 
back  part  of  the  chest  by  making  a  burrow  under  the  skin  (a  contour  wound). 
If  a  bullet  is  lodged,  no  attempt  should  be  made  to  remove  it  unless  an 
operation  must  be  done  for  bleeding,  unless  the  bullet  causes  trouble,  or 
unless  it  is  felt  under  the  skin.  Under  no  circumstances  conduct  a  long 
search  for  a  bullet.  If  emphysema  of  the  chest-walls  is  moderate,  strapping 
or  a  bandage  will  control   it;  if  it  is  great,  make  multiple  ])unctures  and  then 

*  Annals  of  Surgery,  A])ril,  1899. 

t  Le  Conte,  in  Annals  of  Surgery,  April,   1899.  %  Annals  of  Surgery.  Jan.,  1898. 


Gangrene  of  the   Lung  66g 

apply  pressure.  In  hernia  of  the  lung  try  to  restore  the  protrusion;  but  if 
restoration  is  impossible  or  if  gangrene  seems  Hkely  to  occur,  ligate  the  base 
of  the  protrusion  with  silk  and  cut  away  the  mass. 

Abscess  of  the  lung  ma}-  follow  ordinary  pneumonia.  It  is  apt  to 
follow  aspiration-pneumonia.  It  is  usually  caused  by  streptococci  or  staphy- 
lococci, but  it  may  result  from  pneumococci  or  colon  bacilli.  These  germs 
may  reach  the  pulmonary  tissue  by  direct  entrance  from  adjacent  organs, 
by  way  of  the  blood  or  by  way  of  the  bronchi  and  alveoli.  Osier  tells  us 
that  pulmonary  abscess  may  result  from  the  aspiration  of  septic  particles 
after  "  wounds  of  the  neck,  operations  upon  the  throat, "  and  suppurative 
lesions  of  the  nose,  larynx,  or  ear.*  Aspiration-pneumonia  may  develop 
when  there  is  difficulty  in  swallowing  from  any  cause,  when  there  is  profound 
exhaustion,  and  when  there  is  palsy  or  inco-ordination  of  any  of  the  muscles 
of  deglutition.  Cancer  of  the  esophagus  may  be  a  cause;  so  may  perforation 
of  the  lung  by  an  abscess,  wound  uf  the  lung,  impaction  of  a  foreign  body 
in  the  lung,  suppuration  about  a  focus  of  tubercle  or  a  metastatic  abscess.  A 
pulmonary  abscess  may  be  of  trivial  size  or  it  may  be  very  large,  invohing  an 
entire  lobe.  There  may  be  one  abscess,  several,  or  many.  When  sup- 
puration results  from  aspiration-pneumonia  or  blood-infection,  there  are 
usually  multiple  abscesses. 

Symptoms. — The  expectoration  is  not  frequent,  but  is  profuse,  and 
during  a  paroxysm  mouthfuls  are  coughed  up  in  rapid  succession.  The 
expectorated  matter  is  sour  or  very  offensive  in  odor  and  contains  fragments 
or  shreds  of  pulmonary  tissue,  which  can  be  identified  as  such  by  the  micro- 
scope. The  patient  lies  upon  the  disea.sed  side  in  order  to  keep  the  pus 
from  running  into  the  bronchi  and  causing  cough.  When  the  cavity  fills 
and  pus  reaches  the  bronchi,  violent  cough  and  expectoration  begin,  continue 
until  the  cavity  is  partly  or  entirely  emptied,  and  then  subside,  perhaps  for 
several  hours.  If  the  abscess-cavity  is  large  and  full  of  pus,  an  area  of  dul- 
ness  on  percussion  can  be  mapped  out.  When  the  pus  is  coughed  out  and 
the  air  enters,  physical  signs  of  a  cavity  are  clear.  The  .v-rays  often  show 
the  situation  of  such  a  cavity. 

The  course  of  abscess  of  the  lung  is  usually  acute.  There  is  fever  of 
the  hectic  type,  rapid  loss  of  weight,  weakness  and  rapidity  of  circulation, 
dyspnea,  pallor,  sleeplessness,  and  great  weakness.  Gangrene  may  arise; 
empyema  or  pyopneumothorax  may  develop;  very  rarely  the  abscess  breaks 
through  the  chest-w^all;  recovery  may  follow  spontaneous  evacuation  or 
drainage  by  coughing  up  pus;  death  may  result  from  exhaustion  or  secon- 
dary septic  lesions.  If  operation  is  performed,  from  50  to  60  ]ier  cent,  of 
the  patients  will  recover. 

The  treatment  is  purely  surgical  (pneumotomy).  Make  an  incision 
over  the  cavity.  Resect  a  portion  of  one  or  more  ribs.  Expose  the  pleura. 
If  the  two  layers  of  the  pleura  are  not  adherent,  suture  them  together  and 
wait  two  days.  If  they  are  adherent,  proceed  at  once.  Search  for  the  ab- 
scess with  an  aspirator  needle.  When  the  cavity  is  found,  open  into  it  with 
the  cautery  and  insert  a  drainage-tube  (page  676). 

Gangrene  of  the  Lung.— This  term  means  the  putrefaction  of  a 
devitalized  portion  of  pulmonary  tissue.     The  tissue  is  devitalized  by  the 

*  See  Osier's  '•  Practice  of  Medicine." 


6/0  Surgery  of  the  Respiratory  Organs 

action  of  pyogenic  micro-organisms.  Gangrene  may  follow  abscess,  bron- 
chitis, or  pneumonia,  or  may  be  due  to  diabetes,  to  embolism  of  the  pul- 
monary artery,  bronchiectasis,  tuberculosis,  malignant  disease,  wounds,  or  the 
lodgment  of  foreign  bodies.  Gangrene  may  be  circumscribed  or  diffused. 
There  may  be  one  cavity,  small  or  large,  or  multiple  cavities  may  form.  The 
gangrenous  area  putrefies,  softens,  and  the  softened  matter  may  be  expector- 
ated, a  gangrenous  cavity  being  formed.  In  some  cases  the  cavity  is,  after 
a  time,  surrounded  by  fibrous  tissue  and  obliterated  by  granulations. 

S5nnptoms. — Expectoration  occurs  only  now  and  then,  but  at  each 
seizure  a  great  quantity  of  matter  is  brought  up  and  this  matter  is  hideously 
offensive.  Occasionally  there  is  no  expectoration.  The  breath  is  very  foul. 
The  patient,  as  in  lung  abscess,  lies  upon  the  diseased  side.  The  expec- 
torated matter  is  mucopurulent,  contains  particles  or  shreds  of  pulmonary 
tissue,  bacteria,  and  altered  blood.  The  fetor  of  the  pus  is  much  greater 
than  is  the  fetor  of  the  pus  of  an  abscess.  Physical  signs  may  indicate  either 
consolidation  or  a  cavity.  There  is  hectic  fever,  great  exhaustion,  deadly 
pallor,  and  diarrhea.  Pulmonary  hemorrhage  is  not  unusual,  and  complica- 
tions spoken  of  in  the  article  upon  Abscess  may  occur.  Recovery  sometimes 
ensues,  the  cavity  closing  by  granulations.  Death  may  take  place  in  a  few 
days.  Often  the  patient  lives  for  weeks,  being  sometimes  better  and  some- 
times worse,  dying  finally  from  exhaustion  or  from  the  effects  of  a  compli- 
cation. 

The  treatment  is  to  operate  as  for  pulmonary  abscess. 

Tuberculous  Cavity  in  the  Lung.— Surgical  Treatment.— For  the 
past  decade  .surgical  thought  has  been  actively  directed  toward  placing  on 
a  scientific  footing  operations  for  pulmonary  phthisis.  The  matter  is  still 
in  a  transition-stage,  and  operations  at  present  have  but  a  very  hmited  field 
of  application,  although  Sonnenberg  and  others  have  reported  cures.  Baglivi, 
in  the  seventeenth  century,  endeavored  to  tap  and  inject  tuberculous  cavities. 
Hastings  and  Stucke  did  the  same  thing  in  the  eighteenth  century.  Hosier, 
a  number  of  years  ago,  attempted  to  treat  cavities  by  introducing  a  trocar 
into  the  cavity  and  injecting  permanganate  of  potassium  solution  through 
the  cannula.  Patients  were  not  benefited  by  this  procedure.  The  plan  was 
revived  by  Pepper  in  1874.  The  results  are  bad  and  the  operation  dangerous. 
Hillier  tried  injection  of  corrosive  sublimate  into  the  lung-parenchyma,  but 
the  effect  of  the  injections  was  disastrous.  Vidal  advocates  counter-irritation 
by  the  actual  cautery  and  maintains  that  congestion  improves  nutrition. 
When  the  strength  of  the  patient  is  well  preserved  and  the  pulmonary  lesion 
is  circumscribed  and  slowly  progre.ssive,  it  may  be  justifiable  to  perform 
an  operation,  open  the  cavity,  and  treat  it  directly  (pneumotomy).  That 
pneumotomy  might  be  performed  successfully  was  suggested  to  surgeons 
by  ob.serving  patients  recover  after  sword-thrusts  into  the  lung.  Baglivi 
incised  the  lung  in  1643.  Fowler  says  it  is  not  justifiable  to  operate  if  the 
disea.se  has  come  "to  a  standstill."  The  same  surgeon  states  that  the  only 
accessible  region  is  bounded  above  by  the  clavicle,  to  the  inner  side  by  the 
manubrium,  to  the  outer  side  by  the  lesser  pectoral  muscle,  and  below  by 
the  .second  rib.*     This  operation  does  not  cure  any  one,  but  it  may  cause 

*  See  the  very  full  and  thoughtful  article  by  George  Ryerson  Fowler  on  "The  Surgery 
of  Intrathoracic  Tuberculosis,"  Annals  of  Surgery,  Nov.,  1896. 


Exploratory    Puncture  of  the   Pleural   Sac  671 

distinct  improvement  when  there  is  hectic  from  an  ill-drained  cavity  contain- 
ing the  products  of  a  mixed  infection.  In  an  advanced  case  there  is  usually 
more  than  one  cavity,  and  then  the  operation  is  contraindicated.  Before 
attempting  it,  be  sure  the  case  is  advanced  and  that  the  cavity  is  single. 
Locate  the  cavity  by  auscultation,  percussion,  and  the  .r-rays.  (See  Willard, 
"Jour.  Amer.  Med.  Assoc,"  Sept.  20,  1902.) 

Mauclaise  says  that  pneumotomy  is  only  justifiable  in  circumscribed 
tuberculous  cavities  without  peripheral  infiltration  and  in  pulmonary  ab- 
scesses.* Bronchiectatic  cavities  are  usually  multiple;  they  are  excessively 
difficult  to  locate,  and  treatment  by  pneumotomy  should  not  be  attempted. 
In  the  treatment  of  pulmonary  tuberculosis  resection  of  the  diseased  area 
has  been  proposed  (pneumectomy).  Tuffier  successfully  performed  this 
operation.  Surgeons,  as  a  rule,  do  not  believe  in  pneumectomy.  Reclus 
voices  the  general  opinion  when  he  says  the  operation  is  not  required  if 
the  area  of  disease  is  very  hmited,  as  such  a  condition  is  frequently  curable 
by  medicinal  means,  and  it  does  no  good  if  the  area  of  disease  is  extensive,  f 

It  has  long  been  known  that  pneumothorax  might  benefit  a  tuberculous 
lung.  Attempts  have  been  made  by  Farlanini  and  Murphy  to  cure  phthisis 
by  the  dehberate  production  of  pneumothorax.  Murphy  injects  nitrogen 
gas  into  the  pleural  sac,  and  believes  that  the  method  is  of  great  value.  It 
is  maintained  that  Murphy's  operation  occludes  the  lymph-channels,  prevents 
bleeding,  compresses  the  lung,  favors  the  development  of  fibrous  tissue,  and 
leads  to  heahng  of  cavities.  Every  third  or  fourth  week  120  c.c.  of  nitrogen 
gas  are  injected  into  the  pleural  sac.  (See  Willard  in  "Jour.  Amer.  Med. 
Assoc,"  Sept.  20,  1902;  Murphy's  paper  before  Amer.  Med.  Assoc,  in  1S98; 
Lemke  in  "Jour.  Amer.  Med.  Assoc,"  Oct.  14,  21,  28,  1899.) 

It  has  been  suggested  that  in  extensive  unilateral  tuberculosis  of  the 
lung  resection  of  a  number  of  ribs  will  favor  cure  by  permitting  retraction 
of  the  chest- wall.  J 

Operations  on  Pleura  and  Lungs. 

Exploratory  Puncture  of  the  Pleural  Sac— Puncture  often  gives 
valuable  information  as  to  the  existence  of  fluid  in  the  pleural  sac  and  as 
to  the  nature  of  the  fluid.  The  operation  must  be  performed  with  aseptic 
care,  otherwise  a  serous  effusion  might  be  converted  into  a  purulent  effusion, 
and  either  a  serous  or  a  purulent  effusion  might  be  rendered  putrid.  A 
large  hypodermatic  syringe  with  a  long  and  strong  needle  is  used  for  ex- 
ploratory puncture.  A  slender  needle  breaks  easily  and  is  unsafe.  In  order 
to  prevent  breaking  of  the  needle  impress  upon  the  patient  the  absolute 
necessity  of  keeping  quiet  and  avoiding  any  violent  respiratory  or  general 
movement  during  the  operation.  It  is  not  desirable  to  stick  the  lung,  al- 
though harm  rarely  results  from  such  an  accident.  If  no  fluid  is  found  in 
the  pleura  on  one  trial,  several  other  punctures  should  be  made.  What  is 
known  as  a  dry  tap  may  be  due  to  the  entire  absence  of  fluid,  to  encapsulation 
of  fluid  in  a  region  not  invaded  by  the  needle,  to  the  lodgment  of  the  point 
of  the  needle  in  thickened  pleura  or  in  an  adhesion,  or  to  blocking  of  the 

*  La  Tribune  medicale,  Sept.  21,  1S93.  f  Revue  de  Chirurgie,  Nov.  11,  1S95. 

X  Allis,  to  State  Med.  Sec.  of  Penna.  in  1891. 


672  Surgery   of  the   Respirator}-   Organs 

lumen  of  the  needle  with  coagula.  Fowler  points  out  that  if  a  person  has 
been  recumbent  for  a  long  time  the  upper  layer  of  fluid  may  be  clear  while 
the  lower  layer  is  purulent.*  The  fluid  should  be  collected  in  a  sterile  glass 
tube  and  subjected  to  a  carefu'  bacteriological  study. 

Paracentesis  Thoracis.— The  operation  of  tapping  with  a  simple 
trocar  and  allowing  the  fluid  to  flow  out  through  the  cannula  is  no  longer 
practised  except  in  an  emergency  when  an  aspirator  cannot  be  obtained 
or  in  an  early  stage  of  non-traumatic  pneumothorax.  An  aspirator  is  a  much 
better  instrument. 

Aspiration. — Aspiration  consists  in  the  introduction  into  the  pleural 
sac  of  the  tip  of  a  hollow  needle,  the  other  end  of  which  is  attached  by  means 
of  a  rubber  tube  to  a  bottle  from  which  the  air  has  been  exhausted.  The 
fluid  does  not  run  out,  but  is  sucked  out,  air  is  excluded,  and  bacteria  do 
not  enter  the  pleural  sac.  Fig.  266  shows  a  pneumatic  aspirator.  No 
anesthetic  is  required.  The  patient's  skin,  the  instruments,  and  the  sur- 
geon's hands  must  be  thoroughly  asepticized.  The  patient  is  given  a  little 
whiskey,  and,  unless  he  is  very  weak,  he  assumes  a  semi-erect  attitude  with 
the  arm  hanging  by  the  side.  The  trocar  is  introduced  in  the  fifth  interspace, 
just  in  front  of  the  angle  of  the  scapula.  The  surgeon  marks  the  upper  bor- 
der of  the  sixth  rib  with  the  index-finger,  and  plunges  in  the  trocar  just  above 
the  finger,  thus  avoiding  the  intercostal  artery,  which  lies  along  the  lower 
border  of  the  rib  above.  He  guards  the  needle  with  the  index-finger  to  pre- 
vent its  going  in  too  far.  The  fluid  is  withdrawn  rather  slowly  in  order 
that  the  patient  may  escape  syncope  and  violent  cough.  If  the  patient  be- 
comes very  faint,  the  operation  should  be  abandoned.  All  the  fluid  present 
should  not  be  removed  at  one  sitting — complete  removal  of  a  large  eft'usion  is 
not  safe.  The  operation  can  be  repeated  if  necessary.  After  withdrawing  the 
cannula  place  iodoform  collodion  over  the  opening  in  the  chest.  In  an  early 
stage  of  non-traumatic  pneumothorax  perform  paracentesis  without  suction. 
In  non-purulent  pleuritic  effusion,  if  the  lungs  will  not  expand  after  tappings, 
perform  thoracotomy.  In  some  cases  aspiration  is  followed  by  pulmonary 
embolism  or  embohsm  at  a  distance.  Syncope  is  a  not  unusual  result.  Con- 
vulsions occasionally  occur.  In  rare  cases  the  sudden  withdrawal  of  a  large 
effusion  is  followed  by  albuminous  expectoration,  as  was  pointed  out  by 
Pinault  in  1853.  I^  usually  begins  from  a  few  minutes  to  half  an  hour  after 
aspiration.  When  this  complication  arises  the  pulse  is  very  weak,  there 
is  .severe  dyspnea,  cyanosis,  cough,  and  the  expectoration  of  quantities  of 
a  yellow,  frothy  fluid.  Riesman  ("Amer.  Jour,  of  Med.  Sciences,"  April, 
1902)  demonstrates  that  the  condition  is  due  to  pulmonary  edema  and  not 
to  puncture  of  the  lung.  The  sudden  withdrawal  of  fluid  by  aspiration 
relieves  the  pressure  which  was  compre.ssing  the  lung,  the  lung  becomes 
congested  with  blood  (congestion  by  recoil,  Riesman  calls  it),  the  blood 
distends  weakened  vessels,  and  profuse  transudation  takes  place  into  the 
air-cells.  Most  cases  recover  in  a  few  hours  or  a  day  or  two.  Severe  cases 
die  from  asphyxia.  Terrilon  collected  23  cases  with  2  deaths.  If  albu- 
minous expectoration  arises  dry  cup  the  chest  and  counter-irritate  with 
mustard  plasters.  Perform  venesection.  Give  oxygen  by  inhalation.  Ad- 
minister atropin  hypodermatically.  Employ  artificial  respiration  it  necessary. 
*  Annals  of  Surgery,  Noveniljer,  1896. 


Thoracotomy  673 

Thoracotomy  is  an  incision  into  the  cavity  of  the  pleura.  It  may 
be  merely  an  intercostal  incision,  or  may  be  an  opening  into  the  chest  after 
resecting  a  portion  of  a  rib.  Often  in  a  child  with  empyema  good  drainage 
can  be  obtained  by  an  intercostal  incision,  but  in  most  children  and  in  all 
adults  a  rib  should  be  resected.  The  instruments  required  for  rib  resec- 
tion and  thoracotomy  are  a  scalpel,  a  grooved  director,  forceps  (hemostatic 
and  dissecting),  scissors,  a  periosteum  elevator,  retractors,  a  costotome  or 
metacarpal  saw,  rongeur  forceps,  drainage-tubes,  and  needles. 

If  there  is  very  little  dyspnea,  ether  can  be  given.  If  there  is  considerable 
dyspnea,  chloroform  should  be  gi^•en.  If  there  is  severe  dyspnea,  no  general 
anesthetic  is  admissible.  In  severe  dyspnea  the  patient  is  using  certain 
voluntary  muscles  to  aid  him  in  obtaining  air.  A  general  anesthetic  abolishes 
the  activity  of  the  voluntary  muscles  of  respiration,  and  so  might  cause 
suffocation.  In  such  cases  the  operation  can  be  done  with  fair  satisfaction 
after  the  injection  of  eucain  or  after  infiltrating  the  superficial  tissues  of 
the  chest-wall  with  Schleich's  fluid,  or,  what  is  better,  preliminarv  aspiration 
can  be  performed.  Aspiration  will  permit  of  the  subsequent  administration  of 
a  general  anesthetic.  The  patient  on  whom  thoracotomy 
is  to  be  performed  is  placed  supine,  the  diseased  side  being 
at  or  over  the  edge  of  the  table.  He  must  never  be  placed 
on  the  sound  side,  because  he  breathes  only  with  that  side, 
and  pressure  on  it  may  be  dangerous. 

The  arm  of  the  diseased  side  should  be  elevated  to  a 
right  angle  with  the  body.  If  the  surgeon  desires  to  obtain 
only  intercostal  drainage,  he  should  make  a  longitudinal 
incision  about  three  inches  in  length  at  the  upper  border 
of  the  sixth  or  seventh  rib,  and  the  middle  of  this  incision 
should  correspond  to  the  midaxillarv  line.     This  incision 

11  11  .1  1        "  Ti-  -11  11  F'a- 347- — Resection 

is  carried,  layer  by  layer,  to  the  pleura.     It,  as  will  usually      ^f  ^  ^-^^  (Esmarch  and 
be  the  case,  he  wishes  to  remove  a  portion  of  a  rib,  he      Kowaizig). 
will  make  an  incision  about  three  inches  in  length  directly 

upon  the  outer  surface  of  the  rib  he  wishes  to  remove,  and  the  middle  of  this 
incision  corresponds  to  the  midaxillary  line.  Some  surgeons  resect  a  portion 
of  the  fifth  rib,  some  remove  a  bit  of  the  eighth  rib,  and  Munro  *  shows 
that  at  the  level  of  the  eighth  rib  there  is  no  danger  of  injuring  the  diaphragm. 
By  many  operators  a  portion  of  the  seventh  or  eighth  rib  is  remo\ed  in  front 
of  the  line  of  the  posterior  axillary  fold. 

I  agree  with  Hutton  that  a  portion  of  the  sixth  rib  in  the  midaxillary 
line  should  be  removed.!  The  reasons  given  by  Hutton  for  the  selection 
of  this  rib  are:  (i)  It  is  over  the  portion  of  the  lung  which  expands  last. 
An  empyema  is  drained  only  partly  by  gravity,  and  the  fluid  is  really  forced 
out  and  the  cavity  obliterated  by  lung  expansion.  If  an  incision  is  made 
anterior  or  posterior  to  this  point,  the  expanding  lung  will  block  the  drainage- 
opening,  and  a  pus-cavity  without  drainage  will  remain  in  the  midaxillary 
line.  (2)  Such  an  incision  permits  a  patient  to  he  on  his  back  without 
making  pressure  on  the  drainage-tube. 

The  periosteum  of  the  outer  surface  of  the  rib  must  be  divided  in  the 

*  Medical  News,  Sept.  2.  1899. 

f  See  W.  Menzies  Hutton  on  "Empyema,"'  in  Brit.  Med.  Tour.,  Oct.  29,  1898. 
43 


6/4  Surgeiy   of  the   Respiratory   Organs 

same  direction  as  the  superficial  incision.  The  exposed  rib  is  stripped  of 
periosteum  front  and  back  by  means  of  a  periosteal  separator,  and  with 
the  periosteum  at  the  lower  border  of  the  rib  the  intercostal  artery  is  lifted 
out  of  harm's  way.  The  rib  can  be  divided  by  means  of  cutting  forceps, 
a  chain-saw,  or  a  Gigli  saw.  I  prefer  a  costotome  as  it  accomplishes  the 
section  most  rapidly.  The  usual  method  is  to  push  a  periosteal  separator 
under  the  rib,  and  saw  the  bone  in  two  places  by  means  of  a  metacarpal 
saw  (Fig.  347).  An  inch  or  more  of  the  rib  should  be  removed.  The  inter- 
costal artery  is  ligated  at  each  end  of  the  incision,  the  periosteum  is  re- 
moved and  the  pleura  is  opened.  The  object  of  removing  the  periosteum 
is  to  prevent  the  rapid  formation  of  bone  which  might  narrow  the  opening 
and  interfere  with  drainage.  The  actual  opening  of  the  pleura  is  carried 
out  in  the  same  way  in  intercostal  incision  and  after  rib-resection.  A 
grooved  director  is  pushed  into  the  pleural  sac,  and  the  opening  is  enlarged 
by  means  of  the  forceps  and  the  finger. 

The  finger  removes  all  masses  of  tuberculous  material  or  aplastic  lymph 
within  reach.  If  the  finger  finds  the  lung  bound  down  with  dense  adhesions 
so  that  it  cannot  expand,  simple  rib-resection  will  not  cure  the  patient,  and 
Estlander's,  Schede's,  or  Fowler's  operation  should  be  done.  Some  surgeons 
advocate  immediate  irrigation  after  opening  an  acute  empyema,  but  this 
procedure  is  unsafe.  It  is  true  that  in  most  cases  irrigation  does  no  harm, 
but  in  no  case  will  it  sterilize  the  cavity,  and  in  some  cases  it  is  very  dangerous. 
The  pleura  is  very  susceptible  to  the  action  of  irritants.  This  is  especially 
true  of  young  children.  It  happens  occasionally  that  the  injection  of  the 
blandest  fluid  is  followed  by  intense  dyspnea,  great  shock,  disturbances 
of  respiration  and  circulation,  convulsions,  and  even  death  (Quenu).  The 
convulsions  which  occasionally  follow  pleural  irrigation  were  called  by  de 
Cerenville  plettral  epilepsy.  In  putrid  empyema  it  is  proper  to  irrigate. 
Irrigation  will  remove  part  of  the  actively  poisonous  putrid  matter,  and 
the  retention  of  putrid  matter  is  a  greater  danger  than  irrigation.  It  used 
to  be  rather  a  common  custom  to  make  a  counter-opening  by  cutting  down 
upon  the  long  probe  pushed  against  the  chest-wall  after  being  introduced 
through  the  incision,  but  a  counter-opening  is  of  no  particular  use.  A 
drainage-tube  about  two  inches  in  length  is  introduced  and  stitched  in  place. 
The  tube  must  not  be  long  enough  to  touch  against  the'  lung.  A  safety- 
pin  is  clamped  upon  the  tube  to  keep  it  from  slipping  into  the  chest.  A 
tape  should  be  fastened  to  each  side  of  the  tube  and  tied  about  the  chest 
to  prevent  it  from  slipping  out.  Arrest  bleeding,  suture  the  skin,  dress 
with  gauze,  wood-wool,  and  a  binder,  and  have  the  dressings  changed  as 
soon  as  they  become  soaked  at  one  point.  Several  times  a  day  change 
the  patient's  position.  At  each  change  of  dressings  direct  him  to  lie  on 
the  diseased  .side  for  half  an  hour,  and  with  the  foot  of  the  bed  raised  for 
half  an  hour.  Healing  takes  place  by  ascent  of  the  diaphragm,  expansion 
of  the  lung,  and  retraction  of  the  chest-wall.  Expansion  of  the  lung  is  favored 
by  expiratory  acts;  hence  cause  the  patient  several  times  a  day  to  blow 
into  a  wash-bottle  filled  with  water.  Remove  the  drainage-tube  when  the 
discharge  becomes  thin  and  scanty  (about  the  eighth  or  tenth  day,  as  a  rule). 
If  an  empyema  ceases  to  improve  and  remains  stationary  for  four  to  six 
weeks  after  it  has  been  drained,  firm  adhesions  exist.  The  surgeon  must 
perform  the  operation  of  Schede,  Estlander,  or  Fowler. 


Schede's  Operation 


675 


Thoracoplasty  (Estlander's  Operation)  is  employed  in  old  cases  of 
empyema  in  which  drainage  has  failed,  and  in  cases  with  retracted  chest-wall, 
collapsed  lung,  thickened  pleura,  and  cavities  whose  rigid  walls  will  not  col- 
lapse. The  procedure  recognizes  the  fact  that  after  pus  is  evacuated,  if  the 
lung  is  adherent,  it  cannot  expand  to  fill  the  space  once  occupied  by  fluid,  and 
that  the  rigid  chest-wall  cannot  fall  in  as  a  substitute  for  the  lung.  It  seeks 
to  destroy  the  rigidity  of  the  chest- wall  and  to  permit  it  to  collapse  and  thus 
obliterate  the  cavity  of  the  empyema.  When  the  surgeon  resects  a  rib  and 
finds  a  cavity  with  uncoUapsible  walls,  or  a  lung  bound  down  with  firm 
adhesions,  he  should  perform  thoracoplasty.  This  operation  causes  the 
obliteration  of  the  cavity  by  collapsing  that  portion  of  the  chest-wall  overly- 
ing it.  The  cavity  is  usually  in  the  upper  or  central  part  of  the  pleural 
space.  The  instruments  required  are  the  same  as  those  for  resection  of 
a  rib.  The  position  is  the  same  as  that  for  rib-resection.  The  length  of 
the  incision  depends  on  the  size  of  the  cavity. 
The  surgeon  usually  removes  portions  of  the 
second,  third,  fourth,  fifth,  sixth,  and 
seventh  ribs.  Make  a  transverse  incision 
along  the  center  of  an  intercostal  space, 
and  through  this  incision  remove  the  ribs 
above  and  below  by  the  method  set  forth 
on  page  674  (the  removal  of  six  ribs  will 
require  three  incisions).  Instead  of  this 
incision,  we  can  make  a  vertical  incision 
or  a  U-shaped  flap.  Always  take  away 
the  periosteum  in  order  to  prevent  repro- 
duction of  the  ribs.  In  cavities  which  are 
surrounded  by  firm  adhesions,  and  in  old 
cases  in  which  the  pleura  is  greatly  thick- 
ened, irrigation  is  safe.  If  the  cavity  is 
small,  it  should  be  packed  with  iodoform 
gauze  and  allowed  to  granulate;  if  large, 
it  should  be  drained  by  a  large  tube,  the 
skin  being  sutured  by  silkworm-gut. 

Schede's  Operation. — Schede  showed  that  when  the  pleura  is  much 
thickened  even  Estlander's  operation  will  not  permit  the  chest-wall  to  col- 
lapse and  fill  the  cavity  once  occupied  by  the  fluid.  The  instruments  used 
are  the  same  as  for  Estlander's  operation.  A  U-shaped  flap  is  made  from 
the  level  of  the  axilla  in  front  to  the  level  of  the  second  rib  and  between 
the  scapula  and  spine  behind.  The  lowest  level  of  this  incision  corresponds 
to  the  lowest  limit  of  the  pleura  (Fig.  348).  The  flap  is  loosened  and 
raised,  and  the  scapula  is  lifted  with  it.  The  ribs  from  the  second  rib 
down  and  from  the  costal  cartilages  to  the  tubercles  are  removed,  along 
with  the  intercostal  muscles  and  the  pleura.  This  is  accomplished  by  cutting 
with  bone-shears  and  scissors.  Hemorrhage  is  arrested.  The  pleura  is 
curetted.  A  drainage-tube  or  a  piece  of  iodoform  gauze  is  introduced,  and 
the  raw  flap  is  laid  against  the  visceral  layer  of  the  pleura.  The  superficial 
incision  is  sutured,  except  at  the  point  where  the  tube  of  the  gauze  emerges. 
The  mortality  from  Schede's  operation  is  from  15  to  20  per  cent. 


Fig.  34S. — Incision  for  Schede's  oper- 
ation of  thoracoplasty  (Esmarch  and 
Kowalzig). 


^^6  Surgery  of  the   Respiratory  Organs 

Total  Pleurectom}  or  Pulmonary  Decortication  (Fowler's  Oper- 
ation).— In  the  spring  of  1S93  de  Lorme  performed  some  experiments  on  dogs 
looking  to  the  development  of  the  operation.  In  October,  1893,  George  Ryer- 
son  Fowler,  without  any  knowledge  of  de  Lorme's  investigation,  operated  on 
a  man  and  cured  a  chronic  empyema.  The  French  surgeon's  first  operation 
was  months  later.  Extensive  rib-resection  is  practised.  This  is  better  than 
de  Lorme's  trap-door  flap,  which  causes  pneumothorax,  a  condition  which 
retards  lung  expansion.  The  thickened  pleura  is  removed  from  the  chest- 
wall,  lung,  pericardium,  and  diaphragm,  any  sinus  is  extirpated,  and  all 
granulation  tissue  is  taken  away.  This  operation  completely  removes  all 
infected  tissue.  Fowler  makes  a  report  of  30  cases.  Eleven  cases  were 
completely  cured.  In  17  cases  the  empyema  was  cured,  but  6  of  them  had 
tuberculosis.  There  were  3  deaths.  The  combined  statistics  of  Fowler, 
de  Lorme,  and  Cestan  show  35.7  per  cent,  cured,  19.7  per  cent,  improved, 
33.9  per  cent,  not  cured,  and  10  per  cent,  died  (Kurpjweit,  in  "Beitrage 
zur  klinischen  Chirurgie,"  Bd.  xxxiii,  H.  3). 

Pneumotomy  for  Abscess  of  the  Lung. — The  instruments  required 
are  scalpels,  hemostatic  forceps,  dissecting  forceps,  a  dry  dissector,  retrac- 
tors, a  periosteum-elevator,  a  metacarpal  saw,  scissors,  needles  (curved  and 
straight),  and  a  Paquelin  cautery. 

Operation. — Give  chloroform  or  use  a  local  anesthetic.  Place  the  patient 
recumbent  with  the  shoulders  a  httle  raised.  Make  a  U-shaped  flap  over 
the  seat  of  disease.  If  the  intercostal  spaces  are  wide,  cut  down  in  a  space 
to  the  pleura.  If  they  are  not  wide,  resect  a  portion  of  a  rib.  If  it  is  found 
that  adhesions  do  not  exist  between  the  pulmonary  and  costal  layers  of  the 
pleura,  stitch  these  layers  together  with  catgut  and  postpone  further  opera- 
tion for  forty-eight  hours.  If  adhesions  exist,  proceed  at  once.  Chloroform 
can  be  put  aside  when  pleura  is  exposed.  Fowler  calls  attention  to  the 
fact  that  lung-tissue  is  so  insensitive  that  the  administration  of  an  anes- 
thetic can  be  suspended  as  soon  as  the  pleura  has  been  opened.  Incise  the 
agglutinated  layers  of  the  pleura,  and  pass  an  aspirating-needle  into  the 
lung  in  various  directions.  When  the  abscess  is  located  open  it  with  the 
cautery.  Carry  the  Paquelin  cautery  slowly  into  the  lung  in  the  direction 
of  the  abscess-cavity.     The  cautery  knife  should  be  at  a  dull-red  heat. 

When  the  cautery  opens  the  cavity  of  the  abscess,  withdraw  the  instru- 
ment and  insert  a  drainage-tube  or  a  bit  of  iodoform  gauze,  and  suture  the 
flap  of  superficial  tissue.  If  the  abscess  is  not  found  after  one  or  two  punc- 
tures with  the  aspirating-needle,  abandon  the  attempt. 

Tuffler  explores  for  an  abscess  by  what  he  calls  decollement  oj  the  parietal 
pleura.  He  exposes  the  parietal  layer  of  the  pleura,  passes  his  hand  between 
this  layer  and  the  chest-wall,  strips  the  pleura  off  over  a  considerable  area, 
and  is  able  to  feel  the  lung  Ijelow  and  thus  determine  its  condition. 


Wounds  of  the  Salivary  Glands 


677 


XXVI.    DISEASES    AND  INJURIES  OF  THE  UPPER  DIGESTIVE 

TRACT. 

Injuries  and  Diseases  of  the  Face,  Nose,  Mouth,  Salivary  Glands, 
Tongue,  Jaws,  and  Esophagus.— Wounds  of  the  Salivary  Glands. — An 
aseptic  wound  usually  heals  and  rarely  results  in  a  salivary  fistula,  although 
after  healing  it  is  not  unusual  for  an  encysted  collection  of  saliva  to  gather 
under  the  skin.  Such  a  collection  of  sahva,  if  it  does  not  disappear  spontane- 
ously, can  usually  be  gotten  rid  of  by  continued  pressure.  When  a  wound  of 
a  salivary  gland  is  infected,  a  single  fistula  or  multiple  fistulae  may  be  left  as 
a  legacy.  A  salivary  fistula  is  very  annoying,  because  the  saliva  flows  con- 
stantly. A  fistula  usually  heals  spontaneously  after  a  long  time,  but  heal- 
ing can  be  quickly  brought  about  by  touching  the  orifice  with  the  Paquelin 
cautery. 

Wound  of  Steno's  dud  is  apt  to  cause  a  fistula,  and  the  condition  is  often 
difficult  to  cure.  In  this  condition,  when  the  duct  was  cut  across,  the  central 
end  grows  fast  to  the  cutaneous  surface.  Fistula  of  Steno's  duct  may  also  be 
caused  by  obstruction  and  rupture  of  the  duct  and  by  suppurative  or  gan- 
grenous processes. 

In  wounds  of  the  duct  the  ends  should  be  brought  as  near  together  as 
possible  with  catgut  sutures  which  do  not  enter  the  lumen  of  the  duct;  an 
incision  .should  be  made  through  the  mucous  membrane  to  permit  drainage 
of  saliva,  if  the  mucous  membrane  is  not  already  opened,  and  the  skin  should 
be  sutured.  In  some  cases  the  central  end  of  the  duct  may  be  carried  into  the 
mouth  and  sutured  to  the 
mucous  membrane.  If,  after 
an  injury  of  Steno's  duct, 
saliva  gathers  under  the  skin, 
make  an  incision  through  the 
mucous  membrane,  to  give  a 
route  for  the  saliva  to  enter  the 
mouth,  and  apply  pressure  ex- 
ternally. When  a  fistula 
forms,  it  may  be  cured  by  the 
cautery  and  pressure,  but,  if 
the  peripheral  portion  of  the 
duct  is  obliterated,  which  can 
be  determined  with  a  sound,  an  operation  must  be  performed.  Tillmanns  ad- 
vocates cutting  out  the  external  portion  of  the  fistula  by  two  elliptical  incisions. 
A  trocar  is  passed  through  the  bottom  of  the  wound  in  two  places,  about  half  a 
centimeter  apart;  a  piece  of  stout  silk  is  drawn  through  the  holes  and  tied  tightly 
and  the  superficial  incision  is  closed.  The  silk  cuts  through  and  makes  an 
internal  fistula.  Another  method  is  to  make  an  incision,  find  and  isolate  the 
central  end  of  the  duct,  open  the  mucous  membrane,  suture  the  duct  to  it,  and 
close  the  superficial  wound. 

De  Guise's  operation  is  shown  in  Fig.  349.  He  threads  a  piece  of  silk 
through  two  needles  and  carries  the  needles  into  the  mouth  so  that  the  silk 
will  embrace  a  bit  of  tissue  half  a  centimeter  in  length.     The  silk  is  tied  tightly 


Fig-  349-- 


-De  Guise's  operation  for  salivary  fistula 
(Esmarch  and  Kowalzig) 


6/8  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

within  the  mouth,  the  ends  are  cut  off,  and  the  margins  of  the  fistula  at  the 
surface  are  freshened  and  sutured. 

Parotitis. — Mumps,  or  epidemic  parotiditis,  is  treated  by  the  physician. 
In  this  condition  the  submaxillary  and  sublingual  glands  are  usually  involved 
as  well  as  the  parotid.  In  pyemia  metastatic  abscesses  may  form  in  the  par- 
otid gland.  Great  swelhng  arises,  respiration  is  often  embarrassed,  and  early 
incision  is  necessary.  Parotid  inflammation  other  than  mumps  is  usually  due 
to  the  passage  of  bacteria  up  Steno's  duct,  the  source  of  the  microbes  being  a 
foul  condition  of  the  mouth,  particularly  noma  or  stomatitis.  Hence,  such  in- 
flammation is  most  common  during  the  existence  of  acute  infectious  diseases 
and  sepsis.  Suppuration  or  even  gangrene  may  occur.  As  a  rule  only  one 
gland  is  attacked,  but  both  may  be.  It  is  a  well-known  fact  that  occasionally, 
after  an  abdominal  operation,  non-suppurative  inflammation  of  the  parotid 
gland  occurs.  In  non-suppurative  parotitis  there  is  pain,  tenderness,  obvious 
swelling,  and  hyperemia  of  the  skin,  and  it  is  difficult  to  open  the  mouth  or 
swallow.  When  suppuration  occurs,  all  of  the  above  symptoms  are  intensified, 
the  discoloration  becomes  dusky,  the  skin  becomes  shiny  and  edematous,  the 
constitutional  symptoms  of  pus-formation  exist,  and  there  is  usually  delirium. 

Treatment. — In  the  non-suppurative  form  apply  an  ice-bag  over  the  gland 
for  the  first  twenty-four  hours  and  then  substitute  heat.  Wash  the  mouth 
out  frequently  with  an  antiseptic  wash  and  apply  ichthyol  and  lanohn  to 
the  swollen  region.  In  the  suppurative  form  make  several  openings  by 
Hilton's  method,  seeking  for  points  of  softening;  apply  hot  antiseptic  fomenta- 
tions, wash  the  mouth  frequently  with  an  antiseptic  fluid,  and  combat  sepsis 
by  appropriate  constitutional  treatment. 

Salivary  Concretions. — The  sahva  contains  in  solution  certain  salts 
which  may  deposit.  Deposited  on  the  teeth  they  constitute  tartar.  De- 
posited in  a  salivary  duct  or  the  acini  of  a  gland  they  constitute  a  calculus. 
The  salts  deposited  are  carbonate  and  phosphate  of  lime.  A  calculus  may 
consist  purely  of  these  two  salts  or  there  may  be  a  foreign  body  nucleus.  A 
calculus  is  a  possible  result  of  an  inflammation  which  blocks,  constricts,  or 
roughens  a  duct  or  acinus  and  decomposes  saliva.  Small  concretions  are  often 
passed.  Concretions  the  size  of  a  bean  are  retained.  A  concretion  may 
attain  the  size  of  an  English  walnut.  A  concretion  does  not  block  a  duct 
continuously,  but  does  .so  now  and  then,  causing  swelling  and  tenderness  of  the 
gland.  A  retained  calculus  can  be  palpated  by  a  finger  in  the  mouth  and  a 
finger  externally. 

Treatmenl.^k  calculus  in  a  duct  is  extracted  by  making  an  incision  through 
the  mucous  membrane.  If  a  very  large  calculus  forms  in  the  submaxillary 
gland,  the  gland  should  be  removed  through  an  external  incision. 

Harelip  and  Cleft  Palate. — Harelip  is  a  congenital  cleft  in  the  upper 
lip  due  to  defective  development.  Cle]l  palate  is  a  congenital  fissure  in 
the  soft  palate  or  in  both  the  hard  and  .soft  palates.  In  harelip  the  cleft 
is  usually  complete,  through  the  entire  lip  into  the  nostril,  but  in  rare  ca.se 
it  may  only  show  as  a  furrow  in  the  mucous  edge  or  as  a  split  from  the  nostril 
partly  into  the  lip.  It  is  most  common  on  the  left  side.  In  double  harelip  the 
central  jjortion  of  the  lip  is  often  adherent  to  the  tip  of  the  nose.  Double 
harelip  may  be  free  from  complication,  but  is  often  associated  with  a  malforma- 
tion of  the  alveolus  and  palate.     Median  harelip  is  exceedingly  rare.     In  cleft 


Harelip  and   Cleft   Palate  679 

palate  the  septum  of  the  nose  is  usually  adherent  to  the  palatine  process 
opposite  the  side  upon  which  the  fissure  exists.  In  those  rare  cases  of  cleft 
palate  double  in  front,  the  nasal  septum  is  attached  only  to  the  premaxillary 
bone,  and  the  premaxillary  is  not  attached  at  all  to  the  superior  maxillary  bone. 
In  harelip  there  is  frequently  a  cleft  in  the  alveolus,  and  almost  always  flatten- 
ing of  the  corresponding  side  of  the  nose.  Harelip  is  often  associated  with 
cleft  palate,  talipes,  and  other  deformities.  It  is  a  great  deformity,  and  in- 
terferes with  sucking,  swallowing,  and  articulation. 

Operation  for  harelip  should  be  performed  between  the  third  and  sixth 
months  of  hfe  in  a  child  in  good  health,  free  from  stomach  trouble,  cough,  or 
coryza,  but  operation  is  not  advisable  in  the  early  weeks  of  life.  Always,  if 
possible,  operate  before  dentition  begins  (seventh  month).  If  the  child  is  in 
poor  health,  postpone  the  operation  until  restoration  has  so  far  advanced  as  to 
render  operation  safe.  While  waiting  for  operation  be  sure  the  child  is  getting 
enough  food.  If  it  cannot  suck,  feed  it  with  a  spoon.  If  a  cleft  exists  in  the 
palate,  operate  first  upon  the  lip,  because  the  pressure  of  the  parts  after  the 
edges  of  the  gap  are  approximated  aids  in  the  closure  of  the  bony  cleft.  Cleft 
palate  interferes  with  sucking,  deglutition,  mastication,  and  articulation.  In 
severe  cases  the  food  passes  into  the  nose  and  excites  inflammation.  Loss  of 
control  of  the  palate-muscles  ahvays  "exists,  and  hquids  and  solids  are  liable  to 
pass  into  the  windpipe.  Clefts  in  the  hard  palate  should  not  be  operated  on 
until  the  second  year,  but  should  be  operated  upon  then,  otherwise  speech  will 
be  permanently  affected.  Some  surgeons  refuse  to  operate  until  the  tenth  or 
twelfth  year,  but  operation  done  this  late  will  not  correct  speech-defect  (Ed- 
mund Owen).  The  patient  at  the  period  of  operation  should  be  well  and  free 
from  cough.  In  many  cases  the  passage  of  food  and  drink  into  the  nose  can 
largely  be  prevented  by  the  use  of  a  diaphragm. 

Operation  for  Harelip. — The  instruments  required  are  a  tenotome  and 
scalpel,  toothed  forceps,  hemostatic  forceps,  scissors  curved  on  the  flat  and 
pointed,  straight  blunt-pointed  scissors,  needles  (straight  and  curved),  silver 
wire  or  silkworm-gut  and  silk  sutures,  a  mouth-gag  and  tongue-forceps,  a 
needle-holder,  and  sequestrum-forceps,  each  blade  protected  by  a  rubber  tube. 
Wrap  the  child  in  a  sheet;  place  it  in  the  Trendelenburg  position,  and  rest  the 
head  upon  a  sand-pillow.  The  surgeon  stands  to  the  right  side  of  the  patient. 
Ether  or  chloroform  is  given.  For  single  harehp,  separate  with  the  scissors 
the  upper  lip  from  the  bone  on  each  side  of  the  cleft  until  approximation  of  the 
cleft  can  be  effected  without  tension.  If  the  premaxillary  bone  of  one  side 
projects  more  than  its  fellow,  grasp  it  with  sequestrum-forceps  and  bend  it  back 
(Jacobson  and  Treves).  Clamp  the  upper  lip  at  each  angle  of  the  mouth  to 
prevent  hemorrhage.  If  the  edges  are  of  equal  or  nearly  equal  length,  and  if 
the  gap  is  not  very  wide,  perform  Malgaigne's  operation.  This  is  performed  as 
follows:  a  flap  is  detached  on  each  side,  the  detachment  beginning  at  the  upper 
angle  of  the  gap;  each  flap  is  detached  above  but  remains  attached  below. 
The  flaps  are  separated  from  the  bone,  and  are  drawn  downward  so  as  to  form 
a  prominence  at  the  vermilion  border  (Fig.  3  50).  If  the  edges  are  pared  so  that 
in  closure  the  vermilion  border  is  even,  when  the  parts  are  healed  a  gutter  will 
be  visible  at  the  line  of  union.  The  edges  are  approximated  by  an  assistant, 
and  silkworm-gut  sutures  or  silver  wires  are  passed  by  means  of  a  straight 
needle.     Each  suture  goes  down  to  the  mucous  membrane.     The  first  suture 


68o 


Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


is  passed  through  the  middle  of  the  lip,  one-third  of  an  inch  from  the  cleft. 
Three  or  four  main  sutures  are  passed  through  the  thickness  of  the  hp,  and  are 
tied  and  cut  off.  Two  or  three  fine  silk  or  catgut  sutures  are  passed  by  a 
curved  needle  through  the  vermilion  border  of  the  lip  and  the  mucous  mem- 
brane of  the  mouth,  and  are  tied  and  cut  off.  A  small  piece  of  gauze  is  placed 
over  the  Hp  and  is  held  in  place  by  straps  of  rubber  plaster.  After  operation 
prevent  the  child  crying  by  feeding  it  often  and  giving  it  small  doses  of  lau- 
danum. Heath  orders  two  drops  of  laudanum  in  one  ounce  of  distilled  water, 
a  teaspoonful  to  be  given  every  two  or  three  hours.  About  the  sixth  day  one- 
half  the  sutures  are  taken  out,  and  on  the  eighth  or  ninth  day  the  remaining 
ones  are  removed.  In  many  cases  no  further  procedure  is  necessary,  but  if 
after  some  weeks  the  prominence  at  the  lip-border  does  not  shrink,  it  can  be 
readily  clipped  away.  Harelip-pins  are  not  used  at  the  present  time,  and  are 
not  needed  if  the  lip  is  well  separated  from  the  bone.  If  the  edges  of  the  cleft 
are  of  unequal  length,  Edmund  Owen's  operation  can  be  performed  (see 
below,  under  Double  Harelip),  or  we  can  perform  Mirault's  operation,  as 
shown  in  Fig.  352. 

In  double  harelip  the  operation  is  similar  to  that  for  single  harelip.     If  the 
intervening  piece  is  vertical  and  is  covered  with  healthy  skin,  complete  each 


Fig.  350. — Malgaigne's  op- 
eration for  harelip. 


Fig.  351. — Incisions  for  double  hare- 
lip (Esmarch  and  Kowalzig). 


Fig.  352. — Mirault's  operation 
for  single  harelip  (Esmarch). 


operation  as  for  single  harelip,  closing  both  fissures  at  once  with  silver  wire  in  a 
strong,  healthy  child,  closing  them  at  intervals  of  three  weeks  in  one  not  so 
lusty  (Fig.  351).  Excise  the  septum  if  it  is  deformed.  The  premaxillary  bone 
should  in  most  instances  be  removed,  the  skin  over  it  being  preserved.  Sir 
Wm.  Fergusson  was  accustomed  to  incise  the  mucous  membrane  and  shell  out 
this  bone.  The  premaxillary  bone  can  be  forced  back  into  hne,  being  held,  if 
neces.sary,  by  catgut  suture  of  the  periosteum;  but  if  saved  it  is  hable  to  necrose 
and  its  teeth  soon  decay.  Heath  removes  this  bone  two  weeks  before  operating 
on  the  lip.  If  there  is  much  hemorrhage  after  removal  of  the  bone,  arrest  it 
with  a  hot  wire  or  with  Horsley's  wax.  Fig.  351  shows  incisions  for  double 
harehp.  Edmund  Owen's  operation  is  very  useful  (Figs.  353,  354)-  Iri  this 
operation  very  thick  flaps  are  cut.  The  prolabium  and  incisive  bone  are  re- 
moved. The  flaps  are  cut  as  shown,  Fig.  353,  on  one  side  by  line  ab,  and  on 
the  other  side  by  line  cde.  a  is  brought  to  e,  b  is  l^rought  to  d,  j  is  brought  to  c, 
and  sutures  are  applied  (Fig.  354). 

Operation  for  Cleft  Palate.— li  is  true  that  during  the  early  years  of  growth 
a  cleft  diminishes  in  size;  but  to  wait  too  long  before  we  operate  means  per- 
manent sfjeech-impairment.  Bony  clefts  should  be  operated  upon  during  the 
second  year.     Clefts  of  the  .soft  palate  only  may  be  operated  ui)on  during  the 


Harelip  and   Cleft  Palate  68 1 

first  six  months.  If  both  the  hard  and  soft  palates  are  cleft,  close  both  at  one 
operation.  Edmund  Owen  has  recently  put  forth  a  convincing  plea  for  early 
operation.*  He  says  he  is  operating  earlier  and  earlier,  and  quotes  Chilton 
as  the  gentleman  who  led  him  to  do  so.  Owen  maintains  that  if  speech  is  to  be 
improved  operation  must  be  done  early,  and  he  formulates  some  very  valuable 
rules  of  preparation  and  care:  Have  the  child  in  the  best  condition,  free  from 
cough  and  stomach  disorder.  Operate  in  the  summer.  Place  the  child  under 
the  charge  of  a  nurse  several  days  before  the  operation.  For  suture  of  the  soft 
palate  {staphylorrhaphy)  Treves  says  the  following  instruments  are  essential: 
■two  sharp-pointed  tenotomes,  a  blunt-pointed  tenotome,  a  rectangular  knife, 
two  pairs  of  long  forceps  (one  with  tenaculum  points,  one  serrated),  a  fine  hook, 
a  pair  of  sharp-pointed  curved  scissors,  scissors  curved  on  the  flat,  periosteum- 
elevators,  two  long-handled  needles  with  eyes  at  their  points,  a  suture-catcher, 
a  tubular  needle  for  wire  sutures,  hemostatic  forceps.  Whitehead's  gag  and 
retractors,  silver  wire,  silkworm-gut,  and  sponge-holders;  also  an  electric 
forehead-light.  The  patient's  body  may  be  raised,  with  his  head  elevated  and 
rested  upon  a  sand-bag.  A  better  position  is  that  of  Trendelenburg,  as  it  pre- 
vents the  trickling  of  blood  into  the  windpipe.     Chloroform  is  given.     The 


Fig.  353. — Double  harelip,  the  prolabium  and  Fig.   354.  —  The   two   sides   of  the   lip   drawn 

incisive  bone  having  been  removed  (Owen).  together  and  secured  by  sutures  (Owen). 

gag  is  introduced;  the  edges  of  the  mucous  membrane  are  pared  with  a  teno- 
tome; the  sutures  are  introduced  from  below  upward,  silkworm-gut  being  used 
for  the  uvula  and  lower  part  of  the  velum,  silver  wire  for  the  remainder  of  the 
cleft;  each  suture,  as  it  is  passed,  is  tied  or  twisted,  but  is  not  cut  until  the  ne.xt 
suture  is  inserted,  and  serves  as  a  handle.  If  there  is  too  much  tension  to 
allow  of  the  sutures  being  tied  as  they  are  inserted,  all  the  sutures  are  passed  and 
loosely  twisted.  A  longitudinal  incision  is  made  upon  each  side,  internal  to  the 
hamular  process,  the  mucous  membrane  being  cut  with  a  sharp  tenotome,  the 
deeper  structures  being  divided  with  a  blunt  tenotome;  the  sutures  are  tied  or 
twisted  and  cut  (Fig.  355).  In  Fergusson's  operation  for  cleft  of  the  hard 
palate  {uranoplasty)  the  mucous  edges  are  pared  and  the  sutures  inserted  but 
not  tied.  Make  an  incision  upon  each  side  down  to  the  bone,  the  incision  being 
midway  between  the  cleft  and  the  alveolus.  Divide  the  bone  on  each  side,  by 
means  of  a  chisel,  to  the  full  length  of  the  incision,  and,  using  the  chisel  as  a 
lever,  force  each  half  of  the  bone  toward  the  gap.  Tie  the  .sutures,  and  plug 
each  lateral  incision  with  a  piece  of  iodoform  gauze  (Fig.  356).  After  the 
operation  for  cleft  palate  put  the  patient  to  bed  for  one  week;  forbid  talking; 
give  fluid  or  semisolid  food  at  intervals  of  two  or  three  hours  for  three  weeks; 

*  Lancet,  Jan.  4,  1S96. 


682  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

wash  out  the  mouth  very  often  (ahvays  after  eating)  with  a  solution  of  boric 
acid  and  hsterine  or  Condy's  fluid.  Sutures  are  removed  in  from  two  to 
three  weeks. 

Edmund  Owen*  operates  as  follows:  pare  a  strip  of  mucous  membrane 
from  each  side  of  the  fissure  from  the  tip  of  the  uvula  to  the  top  of  the  gap. 
Make  a  free  incision  '■  along  the  alveolar  aspect  of  the  palate  "  close  to  the  teeth. 
Lift  up  the  strips  of  mucoperiosteum  and  shift  them  toward  the  cleft.  Sever 
the  attachments  of  the  soft  palate  to  the  posterior  border  of  the  hard  palate  and 
extend  the  alveolar  incision  well  backward.  This  incision  relieves  tension. 
Sew  up  with  wire;  twist  and  cut  each  wire,  leaving  an  end  one-eighth  of  an  inch 
long.  This  procedure  causes  the  child  to  keep  his  tongue  from  the  suture-line. 
For  the  first  twenty-four  hours  give  only  water,  and  after  this  period  feed  with 
beef-jelly  and  liquids. 

When  feeding  is  begun  attempt  irrigation  or  spraying  if  it  does  not  alarm 
the  child.  In  a  day  or  two  the  patient  can  take  sweetened  orange-juice, 
custard-pudding,  finely  sieved  meat  or  chicken.  The  best  fluid  for  irrigation 
is  Condy's  fluid  or  mild  carbolic  acid  (Owen). 


Fig.  355. — Staphylorrhaphy  (Esmarch  and 
Kowalzig-). 


-Uranoplasty  (Esmarch  and 
Kowalzig). 


Get  the  child  out  in  the  air  a  day  or  two  after  the  operation  and  keep  it  out 
all  day.     (The  entire  article  of  Mr.  Owen  will  well  repay  a  careful  reading.) 

Carcinoma  of  the  Lower  Lip. — Cancer  commonly  arises  in  the  lower  lip, 
very  rarely  in  the  upper  lip.  Males  suffer  frequently,  but  females  are  not  very 
often  attacked.  In  some  cases  it  seems  to  arise  in  smokers  at  the  point  on  the 
Hp  where  the  pipe  habitually  rested.  A  short-stemmed  clay  pipe,  which  grows 
hot  when  it  is  smoked,  is  particularly  apt  to  lead  to  the  growth  of  cancer.  The 
region  of  the  lip  which  is  most  liable  to  cancer  is  the  junction  of  the  skin  and 
mucous  membrane.  The  growth  may  begin  in  a  fissure  or  abrasion,  may 
start  in  an  eczematous  area,  but  most  frequently  arises  as  an  indurated  area 
which  quickly  ulcerates.  After  a  cancer  has  existed  for  a  variable  time  the 
submental  and  .submaxillary  lymphatic  glands  become  diseased.  This  in- 
volvement cannot  be  detected  by  external  manipulation  in  the  earliest  stages; 
hence  it  is  not  proper  to  conclude  that  glandular  involvement  is  absent  .simply 
because  it  cannot  be  palpated.  It  occasionally  happens  that  glands  enlarge 
because  of  septic  absorption,  and  this  enlargement  may  even  precede  car- 
cinomatous involvement.  From  an  operative  point  of  view  the  glands  should 
always  be  regarded  as  carcinomatous.     If  cancer  is  not  operated  upon,  it 

*  Lancet,  Jan.  4,   1896. 


Carcinoma  of  the   Lower   Lip 


683 


destroys  the  Hp,  invoh^es  the  glands  of  the  neck  extensively,  the  floor  of  the 
mouth,  the  periosteum  and  lower  jaw,  and  produces  death  in  from  three  to  five 
years.  If  the  jaw  is  involved,  the  prognosis  is  bad,  and  it  is  practically  hope- 
less if  the  floor  of  the  mouth  is  involved. 

Treatment. — The  treatment  consists  in  the  early  and  thorough  removal  of 
the  growth  with  the  knife,  and  also  in  the  removal  of  the  fatty  tissue  and  glands 
from  the  submaxillary  triangles  and  from  the  submental  region.  The  growth 
must  be  thoroughly  removed,  that  is,  the  incision  must  be  at  least  half  an  inch 
wide  of  the  disease.  Thorough  early  removal  will  cure  about  50  per  cent,  of 
cases.  For  many  years  a  favorite  operation  has  been  the  V-shaped  incision, 
the  skin-edges  being  sutured  by  silkworm-gut,  the  sutures  being  passed  almost 
to  the  mucous  membrane  and  being  inserted  so  as  to  compress  the  vessels  when 


Fig-  357- — Grant's  operation  for  carcinoma  of  the  lip. 


Fig.  358. — Removal  of  lower  lip  and  cheilo- 
plasty  (Esmarch  and  Kowalzig). 


Fig.  359. — Suturing  in  cheiloplasty  (Esmarch 
and  Kowalzig). 


tied,  and  the  mucous  membrane  being  sutured  with  fine  silk  or  catgut.  The 
V-shaped  incision  should  only  be  used  for  a  small  growth.  After  the  removal 
of  the  growth  from  the  lip  a  vertical  incision  is  made  from  the  point  of  the  V 
over  the  cricoid  cartilage,  and  from  the  origin  of  this  incision  incisions  are  made 
in  each  direction  along  the  under  surface  of  the  body  of  the  jaw.  The  glan- 
dular area  is  thus  exposed,  and  after  the  removal  of  the  fat  and  glands  the 
wound  is  sutured  with  silkworm-gut.  Better  than  the  V-shaped  incision  is  the 
method  devised  by  W.  W.  Grant,  of  Denver.*  In  this  operation  the  growth  is 
removed  and  cheiloplasty  is  performed.  This  operation  secures  a  larger,  less 
rigid,  and  more  useful  lip  than  does  the  older  method.  In  this  operation  the 
growth  is  removed  by  two  perpendicular  incisions  and  a  transverse  cut  (Fig. 
357).     From  each  lower  angle  of  the  wound  an  oblique  incision  is  made  (Fig. 

*  Medical  Record,  May  27,  1899. 


684  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

357,  6  e,  f/),  and  these  incisions,  if  carried  below  the  jaw,  permit  the  removal  of 
Ivmph-glands.     The  flaps  are  sutured  as  shown  in  Fig.  357. 

In  a  case  in  which  the  hp  is  extensively  involved  the  entire  lip  should  be 
removed  and  a  new  lip  should  be  taken  from  sound  tissue  and  fastened  in  place. 
This  operation  is  shown  in  Figs.  358  and  359. 

Tongue-tie  is  a  congenital  shortness  of  the  frenum.  The  tongue  cannot 
be  protruded  beyond  the  incisor  teeth.  Swallowing  is  interfered  with,  and 
later  in  hfe  articulation  is  impeded.  Treat  tongue-tie  by  tearing  up  the  frenum 
with  the  thumb-nail.  If  this  fails,  catch  the  frenum  in  the  slit  in  the  handle  of  a 
grooved  director,  push  the  director  toward  the  base  of  the  tongue,  and  nick 
the  frenum  with  scissors  curved  on  the  flat  and  pointed  toward  the  floor  of  the 
mouth.  The  nick  should  be  nearer  to  the  floor  of  the  mouth  than  to  the 
tongue. 

Ranula  is  a  retention-cyst  of  the  duct  of  the  submaxillary  or  the  duct  of  the 
subhngual  gland.  A  ranula  when  first  formed  contains  saliva,  but  after  a  time 
the  saHva  undergoes  a  change,  and  in  appearance  comes  to  resemble  mucus. 
Mucous  cvsts  occur  in  the  floor  of  the  mouth,  resulting  from  obstruction  of  the 
ducts  of  the  mucous  glands  of  Nuhn  and  Blandin.  These  glands  he  on  each 
side  of  the  frenum  of  the  tongue.  Such  a  cyst  is  often  spoken  of  as  a  ranula. 
A  ranula  appears  upon  the  floor  of  the  mouth  on  one  side  and  pushes  the 
tongue  toward  the  opposite  side.  The  treatment  of  a  mucous  cyst  is  by  ex- 
cision of  a  portion  of  the  cyst-wall  and  cauterization  of  the  interior  with  pure 
carbolic  acid;  or  by  cutting  a  flap  from  the  cyst-wall  and  stitching  it  aside  so 
as  to  keep  a  permanent  opening.  Such  an  operation  may  cure  a  genuine 
ranula,  but  will  often  fail.  In  true  ranula  an  external  incision  should  be 
made,  and  through  this  both  the  cyst  and  the  gland  should  be  removed.  This 
plan  is  recommended  by  Mintz.* 

Thyro-lingual  Cysts  and  Sinuses. — The  thyro-lingual  duct  runs  from 
the  base  of  the  tongue,  down  the  mid-hne  of  the  neck,  back  of  the  hyoid  hne, 
to  the  upper  portion  of  the  front  surface  of  the  trachea,  where  it  bifurcates, 
each  branch  passing  to  a  lateral  lobe  of  the  thyroid  gland.  This  fetal  struc- 
ture under  normal  conditions  closes,  the  foramen  caecum  marking  its  upper 
end.  The  duct  may  persist  between  its  origin  and  the  hyoid  bone,  de- 
veloping, it  may  be,  into  a  sublingual  dermoid.  The  portion  behind  and 
below  the  hyoid  may  remain,  and  develop  into  a  subhyoid  bursa.  The  part 
inferior  to  the  hyoid  may  persist,  give  origin  to  a  cyst  which  ruptures  and 
constitutes  an  incomplete  cervical  -fistula.  The  duct  may  remain  open  from 
the  mouth  and  make  by  bursting  an  opening  in  the  neck  '(complete  cervical 
fistula).  The  small  diameter  of  a  cervical  fistula  renders  probing  to  any 
depth  impossible.  To  determine  if  a  fistula  is  complete,  inject  quassia 
solution  into  the  lower  end,  and  the  patient  will  experience  a  bitter  taste; 
or  inject  a  colored  fluid  which  will  run  from  the  mouth. 

Treatment. — A  cyst  or  dermoid  should  be  dis.sected  out.  A  fistula  re- 
quires the  complete  removal  of  its  epithelial  lined  walls.  No  lesser  operation 
will  cure.     In  one  case  I  operated  four  times  Ijefore  securing  success. 

Carcinoma  of  the  Tongue. — This  is  one  ui  the  most  dreadful  forms  of 
cancer.  It  is  quite  a  common  disease.  It  begins,  as  a  rule,  near  the  tip,  on 
the  side  or  at  the  ba.se  of  the  anterior  two-thirds  of  the  tongue,  as  an  ulcer  hav- 

*  Zeitschiift  fur  Chirurj^ie,  Maicli,  1899. 


Carcinoma  of  the   Tongue  685 

ing  at  first  a  papillary  structure,  as  a  fissure  which  indurates,  or  as  an  indurated 
area  which  ulcerates.  The  cause  of  the  growth  may  sometimes  be  traced  to  the 
irritation  of  a  jagged  tooth,  or  to  the  smoking  of  a  pipe,  or  to  holding  nails  in 
the  mouth,  as  is  done  by  those  who  nail  laths.  Cancer  may  follow  a  chronic 
inflammation — leukoplakia,  for  instance.  As  in  cancer  of  the  hp,  men  are 
much  more  frequently  affected  than  women.  In  most  cases  the  disease 
spreads  rapidly;  produces  early  and  extensive  glandular  involvement;  disease 
of  the  floor  of  the  mouth ;  dribbling  of  saliva ;  difficulty  in  masticating,  swallow- 
ing, and  talking;  foulness  of  the  breath;  severe  pain  w-hich  usually  radiates  to- 
w^ard  the  ear,  and  often  a  fatal  septic  trouble.  Cases  not  operated  upon  usually 
die  within  two  years.  There  is  a  very  rare  form  of  carcinoma  described  by 
Wolfler,  which  grows  very  slowly  or  even  remains  latent  for  years. 

One  reason  why  cancer  of  the  tongue  grows  so  rapidly  has  been  pointed  out 
bv  Heidenhain,  of  Greifswald.  The  lingual  muscles  are  contracting  almost 
constantly,  and  as  a  result  cancer-cells  are  forced  along  the  lymph-spaces  to 
healthy  areas. 

Treatment. — A  cancer  of  the  tongue  should  be  removed  radically  at  the 
earliest  possible  moment.  Before  any  operation  is  undertaken  all  stumps  of 
teeth  should  be  extracted.  During  several  days  preceding  an  operation 
the  teeth  should  be  scrubbed  twice  a  day  with  a  brush  and  soap,  and  the 
mouth  rinsed  with  hydrogen  peroxid.  The  nares  and  nasopharynx  should 
be  sprayed  with  peroxid  of  hydrogen  and  then  with  boric-acid  solution  every 
second  or  third  hour  when  the  patient  is  awake. 

In  this  disease  not  only  the  tongue,  but  also  the  adjacent  lymphatic  glands 
must  be  removed.  The  lymph-vessels  from  the  tongue  pass  to  the  submax- 
illary and  deep  cervical  lymphatic  glands. 

It  was  my  belief  until  recently  that  in  a  very  recent  and  limited  case  only 
the  glands  on  the  diseased  side  require  removal,  but  that  in  an  advanced 
case  the  glands  must  be  removed  from  both  sides  of  the  neck.  Experience 
has  convinced  me  that  in  any  case  the  glands  on  both  sides  should  be  re- 
moved. Kuttner,  of  Tubingen,  has  demonstrated  that  lymph  from  one 
side  of  the  tongue  may  flow  to  glands  on  the  same  side  of  the  neck;  but  some 
also  may  flow  to  the  opposite  side  of  the  tongue.  Two  operations  are  to  be 
considered:  partial  removal  and  complete  removal. 

Partial  Removal  of  the  Tongue. — This  operation  is  restricted  to  recent  cases 
in  which  one  side  only  of  the  anterior  portion  of  the  tongue  is  involved.  The 
operation  does  not  offer  as  good  a  chance  of  cure  as  complete  excision,  because 
lymph  containing  cancer-cells  may  have  reached  the  opposite  side  of  the 
tongue.  Even  in  partial  re^moval  the  glands  should  be  removed  from  both 
sides. 

In  performing  the  operation  of  partial  excision  introduce  a  mouth-gag, 
place  a  silk  ligature  on  each  half  of  the  tip  of  the  tongue,  and  draw  the  tongue 
out  of  the  mouth  (Barker).  Place  the  patient  in  the  Trendelenburg  position. 
Split  the  tongue  back  in  the  middle  line  with  the  scissors,  and  loosen  the  can- 
cerous side  from  the  floor  and  side  of  the  mouth.  Pass  a  stout  silk  ligature 
through  the  base  of  the  tongue  posterior  to  the  cancer.  Draw  the  organ  out 
and  cut  oft"  the  diseased  side  in  front  of  the  ligature  but  back  of  the  disease. 
Tie  -the  vessels,  remove  the  constricting  and  traction  threads,  and  treat  sub- 
sequently as  in  cases  of  complete  removal. 


686 


Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


Complete  Removal  oj  the  Tongue  {Kocher's  Method). — Kocher  recom- 
mends a  preliminary  tracheotomy  in  tongue-excision,  but  the  Trendelenburg 
position  renders  this  procedure  unnecessary  so  far  as  fear  of  the  passage  of 
blood  into  the  larynx  and  trachea  is  concerned.  The  instruments  required  are 
a  scalpel,  retractors,  a  dry  dissector,  hemostatic  and  dissecting  forceps,  a  tenac- 
ulum, aneurysm-needle,  tenaculum  forceps,  needles,  sutures,  and  scissors.  In 
this  operation  the  patient  is  placed  in  the  Trendelenburg  position,  the  surgeon 
standing  to  the  side.  Ether  or  chloroform  is  given.  Ligate  the  hngual 
artery  on  the  side  opposite  to  the  one  where  the  main  incision  is  to  be  made. 
Remove  the  glands  on  that  side  and  suture  the  wound.  An  incision  is  then 
made  on  the  side  opposite  to  that  on  which  the  artery  was  ligated.  This  in- 
cision passes  from  behind  the  lobe  of  the  ear,  along  the  anterior  edge  of  the 
sternocleidomastoid  to  about  the  middle  of  the  margin  of  this  muscle.  From 
this  point  the  incision  is  carried  to  the  level  of  the  hyoid  bone  and  then  to  the 
symphysis  menti,  along  the  anterior  belly  of  the  digastric  muscle  (Fig.  360). 
The  flap  is  dissected  and  turned  up ;  the  facial  and  lingual  arteries  are  ligated ; 
"the  submaxillary  fossa  is  evacuated"  (Treves);  the  sublingual  and  sub- 
maxillary glands  are  removed;  the  mylo- 
hyoid muscle  is  divided;  the  mucous  mem- 
brane is  incised  close  to  the  jaw,  and  the 
tongue,  caught  with  tenaculum-forceps,  is 
drawn  through  the  opening.  The  tongue  is 
split  in  the  middle  with  scissors,  and  the  near 
half  is  removed,  bleeding  is  arrested,  the  re- 
maining half  of  the  tongue  is  cut  through,  and 
the  vessels  are  tied.  Stitch  the  mucous  mem- 
brane of  the  stump  to  the  mucous  membrane 
of  the  floor  of  the  mouth  with  catgut  sutures. 
Kocher  does  not  suture  the  skin-wound; 
many  surgeons  do  suture  it  and  employ 
drainage-tubes.  I  follow  the  suggestions  of 
Some  hours  after  the  operation,  when  oozing 
has  ceased,  dust  the  mouth-wound  with  iodoform.  The  patient,  as  soon  as 
possible,  is  propped  up  in  bed,  and  he  must  not  swallow  the  discharges  if 
it  can  be  avoided.  The  mouth,  every  half  hour,  is  sprayed  with  peroxid  of 
hydrogen  and  washed  with  a  carbolic  solution  (i  :  60).  Every  three  hours 
after  washing  the  floor  of  the  mouth  and  the  stump  the  parts  should  be  dried 
with  absorbent  cotton  and  dusted  with  iodoform.  For  twenty-four  hours  after 
the  operation  nothing  is  given  by  the  mouth  except  a  little  cracked  ice,  the 
patient  being  fed  per  rectum.  At  the  end  of  twenty-four  or  forty-eight  hours 
some  liquid  food  is  given  from  a  feeding-cup.  The  patient  will  soon  learn  to 
swallow;  but  if  he  cannot  swallow  easily,  he  is  fed  with  a  tube.  Treves,  in  his 
clear  and  positive  directions  for  after-treatment,  states  that  nutrient  enemata 
are  to  be  continued  until  sufficient  nourishment  is  taken  b\-  the  mouth;  that 
the  mouth  should  be  flushed  by  irrigation,  and  must  be  washed  immediately 
after  taking  food;  that  morphin  is  to  be  avoided;  and  that  the  patient  can 
usually  leave  the  ho.spital  in  from  seven  to  ten  days. 

W hitehead'' s  Operation. — Whitehead  removes  the  entire  tongue  from  within 
the  mouth  by  the  use  of  scissors.     He  passes  a  ligature  through  the  tip,  cuts  the 


_   360. — Kocher's  excision  of  tongue 
(Esmarch  and  Kowalzig). 

Treves  as  to  after-treatment. 


Stricture   of  the   Esophagus  687 

frenum,  draws  the  tongue  strongly  forward,  and  separates  by  a  series  of  clips 
with  the  scissors.  The  lingual  arteries  are  tied  as  cut.  "  The  stump  should  be 
kept  under  control,  as  regards  hemorrhage,  by  a  stout  silk  ligature  passed 
through  the  remains  of  the  glosso-epiglottidean  fold  and  retained  for  twenty- 
four  hours. "  * 

Heath  has  shown  that  if  the  foreiinger  be  passed  to  the  epiglottis  and  used 
to  "hook  forward"  the  hyoid  bone,  the  lingual  arteries  are  stretched  and 
portions  of  the  tongue  can  be  removed  almost  without  bleeding.  It  is  rarely 
desirable  in  Whitehead's  operation  to  remove  the  glands  and  the  tongue 
at  one  seance.  To  do  so  increases  shock  and  the  danger  of  death.  The  rule  of 
procedure  set  forth  by  W.  Watson  Cheyne  f  is  eminently  wise.  This  rule  is  as 
follows:  If  glandular  involvement  is  trivial  or  not  detectable,  it  is  perfectly 
proper  to  remove  the  tongue  first,  and  after  a  week  or  so  remove  the  glands. 
If  the  glandular  involvement  is  marked,  growth  in  the  glands  will  be  much  more 
rapid  than  growth  in  the  tongue.  In  such  a  case  the  glands  should  be  removed 
before  the  tongue,  because,  if  the  tongue  is  removed  before  the  triangles  are 
cleared,  in  the  week  or  two  of  waiting  the  case  may  become  inoperable.  In  the 
majority  of  cases  clear  out  the  triangle  before  removing  the  tongue,  doing  the 
other  operation  in  one  or  two  weeks  when  the  wound  in  the  neck  is  healed.  If 
the  disease  in  the  mouth  is  far  advanced,  do  both  operations  at  one  seance. 

Stricture  of  the  Esophagus. — Fibrous  or  cicatricial  stricture  is  due  to  the 
heahng  of  an  ulcer,  and  results  from  traumatism,  chronic  inflammation, 
syphilis,  tuberculosis,  chronic  ulcer,  prolonged  vomiting,  variola,  gout,  or  to 
swallowing  a  corrosive  substance  or  a  boihng  liquid.  It  is  commonest  in  the 
young,  and  is  apt  to  be  situated  opposite  the  cricoid  cartilage,  at  the  tracheal 
bifurcation  or  near  the  cardiac  end.  Cicatricial  strictures  are  usually  single, 
but  may  be  multiple.  Stricture  following  impaction  of  a  foreign  body  is 
located  at  the  seat  of  impaction  unless  the  tube  has  been  injured  by  efforts  at 
extraction,  in  which  case  multiple  strictures  may  exist  (Maylard).  Strictures 
which  result  from  swallowing  boiling  fluid  or  corrosive  liquid  are  usually  very 
extensive,  and  may  be  multiple.  Syphilitic  stenosis  is  due  to  the  healing  of  a 
gummatous  ulceration,  but  there  is  nothing  characteristic  in  this  kind  of 
stenosis.     Tuberculous  stenosis  is  extremely  rare. 

Symptoms  of  Cicatricial  Stenosis. — The  condition  may  occur  at  anv  age. 
The  chief  symptom  is  difficulty  in  swallowing,  at  first  slight,  but  becoming 
more  and  more  pronounced  until  swallowing  is  almost  or  quite  impossible. 
The  dysphagia  is  first  manifested  to  dry  solids,  then  to  all  solids,  and  finally 
to  liquids.  In  some  cases  vomiting  occurs  after  swallowing.  If  the  stricture 
is  high  up,  the  vomiting  is  almost  immediate;  if  it  is  low  down,  the  vomiting  is 
delayed,  especially  if  the  canal  is  dilated  above  the  stricture.  From  time  to 
time  the  patient  vomits  independently  of  taking  food,  the  ejected  matter  being 
sahva.  The  vomited  matter  is  not  bloody.  The  patient  feels  weak  and 
hungry,  becomes  exhausted  and  emaciated,  and  suffers  from  flatulence,  gas- 
tralgia,  and  constipation. 

There  is  occasionally  slight  uneasiness  or  even  pain  in  the  region  of  the 
stricture,  possibly  "about  the  epigastrium  or  between  the  shoulder-blades" 
(Maylard).  The  stricture  may  be  located  with  a  bougie  and  by  auscultation 
over  the  spine  on  a  line  with  the  supposed  obstruction.     While  a  patient 

*  "American  Text-book  of  Surgery."  f  The  Practftioner,  April.  1899. 


688 


Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


is  swallowing  water,  the  arrest  of  the  fluid  at  the  seat  of  stricture  may  be 
audible.  Even  if  the  fluid  passes,  it  wifl  be  delayed  for  a  time  and  the  dura- 
tion of  deglutition  is  thus  prolonged.  In  order  to  determine  the  time  of 
deglutition  put  the  ear  just  below  the  angle  of  the  left  scapula,  put  a  finger 
on  the  patient's  Adam's  apple,  and  hold  a  watch  in  the  other  hand.  Have 
the  patient  take  a  drink  of  water.  Count  the  time  from  the  moment  the 
Adam's  apple  begins  to  rise  until  the  fluid  is  heard  to  gurgle  into  the  stomach 
(Ogston's  method).  It  ordinarily  requires  four  seconds  for  food  to  pass 
from  the  mouth  into  the  stomach  (Maylard).  The  history  of  the  case  is 
of  much  importance  in  diagnosis.  The  surgeon  must  inquire  about  im- 
paction of  a  foreign  body,  or  swallowing  of  acids,  alkalies,  or  boiling  fluids; 
and  must  examine  for  evidence  of  syphihs.     If  there  is  no  history  of  injury  or 

syphilis,  and  the  patient  is  over 
forty  years  of  age,  the  indications 
point  to  cancer  rather  than  cica- 
tricial stenosis.  The  easy  pas- 
sage of  a  bougie  when  the  patient 
is  anesthetized  shows  that  spasm 
is  the  cause,  and  not  organic  dis- 
ease. Narrowing  due  to  external 
pressure  is  marked  by  positive 
symptoms  of  the  causative  dis- 
ease.* 

Treatment. — Thiosinamin  is 
given  by  some  physicians,  but  I 
have  never  seen  it  accomplish 
the  shghtest  good.  Telleky  f 
recommends  it  in  old  scars  with- 
out inflammation.  He  makes  a 
15  per  cent.  alcohoHc  solution 
and  injects  from  half  a  syringe- 
ful  to  a  syringeful  at  a  dose, 
throwing  the  fluid  beneath  the 
skin  between  the  scapulae.  He 
uses  20  doses  in  the  course  of 
two  weeks.  Gradual  dilatation 
through  the  mouth  is  a  method 
employed  for  at  least  a  time  in  almost  every  case.  Begin  with  the  largest  bougie 
which  will  easily  pass.  Warm  the  bougie,  oil  it,  pass  it  gently,  and  hold  it  in 
position  for  several  minutes,  prolonging  the  time  of  retention  of  the  bougie  as 
treatment  progresses.  Pass  an  instrument  every  second  or  third  day,  gradu- 
ally increasing  the  size.  If  the  stenosis  involves  a  considerable  portion  of 
the  esophagus,  gradual  dilatation  will  almost  certainly  fail  to  cure. 

Symonds  advocates  the  insertion  of  a  tube  through  the  stricture  and 
leaving  it  in  place  until  there  is  decided  dilatation,  and  then  replacing  the 
tube  with  a  larger  instrument.  The  patient  is  fed  through  the  tube.  Gradual 
dilatation    from  below  has  been   practised  in  cases  where   a  bougie   could 

*  See  the  excellent  article  in  Maylard's  "  Surgery  of  the  Alimentary  Canal." 
f  Wien.  klin.  Woch.,  Feb.  20,  1902. 


Fig.  361. — Esophageal  instruments  :  A,  b,  Forceps  ; 
c,  horsehair  probang  ;  d,  coin-catcher  ;  e,  esophageal 
bougie. 


Stricture   of  the   Esophagus 


689 


not  be  passed  from  the  mouth.  A  gastrostomy  is  performed,  and  after  the 
fistula  has  become  sound  the  patient  is  made  to  swallow  "a  shot  to  which 
is  attached  a  silk  thread  "  (Maylard).  The  silk  thread  is  brought  out  through 
the  fistulous  orifice  and  is  attached  to  a  bougie,  and  the  dilating  instrument 
is  pulled  up  through  the  esophagus.  Forcible  dilatation  can  be  employed 
through  the  mouth  or  through  a  gastrotomy  opening,  by  means  of  bougies, 
tents,  or  divulsing  instruments.  Electrolysis  is  used  by  Fort  and  others. 
Some  surgeons  perform  internal  esophagotomy  through  the  mouth  with  a 
special  instrument.     A  fibrous  stenosis  in  the  region  of  the  cricoid    cartilage 


Fig.  362.— Abbe's  method  of  cutting  esophageal  strictures. 


F'g-  3^3- — The  bougie  engaged  in  the  stricture  while  the  string-saw  is  being  used. 


which  is  not  cured  by  gradual  dilatation  should  be  treated  by  the  operation 
of  external  esophagotomy.  In  this  operation  the  stricture  is  divided  by  a 
longitudinal  incision;  "funnel-shaped  retraction  of  the  cut  portion  is  caused 
by  adhesion  to  the  external  tissues  divided,  and  it  lessens  future  contraction.  "* 
If  dilatation  fails  in  the  case  of  a  stenosis  above  the  line  of  the  aortic  arch,  the 
esophagus  may  be  opened  above  the  stricture  (external  esophagotomy),  a 
tenotome  is  introduced  through  the  wound,  the  stricture  is  cut  and  well  dilated 
by  the  passage  of  instruments.  This  operation  is  known  as  Gussenbauer's 
combined  esophagotomy. 

*  W.  J.  Mayo,  Jour.  Aiuer.  Med.  Assoc,  July  29,  1899. 
44 


690  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

If  a  stricture  is  impassable  from  above,  tiie  stomach  should  be  opened 
and  retrograde  dilatation  be  carried  out.  A  firm,  non-dilatable  stricture  in 
the  thoracic  portion  of  the  esophagus  can  be  treated  by  Abbe's  method  (Figs. 
362  and  363).  He  performs  a  gastrotomy,  passes  a  conical  rubber  bougie 
from  the  stomach  into  the  mouth,  ties  a  piece  of  braided  silk  to  the  bougie, 
withdraws  the  instrument  and  leaves  the  silk  in  place.  One  end  of  the 
silk  emerges  from  the  mouth  and  the  other  end  from  the  gastrotomy  wound. 
In  some  cases  he  opens  the  stomach  and  also  opens  the  esophagus  above 
the  stricture;  one  end  of  the  string  comes  out  of  the  esophagotomy  wound 
and  the  other  end  out  of  the  gastrotomy  wound.  The  string  is  used  as  U 
string-  or  bow-saw,  the  stricture  is  divided,  the  silk  is  withdrawn,  full-sized 
bougies  are  passed,  and  the  wound  or  wounds  are  sutured. 

An  operation  devised  by  A.  J.  Ochsner  is  thus  described  by  Mayo  *:  "  The 
anterior  wall  of  the  stomach  is  drawn  out  of  a  left  obhque  incision  through  the 
abdominal  coverings;  a  small  opening  is  made  into  the  stomach  sufficient  in  size 
to  introduce  the  finger.  A  whalebone  probe,  to  the  tip  of  which  a  silk  string 
guide  has  been  tied,  is  now  passed  through  the  esophagus  either  from  above 
or  retrograde,  as  in  the  Abbe  method.  With  this  guide  a  loop  of  silk  is 
drawn  out  of  the  gastric  incision  in  such  manner  as  to  leave  the  guide  as 
a  third  string.  Into  this  loop  a  small  soft-rubber  drainage-tube  three  feet 
or  more  in  length  is  caught  in  the  middle  by  traction  on  the  ends  of  the  doubled 
thread  through  the  mouth;  this  loop  of  rubber  tube  is  drawn  through  the 
stomach  and  made  to  engage  in  the  stricture. 

"  The  greater  the  amount  of  traction,  the  smaller  the  stretched  rubber 
tube,  until  it  is  sufficiently  reduced  in  size  to  enter  the  stenosed  portion; 
by  alternating  the  direction  of  the  pull  the  tube  is  drawn  out  by  its  free  ends 
and  in  by  the  silk  loop.  Increasing  sizes  of  tubes  can  be  employed,  and 
if  necessary  the  third  string  can  be  used  as  a  string-saw,  after  the  Abbe  plan 
of  procedure.  "  In  a  very  severe  case  of  stenosis  gastrostomy  is  performed  to 
keep  the  patient  from  starving.  In  a  case  of  fibrous  stenosis  in  charge  of  the 
author  it  was  found  impossible  to  insert  any  instrument  from  above  or  from 
below.  Gastrostomy  was  performed  by  Kader's  method.  The  patient  was  fed 
through  the  artificial  opening  and  the  esophagus  was  thus  put  at  rest.  Two 
weeks  after  the  operation  it  became  possible  to  pass  a  bougie  from  the  mouth. 
The  gullet  was  gradually  dilated  to  its  normal  cahber  and  the  gastrostomy 
wound  was  closed.  This  case  demonstrates  that  a  stricture  of  the  esophagus, 
hke  a  .stricture  of  the  urethra,  may  become  temporarily  impassable  from 
inflammation,  edema,  and  spasm;  but,  after  the  part  is  put  at  rest,  will  again 
permit  the  passage  of  an  instrument. 

Carcinoma  of  the  Esophagus. — Cancer  causes  obstruction  of  the  esoph- 
agus. It  arises  in  those  beyond  middle  life,  and  is  far  more  common  in 
men  than  in  women.  The  disease  may  begin  at  any  portion  of  the  gullet, 
but  is  least  often  met  with  in  the  central  portion  (Maylard,  Butlin).  Epithe- 
lioma is  the  usual  form,  but  scirrhus  or  encephaloid  may  occur.  Cancer 
soon  ulcerates,  involves  adjacent  parts,  and  affects  the  deep  cervical  and 
posterior  mediastinal  glands. 

Symptoms  oj  Cancerous  Stenosis. — The  patient  is  over  forty  years  of  age, 
is  usually  a  male,  and  presents  the  same  difficulty  of  swallowing  met  with 
*  Jour.  Amer.  Med.  Assoc,  July  29,  1899. 


Diverticula  of  the   Esophagus  691 

in  cicatricial  stenosis.  The  vomited  matter  is  apt  to  contain  blood,  the  use 
of  the  bougie  causes  bleeding;  there  are  generally  decided  pain  and  very 
great  emaciation.  The  seat  of  obstruction  is  located  by  the  bougie  and  by 
listening  over  the  spine  while  the  patient  is  attempting  to  swallow  water. 
The  stomach  is  the  seat  of  pain;  the  mouth  is  dry  and  there  is  often  great 
thirst.  As  the  disease  infiltrates  the  involvement  of  adjacent  regions  pro- 
duces other  symptoms.  Dyspnea  may  result  from  tracheal  pressure.  Pleu- 
ritis,  pericarditis,  or  pneumonia  may  arise. 

Treatment. — The  disease  is  of  necessity  fatal,  and  treatment  is  only  pallia- 
tive. Complete  excision  is  scarcely  feasible.  The  patient  should  be  put 
upon  a  soft,  bland  diet,  small  quantities  being  given  frequently.  When  trouble 
is  experienced  in  swallowing  the  bland  and  soft  food,  pass  a  soft  bougie  every 
third  or  fourth  day.  When  the  patient  becomes  entirely  unable  to  swallow 
soft  food  we  may  insert  a  Symonds  tube  or  do  an  esophagostomy  (if  this  can 
be  performed  below  the  stricture),  or  perform  gastrostomy.  In  every  doubtful 
case  of  esophageal  stricture  give  a  course  of  iodid  of  potassium  before  per- 
forming any  operation. 

Spasmodic  Stricture  of  the  Esophagus  (Esophagismus,  Hysterical 
Stricture). — By  this  term  is  meant  a  spasm  of  the  circular  muscular  fibers 
of  the  gullet,  which  is  most  common  at  one  end  of  the  tube.  This  condition 
not  unusually  arises  in  a  hysterical  individual,  in  which  case  it  will  be  asso- 
ciated with  the  stigmata  of  hysteria,  especially  globus  hystericus.  In  some 
cases  evidences  of  hysteria  are  wanting,  although  the  patient  is  neurotic, 
and  the  condition  is  due  to  a  reflex  irritation.  It  may  arise  in  cases  of  cancer 
of  the  stomach,  cancer  of  the  liver,  ulceration  of  the  larynx,  and  during 
pregnancy.  I  have  seen  two  instances  in  cancer  of  the  stomach.  It  occa- 
sionally occurs  in  tetanus,  and  sometimes  in  epilepsy. 

Symptoms  of  Spasmodic  Stenosis. — It  arises  suddenly  in  a  hvsterical  or 
neurotic  individual.  It  may  last  for  a  time  and  suddenly  pass  away,  or 
may  persist  for  a  long  time.  The  difficulty  in  swallowing  is  irregular;  some- 
times solids  are  taken  more  readily  than  fluids,  and  vice  versa. 

There  may  be  regurgitation;  but  if  it  occurs,  it  does  so  at  once  on  swallow- 
ing food.  Examination  with  a  bougie  detects  the  obstruction.  If  the  bougie 
is  held  firmly  against  it,  in  most  cases  the  spasm  will,  after  a  time,  relax 
and  let  the  instrument  pass.  A  medium-sized  instrument  or  a  large  instru- 
ment may  not  pass  until  the  patient  has  been  anesthetized,  but  in  everv 
case  a  bougie  can  be  passed  after  an  anesthetic  has  been  given. 

Treatment. — The  systematic  passage  of  bougies.  Occasionally  the  passage 
of  an  instrument  but  once  will  cure  a  case.  The  general  health  must  be 
improved,  and  in  persistent  cases  it  may  be  necessary  to  use  electricity  within 
the  esophagus,  employ  cold  locally,  and  administer  the  bromids. 

Diverticula  of  the  Esophagus.— Maylard  tells  us  that  these  pouches 
may  be  due  to  one  of  four  causes — they  may  be  congenital;  may  be  due 
to  stricture;  may  be  caused  by  pressure  from  within,  upon  a  weak  spot  of 
the  wall;  may  be  due  to  traction  from  without,  by  the  healing  and  contrac- 
tion of  an  area  of  inflammation. 

Symptoms. — When  the  diverticulum  is  in  the  neck  a  lump  forms  during 
deglutition,  and  this  lump  may  be  obliterated  by  pressure.  Food  will  pass 
into  the  stomach  onlv  when  the  diverticulum  is  full.     A  bougie  cannot  be 


692  Diseases  and  Injuries  of  tlie  Upper  Digestive  Tract 

passed  unless  the  pouch  is  full  of  food,  at  which  time  it  may  pass  or  may 
not.  Sometimes  it  enters  the  pouch.  This  latter  symptom,  the  variability 
in  the  passage  of  the  bougie,  is  the  evidence  relied  on  for  diagnosis  in  intra- 
thoracic diverticula.  By  listening  with  a  stethoscope  fluid  may  be  heard  to 
pass  into  the  pouch.  After  a  patient  swallows  food  mi.xed  with  subnitrate 
of  bismuth  a  diverticulum  may  be  skiagraphed.  The  opening  may  be  seen 
by  means  of  an  esophagoscope. 

Treatment. — Extirpation  and  suture,  as  performed  by  von  Bergmann, 
Hearn,  and  others.  For  five  days  after  operation  no  food  is  given  by  the 
mouth. 

Injuries  of  the  Esophagus  from  Within. — Injuries  of  the  internal  sur- 
face are  more  common  than  injuries  from  without.  Burns  and  scalds  are 
among  these  injuries.  Wounds  may  be  inflicted  by  foreign  bodies.  Injuries 
of  the  gullet  cause  pain  on  swallowing  and  a  severe  injury  induces  bleeding, 
the  blood  being  both  coughed  up  and  vomited.  A  severe  wound  may  involve 
a  large  vessel  and  cause  violent  or  even  fatal  hemorrhage.  If  the  bronchus 
or  trachea  is  involved,  there  will  be  "  cough  and  expectoration  of  blood,  mucus, 
and  food"  (Maylard).     The  pleural  or  pericardiac  sacs  may  bo  perforated. 

Treatment. — Feed  only  by  the  rectum.  Give  morphin  hypodermatically. 
Do  not  feed  by  the  mouth  for  ten  days,  and  even  then  give  only  fluid  food 
and  jelly.  Symptoms  are  met  as  they  arise.  After  burns  by  caustic,  ad- 
minister the  antidote;  give  large  drafts  of  water  and  wash  out  the  stomach. 
From  two  to  four  weeks  after  a  caustic  has  been  swallowed  and  after  a  burn 
or  scald,  the  use  of  sounds  should  be  begun,  and  sounding  should  be  per- 
sisted in  for  a  con.siderable  time  to  prevent  contraction. 

Injuries  of  the  Esophagus  from  Without,  Other  Structures  not  being 
Seriously  Involved, — Such  injuries  are  rare.  Esophageal  injuries,  as  a  rule, 
are  as.sociated  with  serious  damage  to  adjacent  structures.  These  injuries 
may  be  due  to  stabs  or  to  bullets.  Besides  the  obvious  external  signs  of 
the  injury  there  will  be  difficulty  in  swallowing,  cough,  bloody  expectoration 
or  vomiting;  and  mucus  or  the  contents  of  the  stomach  may  run  out  of  the 
wound. 

Treatment. — Suture  the  wound,  and  feed  by  the  rectum  for  ten  days. 

Foreign  Bodies  Lodged  in  the  Esophagus. — These  accidents  occur 
especially  to  children  and  lunatics,  and  women  are  more  apt  to  suffer  from 
them  than  are  men.  An  extended  list  of  bodies  which  have  been  swallowed 
will  be  found  in  Poulet's  elaborate  treatise.  There  are  three  regions  where 
a  foreign  body  is  especially  apt  to  lodge — viz.,  opposite  the  cricoid  cartilage, 
at  the  level  of  the  diaphragm,  and  at  the  point  where  the  left  bronchus  crosses 
the  gullet.     Small  and  sharp  bodies  may  lodge  anywhere. 

Symptoms. — The  symptoms  are  variable;  if  the  body  is  large,  there  will 
be  pain  and  difficulty  in  swallowing,  and,  in  some  cases,  dyspnea  from  pressure 
upon  the  trachea  or  bronchus.  Occasionally  the  dyspnea  is  such  a  prominent 
feature  that  it  misleads  the  physician  into  the  belief  that  the  foreign  body 
is  lodged  in  the  air-passages.  Death  may  actually  result  from  asphyxia.  In 
some  other  cases  the  symptoms  are  very  slight.  If  the  body  is  sharp,  there 
will  be  hemorrhage  and  severe  pain.  The  blood  may  be  hawked  u[),  or  may 
be  swallowed  anrl  vomited.  A  patient  may  grow  accustomed  to  a  foreign 
bofjv  and   cease   to   notice   it;  but,   on   the  contrary,   the   foreign   body  may 


Foreign   Bodies   Lodged  in  the   Esophagus  693 

produce  inflammation,  and  even  may  ulcerate  into  the  windpipe,  the  pleura, 
the  pericardium,  or  the  aorta.  In  many  cases  of  impaction  a  patient  makes 
violent  efforts  to  hawk,  and  produces  aphonia.  There  may  be  violent 
retching.  Even  after  a  foreign  body  has  been  removed  by  swallowing  or 
otherwise  a  sensation  is  apt  to  remain  as  if  it  were  still  lodged.  The  diag- 
nosis is  made  by  the  history,  the  detection  of  the  body  by  external  manipu- 
lation, by  feeling  it  with  an  esophageal  bougie,  and,  if  bone  or  metal,  seeing 
it  with  the  fluoroscope  or  obtaining  a  skiagraph. 

Treatment. — The  surgeon  should  learn,  if  possible,  the  size,  shape,  weight, 
and  nature  of  the  foreign  body,  and  should  locate  its  point  of  impaction. 
The  e.xact  point  of  lodgment  of  bone  or  a  metallic  body  is  determined  by 
the  A;-rays.*  An  anesthetic  is  given  before  manipulating  in  a  child,  a  nervous 
woman,  or  a  lunatic,  and  is  sometimes  necessary  for  a  man.  If  the  foreign 
body  is  soft,  external  manipulation  may  succeed  in  altering  its  shape,  so  that 
it  may  be  swallowed  or  ejected.  If  the  foreign  body  is  hard,  external  manipu- 
lation may  shift  its  position.  It  is  usually  impossible  to  reach  the  foreign 
body  through  the  mouth  by  means  of  the  fingers  (when  the  body  is  in  the 
rear  of  the  pharynx  it  may  be  pulled  forward  or  pushed  down).  Sharp 
foreign  bodies  may  be  entangled  and  carried  down  when  the  patient  eats 
mush,  bread,  or  boiled  potatoes.  The  administration  of  emetics  is  an  old 
plan  which  occasionally  succeeds,  but  which  is  too  unsafe  to  be  employed. 
Maylard  says  that  when  a  mass  of  food  is  impacted  it  is  occasionally  possible 
to  soften  and  disintegrate  the  mass  by  administering  a  mixture  containing 
pepsin.  The  horsehair  probang  is  a  very  useful  instrument  (Fig.  361,  c). 
It  may  be  used  to  push  a  body  downward  into  the  stomach,  or  to  catch 
the  body  and  pull  it  up.  When  this  instrument  is  withdrawn  it  opens 
like  an  umbrella.  Maurice  H.  Richardson  has  shown  that  in  an  adult  the 
diaphragmatic  opening  is  about  fourteen  and  one-half  inches  from  the 
incisor  teeth,  a  point  to  be  remembered  in  deciding  whether  to  push 
down  or  pull  up  the  impacted  article.  Esophageal  forceps  (Fig.  361, 
A,  b)  are  valuable  in  some  cases.  The  coin-catcher  (Fig.  361,  d)  is  a  useful 
instrument.  Crequy's  plan  of  removal  is  to  take  a  tangled  mass  of  threads, 
tie  a  stout  piece  of  string  about  the  middle  of  it,  coat  it  with  sugar,  and  have 
the  patient  swallow  it.  It  may  pass  the  foreign  body;  if  it  does  so,  on  with- 
drawal it  may  entangle  the  object  and  extract  it.  To  remove  a  fish-hook  with 
line  attached,  the  following  plan  may  prove  successful;  stick  the  line  which  pro- 
jects from  the  mouth  into  a  metal  catheter,  carry  the  catheter  down  to  the  hook, 
and  push  the  hook  out.  It  is  not  proper  to  allow  a  foreign  body  to  remain  in  the 
esophagus  until  it  causes  ulceration.  Neither  is  it  proper  to  make  prolonged 
efforts  to  extract  it  through  the  mcmth.  Such  efforts  may  do  great  harm,  and 
if  one  careful  and  consistent  effort  fails  an  operation  should  be  performed. 
If  the  body  is  lodged  anywhere  above  the  lower  third  of  the  esophagus,  ex- 
ternal esophagotomy  is  performed,  and  usually  on  the  left  side.  Through 
this  wound  the  foreign  body  is  extracted.  The  cut  is  made  on  the  left  side, 
between  the  trachea  and  larynx  in  front  and  the  carotid  sheath  behind,  the 
center  of  the  incision  being  opposite  the  cricoid  cartilage.  AiXev  the  foreign 
body  is  extracted  the  mucous  membrane  is  sutured  with  chromic  catgut, 
and  the  superficial  structures  are  closed  with  silkworm-gut  after  a  drainage- 

*  See  cases  of  White,  Keen,  Alfred  WOdd,  Maclntyre.  Tavlor.  and  others. 


694  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

tube  has  been  inserted.  The  patient  is  fed  by  the  rectum  for  eight  or  ten 
days.  When  a  foreign  body  is  lodged  in  the  lower  portion  of  the  tube,  the 
stomach  is  opened  and  the  body  extracted  by  this  route  (Richardson). 
In  White's  case  of  jackstone  in  the  gullet  gastrotomy  was  performed.  A 
string  was  tied  about  some  rolls  of  gauze,  the  string  was  passed  by  means 
of  a  whalebone  from  the  stomach  into  the  mouth,  and  the  body  was  entangled 
and  drawn  out. 

Surgical  Invasion  of  the  Mediastinum. — The  posterior  mediastinum 
has  been  entered  in  order  to  remove  a  foreign  body  from  the  bronchus  and 
to  extract  a  set  of  false  teeth  wedged  in  the  esophagus.  The  same  method 
can  be  followed  to  reach  suppurative  processes  in  the  mediastinum,  abscesses 
of  the  lung  otherwise  inaccessible,  and  diverticula  of  the  lower  end  of  the 
gullet  (Enderlen,  in  "Deutsche  Zeitschrift  fur  Chirurgie,"  Nov.,  1901).  The 
anterior  mediastinum  may  be  entered  to  remove  a  bullet,  to  drain  an  abscess, 
to  reach  a  wound  of  the  heart  or  lung,  and  to  explore  for  the  cause  of  symp- 
toms. I  explored  the  anterior  mediastinum  after  rib  resection,  found  a 
bullet  imbedded  in  the  aorta,  and  allowed  it  to  remain.  The  padent  re- 
covered.    M.  H.  Milton  *  sphts  the  sternum  and  separates  the  two  pieces. 

*  Lancet,  March  27,  1897. 


Contusion  of  the  Abdominal  Wall  without  Injury  of  Viscera    695 


XXVII.    DISEASES    AND   INJURIES    OF    THE   ABDOMEN. 

Diagnosis  of  Intra=abdominal  Emergencies.— The  exact  diag- 
nosis is  always  difficult  and  is  not  unusually  impossible.  What  a  surgeon 
must  try  to  determine,  and  what  he  usually  can  determine,  is  whether  he 
is  dealing  with  a  trivial  and  temporary  derangement  for  the  relief  of  which 
an  operation  is  entirely  unnecessary,  or  whether  he  is  confronted  with  a 
grave  calamity  which  imperatively  demands  immediate  surgical  aid.  We 
can  decide  that  a  calamity  exists,  but  the  exact  nature  of  the  lesion  is  often 
doubtful  until  operation  is  performed.  Every  operation  in  such  a  case  is 
exploratory.  Before  the  diagnosis  of  a  calamity  is  made  morphin  should 
not  be  given,  because  it  allays  the  pain,  reheves  the  anxiety,  causes  the  dis- 
appearance of  rigidity,  lowers  the  pulse,  abates  shock,  and  hence  veils  the 
real  situation,  so  that  the  most  discerning  surgeon  will  probably  be  misled.  If 
shock  is  profound,  diagnosis  is  usually  impossible,  unless  shock  is  due  to 
hemorrhage,  and  immediate  operation  during  shock  is  not  to  be  thought 
of  except  to  arrest  bleeding.  If  excessive  and  continued  hemorrhage  is 
susp>ected,  immediate  operation  is  indicated.  If  it  is  not  suspected,  the 
patient  should  be  covered  with  blankets  and  surrounded  with  hot-water 
bags,  atropin  should  be  given  hypodermatically,  and  hot  salt  solution 
should  be  administered  by  rectum,  subcutaneously,  or  intravenously. 
Suprarenal  extract  is  a  valuable  remedy  to  maintain  blood-pressure  in 
shock  (Crile).  When  the  patient  reacts,  and  he  usually  will  react, 
an  attempt  is  made  to  make  a  diagnosis.  It  is  perfectly  proper  to  give 
a  single  hypodermatic  injection  of  morphin  (gr.  ^)  after  the  effort  has 
been  made  to  diagnosticate  the  condition.  The  danger  of  deluding  the 
surgeon  is  past  and  the  drug  abates  pain,  lessens  peristalsis,  relieves  mental 
anxiety,  and  is  distinctly  beneficial.  Before  the  morphin  was  given  the 
surgeon  came  to  a  conclusion  as  to  the  necessity  for  operation.  After  the 
morphin  has  been  given,  if  an  operation  is  indicated,  it  is  performed  as 
promptly  as  circumstances  admit.  Whenever  it  is  esteemed  consistent  with 
safety,  the  patient  ought  to  be  removed  to  a  hospital  for  operation. 

Contusion  of  the  Abdominal  Wall  without  Injury  of  Viscera. — 
In  some  cases  of  contusion  of  the  abdominal  wall  only  the  parietes  are  dam- 
aged; in  other  cases  the  viscera  or  the  abdominal  tissues  are  injured.  Con- 
tusion may  involve  the  skin  alone,  or  may  involve  the  skin,  muscles,  and 
peritoneum.  In  simple  contusion  there  is  considerable  shock  if  the  injurv 
is  severe.  There  is  pain,  increased  by  respiration,  motion,  pressure,  and 
attempts  at  urination  or  defecation.  When  tenderness  appears  some  davs 
after  the  accident  there  is  usually  deep-seated  injury.  Extensive  ecchvmosis 
may  appear.  Even  after  a  severe  contusing  force  has  been  applied  there 
may  be  no  discoloration,  and  it  may  happen  that  after  a  slight  force  there 
is  much  discoloration.  There  is  great  ecchymosis  in  anemic  persons,  victims 
of  hemiplegia,  in  obese  individuals,  oj)ium-eaters,  and  drunkards.  In  .severe 
cases  the  tissues  are  pulpetied  and  sloughing  inevitablv  ensues.  Abscess 
occasionally  follows  contusion.  The  prognosis  after  abdominal  contusion  is 
always  uncertain. 


696  Diseases   and   Injuries   of  the   Abdomen 

Treatment  oj  Simple  Contusion. — In  treating  simple  contusion  place  the 
patient  at  rest  in  a  supine  position,  with  the  thighs  t^execl  over  a  pillow; 
obtain  reaction  from  the  shock.  Give  morphin  if  pain  is  severe.  After 
shock  has  passed  off  it  is  advisable  to  place  an  ice-bag  over  the  seat  of  injury. 
If  much  blood  is  extravasated  into  the  abdominal  wall,  aspirate  and  apply 
a  binder.  After  twenty-four  hours  apply  local  heat  by  means  of  the  hot- 
water  bag,  employ  an  ointment  of  ichthyol,  and  move  the  bowels,  if  neces- 
sary, by  salines.  Regard  every  contusion  as  serious,  and  watch  carefully 
for  the  development  of  signs  of  internal  hemorrhage  or  visceral  injury. 

Muscular  Rupture  from  Contusion. — In  this  injury  there  are  severe 
shock  and  pain  (increased  by  respiration  and  movement).  Separation  be- 
tween the  fibers  of  the  muscle  is  distinct  at  first,  but  it  is  soon  masked  by 
effusion  of  blood.  Such  injuries  may  cause  death,  or  may  lead  to  hernia. 
The  rectus  is  the  muscle  most  apt  to  rupture.  The  rupture  is  due  to  sudden 
contraction  rather  than  to  the  direct  effect  of  a  blow. 

The  treatment  is  the  same  as  for  simple  contusion.  Always  apply  a 
binder.  A  hernia  is  returned  and  a  compress  is  applied  over  the  opening 
through  which  it  emerged.     If  strangulation  occurs,  operate  at  once. 

Injuries  with  Damage  to  the  Peritoneum  or  the  Viscera.— 
Rupture  of  the  Peritoneum. — The  peritoneum  may  be  involved  in  an 
abdominal  contusion.  It  may  rupture  even  when  there  is  no  visceral  injury 
or  muscular  contusion..  The  uterine  peritoneum,  the  parietal  peritoneum, 
the  visceral  peritoneum,  or  the  mesentery  may  rupture.  Rupture  of  the 
peritoneum  causes  intra-abdominal  hemorrhage. 

The  treatment  consists  in  opening  the  abdomen,  arresting  the  hemorrhage, 
and  bringing  about  reaction. 

An  injury  to  the  peritoneum  creates  a  point  of  least  resistance,  and  at 
such  a  point  peritonitis  may  develop.  The  peritonitis  is  usually  local,  but 
may  become  general.  After  any  severe  intra-abdominal  injury  the  symp- 
toms of  peritoneal  shock  appear  {peritonism),  and  the  patient  may  rapidly 
die.  In  the  condition  of  peritonism  the  temperature  is  subnormal;  the  ex- 
tremities are  cold;  the  face  is  palhd  and  sunken;  the  pulse  is  small,  weak, 
and  very  frequent;  the  respiration  is  shallow  and  sighing;  there  is  great  thirst; 
the  patient  is  restless  and  turns  uneasily,  and  there  is  rigidity  and  dis- 
tention. Vomiting  almost  always  occurs.  In  some  cases  there  is  regurgita- 
tion rather  than  vomiting.  The  abdomen  is  the  seat  of  a  violent,  persistent 
pain.  The  patient  is  fearful  of  impending  death.  As  the  symptoms  develop 
in  a  grave  case  they  will  point  to  one  of  two  conditions — hemorrhage  or 
peritonitis. 

In  intra-abdominal  hemorrhage  the  subnormal  temperature  and  other 
evidences  of  shock  persist.  Vomiting  ceases,  but  nausea  exists.  The  patient 
is  uncontrollably  restless  and  tosses  about  in  bed.  The  thirst  is  great.  The 
abdomen  is  rarely  rigid.  Fainting-spells  occur.  Blood -examination  shows  a 
marked  fall  in  the  percentage  of  hemoglobin.  Percussion  demonstrates  the 
exi.stence  of  an  efTusion  which  alters  its  position  as  the  patient's  position  is 
altered,  and  which  gradually  increases  in  amount.  Dulness  is  first  met  with 
in  the  loins.  Digital  examination  of  the  rectum  or  vagina  may  aid  in  diagnosis 
because  in  hemorrhage  blood  gathers  in  the  rectovesical  pouch.  If  peri- 
tonitis develops,  the  vomiting  becomes  worse,  the  pain  intensifies,  and  the 
abdf^men  grows  rigid  and  distended. 


Rupture   of   the    Stomach    without    External    Wound         697 
Rupture    of    the    Stomach    without    External    Wound.— The 

usual  cause  of  rupture  is  a  violent  blow,  although  the  accident  may  happen 
while  washing  out  the  stomach.  Rupture  is  more  apt  to  occur  when  the 
stomach  is  distended  with  food  than  when  it  is  empty.  The  rupture  may 
be  partial,  the  peritoneal  coat  not  being  torn.  The  rupture  may  be  com- 
plete. Either  the  anterior  or  the  posterior  wall  may  suffer.  The  region 
of  the  pylorus  is  most  apt  to  be  lacerated.  The  symptoms  of  rupture  are 
collapse,  severe  pain  over  the  entire  abdomen,  great  thirst,  excessive  tender- 
ness, especially  over  the  epigastric  region,  occasionally  vomiting,  the  vomited 
matter  being  usually,  but  not  invariably,  bloody;  tympanitic  distention 
and  muscular  rigidity  coming  on  after  a  few  hours.  Austin  Flint  pointed 
out  years  ago  that  gas  may  enter  the  abdominal  cavity  and  cause  the  diminu- 
tion or  disappearance  of  liver-dulness,  but  the  area  of  liver-dulness  can  be 
lessened  by  great  intestinal  distention,  and  I  have  seen  cases  of  perforation 
of  the  stomach  and  intestine  in  which  it  was  not  lessened  at  all.  After  iu- 
complete  rupture  local  peritonitis  is  frequent;  in  complete  rupture  the  escape 
of  food  into  the  peritoneal  cavity  causes  general  peritonitis.  The  contents 
of  the  stomach  are  not  so  liable  to  escape  after  rupture  of  that  viscus  as  are 
the  contents  of  the  intestine  after  rupture  of  the  gut,  because  of  the  thickness 
of  the  stomach-wall  and  the  tendency  of  the  mucous  membrane  to  evert 
and  block  the  opening.  Perforations  of  the  anterior  wall  are  most  apt  to 
lead  to  extravasation  and  general  peritonitis.  Posterior  laceration  may 
cause  subphrenic  abscess.  To  diagnosticate  between  complete  and  in- 
complete rupture,  Senn  endeavors  to  distend  the  viscus  with  hydrogen  gas; 
in  incomplete  rupture  the  contour  of  the  dilated  stomach  can  be  made  out 
upon  the  surface;  in  complete  rupture  the  viscus  cannot  be  distended,  and 
the  gas  passes  into  the  peritoneal  cavity,  producing  the  physical  signs  of 
tympanites.  This  maneuver  is  open  to  the  objection  that  it  may  increase 
extravasation  in  a  complete  rupture. 

The  treatment  in  complete  rupture  is  as  follows:  if  signs  of  hemorrhage 
are  absent,  endeavor  to  bring  about  reaction  before  operating.  If  these 
signs  are  present,  operate  at  once,  and  have  salt  solution  infused  into  a  vein 
during  the  operation.  Open  the  abdomen.  If  the  seat  of  rupture  is  not 
visible,  it  may  be  found  by  inflating  the  stomach  with  hydrogen.  Flush 
out  the  stomach  and  the  peritoneal  cavity  with  hot  salt  solution;  sew  up  the 
stomach-wound  with  a  double  row  of  silk  sutures,  the  first  row  being  buried 
and  including  the  muscular  coat  and  mucous  coat,  the  second  row  being 
Halsted  sutures;  drain;  close  the  wound  in  the  parietes  with  silkworm-gut; 
feed  by  the  rectum  for  four  days,  and  then  begin  the  administration  of  a 
very  little  food  by  the  mouth.  In  incomf)lete  rupture  the  danger  is  per- 
foration. The  patient  is  put  to  bed,  and  after  reaction  has  taken  place, 
is  fed  by  the  rectum  for  several  days,  and  morphin  is  given  hypodermati- 
cally.  Cases  not  operated  upon  occasionally  recover,  adhesions  arising  and 
perigastric  suppuration  taking  place.  The  mortality  is  e.xtremely  large.  In 
1896  Petry  collected  23  cases  in  which  operation  was  not  performed.  The 
mortality  was  59  per  cent.  This  mortality  is  not  so  large  as  one  would 
anticipate.  It  is  not  impossible  that  some  of  the  cases  were  not  positi\'ely 
instances  of  rupture.  Nevertheless  the  lesion,  for  reasons  previously  stated, 
is  not  nearly  so  dangerous  as  rupture  of  the  intestine.     Another  reason  for 


698  Diseases  and   Injuries   of  the  Abdomen 

the  greater  danger  of  intestinal  ruptures  is  that  fecal  matter  is  much  more 
poisonous  than  the  gastric  contents.  Laparotomy  has  lessened  the  mortality 
of  rupture  of  the  stomach.  Petry  and  also  Eisendrath  mass  together  opera- 
tions for  rupture  of  the  stomach  and  rupture  of  the  intestine.  Petry  finds 
the  group  mortality  to  be  52*.3  per  cent.,  and  Eisendrath  finds  it  to  be  52.5 
per  cent.  Statistics  referring  to  the  stomach  alone  should  show  a  lower 
death-rate. 

Rupture  of  the  Intestine  without  External  Wound. — In  a  great 
majority  of  cases  the  damage  is  produced  by  direct  violence.  Homer  Gage  * 
collected  85  cases;  in  75  the  injury  was  due  to  direct  force,  and  in  32  of 
these  the  force  was  inflicted  by  the  kick  of  a  horse  or  of  a  man.  In  one 
of  my  cases  it  was  due  to  the  kick  of  a  horse,  in  one  to  the  kick  of  a  man, 
and  in  one  to  a  crush  inflicted  by  a  cart-wheel.  In  78  collected  cases  (Gage) 
the  situation  of  the  injury  was  specified:  The  duodenum,  10;  jejunum,  20; 
ileum,  42;  large  intestine,  6.  In  many  cases  there  is  more  than  one  tear, 
and  sometimes  many  tears  exist.  The  mesentery  may  be  lacerated  (in  7 
per  cent,  of  cases,  according  to  Gage;  in  16  per  cent.,  according  to  Curtis). 
The  symptoms  of  this  injury  are  profound  shock,  tympanites,  abdominal 
pain,  and  rigidity,  rapidly  followed  by  peritonitis  if  the  patient  survives. 
In  some  cases  pain  is  referred  to  the  back.  Vomiting  comes  on  soon  after 
the  accident,  the  vomited  matters  being  possibly  at  first  bloody  and  later 
stercoraceous.  The  respiration  is  thoracic,  the  tongue  is  dry,  and  great 
thirst  exists.  The  pulse,  which  is  slow  at  first,  becomes  small  and  rapid 
and  of  high  tension.  Blood  in  the  stools  rarely  appears  early  enough  to 
be  of  diagnostic  value.  There  may  be  no  marked  symptoms  for  an  hour 
or  two  or  for  many  hours.  The  escape  of  gas  into  the  peritoneal  cavity 
may  cause  the  diminution  or  disappearance  of  liver-dulness.  After  anesthe- 
tizing the  patient  hydrogen  gas  insufflated  into  the  rectum  will  come  from 
the  mouth  if  there  is  no  perforation  in  the  stomach  or  the  intestine;  if  a 
perforation  exists,  tympanites  is  much  increased,  and  the  area  of  hver-dulness 
may  disappear.  To  apply  rectal  insufflation  of  hydrogen,  generate  the  gas 
in  a  bottle  by  means  of  zinc  and  sulphuric  acid,  catch  the  gas  in  a  large  rubber 
bag,  and  attach  the  tube  from  the  gas  reservoir  to  a  tip  which  is  inserted 
in  the  rectum.  Give  the  patient  ether  to  relax  the  abdominal  muscles,  direct 
an  assistant  to  press  the  anal  margins  against  the  rectal  tip,  and  when  the 
patient  is  unconscious  turn  on  the  stopcock  and  press  upon  the  reservoir 
(Senn). 

It  has  been  suggested  that  ether  vapor,  mixed  with  air,  can  be  used  instead 
of  hydrogen  gas.f  In  this  method  a  little  ether  is  poured  into  the  bottle  of 
an  aspirator,  the  valves  are  opened,  one  tube  is  carried  into  the  rectum, 
the  other  tube  is  attached  to  a  bicycle  pump,  and  by  working  the  juimp 
the  ether  vapor  is  driven  into  the  bowel.  If  there  is  perforation,  tympanites 
is  notably  increased.  Some  surgeons  regard  the  rectal  insufflation  test  as 
unsatisfactory  and  often  dangerous.  Personally  I  am  not  inclined  to  use  it. 
Its  application  requires  considerable  time,  it  must  of  necessity  increase  fecal 
extravasation,  and,  as  Le  Conte  t   says,  it  "so  distends  the  intestines  that 

*  Annals  of  Surgery,  March,  1902. 

t  Emerson  M.  Sutton,  of  Geneva,  in  Jour.  Am.  Med.  Assoc,  July  23,  1898. 

j  Am.  Jour.  Med.  Sciences,  Dec,  1901. 


Identification  of  the  Intestines  699 

it  may  be  impossible  to  return  them  to  the  abdominal  cavity  until  they  have 
been  emptied  of  gas." 

Treatment  of  Rupture  of  Intestine. — If  symptoms  point  to  dangerous 
hemorrhage,  operate  at  once;  otherwise  do  not  operate  until  reaction  has 
been  obtained.  If  in  doubt  as  to  whether  or  not  rupture  exists,  explore. 
Reaction  is  brought  about  as  previously  directed.  Asepticize  and  anesthe- 
tize. Perform  a  laparotomy;  check  hemorrhage;  find  the  rent,  and  close  it 
by  Halsted  sutures  if  possible.  Because  of  the  frequency  of  multiple 
lesions  the  surgeon  must  not  be  sure  he  has  finished  his  work  when 
he  finds  and  closes  one  tear,  but  he  must  determine  by  careful  search 
that  no  other  tears  exist.  The  surgeon  notes  if  there  is  injury  of  the 
mesentery  and  if  the  circulation  of  any  portion  of  the  bowel  is  inter- 
fered with.  If  there  is  serious  impairment  of  circulation  in  any  part  of  the 
bowel-wall,  perform  intestinal  resection,  followed  by  end-to-end  approxima- 
tion or  lateral  anastomosis.  Flush  the  abdominal  cavity  with  hot  saline 
solution,  and  wipe  the  peritoneal  fossae  and  the  space  between  the  liver  and 
diaphragm  with  gauze.  Finney  eviscerates,  wipes  out  the  abdominal  cavity, 
and  wipes  the  intestines  as  he  restores  them.  Whatever  method  is  used  to 
cleanse  the  abdomen,  remember  that  infectious  material  is  apt  to  accumulate 
between  the  liver  and  diaphragm  and  in  Douglas's  pouch.  Drainage  is  to 
be  used.  The  value  of  operation  for  intestinal  rupture  is  conclusively  demon- 
strated. Curtis  collected  116  cases  which  occurred  before  1887.  Not  a  case 
was  operated  upon  and  every  patient  died.  Homer  Gage  collected  85  cases 
since  1887;  45  were  not  operated  upon  and  every  one  died;  40  were  oper- 
ated upon  and  17  recovered.  At  least  93  per  cent,  will  die  if  not  operated 
upon  (Eisendrath*). 

Identification  of  the  Small  Intestine  and  of  the  Large  Intestine. — 
"In  abdominal  operations  it  is  frequently  imperatively  necessary  that  the 
large  intestine  be  recognized  with  certainty  or  the  small  bowel  be  positively 
identified.  The  size  of  the  tube  will  not  always  aid  in  this  recognition,  as 
a  small  intestine  may  be  distended  enormously  and  a  large  intestine  may 
be  contracted  to  the  size  of  a  finger  because  of  obstruction  above.  The 
longitudinal  muscular  fibers  of  the  large  bowel  are  accentuated  in  three  por- 
tions; these  accentuations  constitute  the  three  longitudinal  bands  which 
begin  at  the  cecum  and  terminate  at  the  end  of  the  sigmoid  flexure  of  the 
colon.  Each  band  is  composed  of  a  number  of  shorter  bands,  the  shortness 
of  these  constituent  bands  permitting  the  sacculation  of  the  large  intestine. 
Longitudinal  bands  and  sacculation  are  not  met  with  in  the  small  gut,  their 
presence  or  absence  being  a  means  of  identification  in  many  cases;  but  when 
the  colon  is  much  distended  the  bands  cannot  be  seen  distinctly  and  the 
sacculation  disappears.  From  the  large  intestine  only  spring  the  appendices 
epiploicai  (small  overgrowths  of  fat  in  pouches  of  peritoneum),  but  they 
are  sometimes  not  well  marked  except  upon  the  transverse  colon,  and  when 
emaciation  exists  they  may  almost  entirely  disappear.  The  relatively  fixed 
position  of  the  large  intestine  and  the  free  mobility  of  the  small  bowel  are 
important  points  of  distinction.  The  foregoing  indicates  that  it  is  not  always 
easy  to  distinguish  between  colon  and  small  gut,  and  that,  according  to  old 
rules,  it  may  be  often  necessary  to  make  large  incisions,  to  see  as  well  as 

*  Jour.  Am.  Med.  Assoc,  Oct.  25,  1902. 


yoo  Diseases  and   Injuries  of   the  Abdomen 

feel,  and  to  handle  a  large  extent  of  the  bowel.  Any  scrap  of  knowledge 
that  will  shorten  an  abdominal  operation,  that  will  permit  of  as  certain  work 
through  a  smaller  incision,  and  that  will  diminish  handhng  of  intraperitoneal 
structures,  tends  to  increase  the  chances  of  recovery.  For  these  reasons  the 
writer  suggests  a  method  of  bow-el-identification  which  rests  upon  the  facts 
that  each  bowel  has  a  posterior  attachment,  that  the  origin  of  the  attach- 
ment differs  according  to  the  bow-el  it  supports,  that  a  single  finger  can  detect 
the  origin  of  the  peritoneal  support  of  any  section  of  the  bowel,  and,  this 
origin  being  known,  the  portion  of  the  bowel  it  supports  is  with  certainty 
deducible.  In  an  exploratory  operation,  for  instance,  the  finger  comes  in 
contact  with  the  bo\yel:  to  determine  whether  it  is  a  large  or  a  small  bowel, 
note  first  if  the  structure  is  movable  or  is  firmly  liexed;  next,  pass  the  finger 
over  the  bowel  and  let  it  find  its  way  posteriorly.  If  dealing  with  a  small 
bowel,  the  finger  will  reach  the  origin  of  the  mesentery  between  the  left 
side  of  the  second  lumbar  vertebra  and  the  right  sacro-iliac  joint;  if  deahng 
with  the  large  bowel,  the  finger  will  reach  the  origin  of  the  mesocolon,  or 
the  point  where  the  colon  is  fixed  posteriorly  and  to  the  side."* 

Rupture  of  the  liver  may  be  caused  by  a  blow,  a  fall  from  a  height, 
or  the  concussion  of  a  railroad  collision.  Occasionally  the  ends  of  fractured 
ribs  are  driven  into  the  organ. 

The  symptoms  are  those  previously  set  forth  as  attending  severe  intra- 
abdominal injury  (p.  696).  In  addition,  there  are  tenderness  over  the  Hver, 
and  often  pain  in  the  abdomen  and  back.  As  a  rule,  the  signs  of  hemorrhage 
are  present.  Sugar  may  appear  in  the  urine.  The  respiration  is  much  em- 
barrassed. After  a  few  days  the  skin  may  itch  and  become  jaundiced,  but 
this  is  rare. 

In  these  cases  operate  at  once  if  hemorrhage  is  severe;  otherwise  operate 
after  bringing  about  reaction.  Stop  bleeding  in  the  liAer  by  cautery,  by 
suture,  or  by  packing.  In  a  superficial  tear  introduce  sutures  of  catgut 
or  silk.  In  a  deep  tear  suture  the  liver  to  the  belly-wall,  pack  the  wound 
with  gauze,  and  surround  it  with  gauze.  Eisendrath  has  collected  37  cases 
of  suture  of  the  liver  for  rupture.  Twenty-two  of  these  recovered  (59.5 
per  cent.).  The  first  operation  was  performed  by  Willette  in  1888.  At  least 
80  per  cent,  will  die  without  operation. f 

Rupture   of    the    Gall=bladder    and    the    Bile=ducts.— Rupture 

of  the  gall-bladder  or  the  ducts  is  most  apt  to  happen  from  injury  when 
gall-.stones  exist.  Peritonitis,  general  or  local,  is  almost  certain  to  follow 
such  a  rupture.  Besides  those  symptoms  common  to  all  severe  abdominal 
injuries,  there  is  often  intense  jaundice. 

Treatment. — Suture  the  laceration  or  make  a  biliary  fistula. 

Rupture  of  the  Spleen. — The  s])leen  may  be  dislocated  as  well 
as  ruptured.  Rupture  of  the  .spleen  is  rare  without  other  serious  injuries. 
An  enlarged  spleen  is  far  more  liable  to  injury  than  a  normal  organ.  The 
u.sual  symptoms  of  abdominal  injury  are  present.  In  addition,  there  are 
pain  over  the  spleen  and  heart,  tenderness  over  the  spleen,  and  great  .short- 
ness of  breath.  Hemorrhage  is  generally  profuse  but  slow.  The  splenic  blood 
contains  numerous  leukocytes  and  clots  rajjidl}',  hence  the  bleeding  is  usually 

*  The  author,  in  Medical  News,  June  9,  1S94. 

t  Eisendratli,  Jour.  Am.  Med.  Assoc,  Nov.  I,  1902. 


Penetrating   Wounds  701 

arrested  for  a  time,  and  a  patient  does  not  often  Ijleed  to  death  rapidly  (Bal- 
lance) . 

Ballance  points  out  that  dulness  is  found  in  the  left  loin,  but,  because 
of  the  clotting  of  the  blood,  the  dulness  does  not  shift  when  the  position  of 
the  patient  is  shifted,  as  it  does  in  bleeding  from  other  intraperitoneal  struc- 
tures. 

Treatment. — Ballance  tells  us  that  after  a  splenic  injury  there  is  shock, 
but  after  a  time  there  is  a  distinct  reaction.  Wait  for  the  reaction,  and 
when  it  occurs  remove  the  spleen.  The  mortality  in  cases  not  operated 
upon  is  probably  about  the  same  as  in  rupture  of  liver  (80  per  cent.).  In 
50  cases  operated  upon  28,  or  56  per  cent.,  recovered  (Eisendrath). 

Rupture  of  Mesentery  Arteries.— The  symptoms  are  those  of  hem- 
orrhage. Aldrich  *  reported  a  case  in  which  death  occurred  on  the 
seventh  day. 

Rupture  of  the  Kidney  (page  937). 

Rupture  of  the  Ureter  (page  939). 

Wounds  of  the  Abdominal  Wall. — Non-penetrating  wounds  are 
to  be  treated  on  general  principles.  They  are  sutured  with  great  care  and 
are  firmly  supported  externally.     Ventral  hernia  may  follow  a  large  wound. 

Penetrating  Wounds. — The  symptoms  of  penetrating  wounds  of  the 
abdominal  wall  are  usually  those  of  shock  and  hemorrhage,  and  later  of 
septic  peritonitis.  Emphysema  is  apt  to  occur  and  viscera  may  protrude, 
and  often  do  in  the  case  of  a  large  incised  or  lacerated  wound.  Extrava- 
sation of  contents  of  intra-abdominal  viscera  is  very  apt  to  occur,  and  is 
sure  to  occur  if  the  viscus  was  distended  when  injured.  Normal  urine  and 
normal  bile  may  do  little  harm,  but  if  either  excretion  is  septic,  disastrous 
consequences  are  certain  to  ensue.  If  intestinal  contents  escape,  septic  peri- 
tonitis is  certain  to  occur.  Bleeding  is  usually  profuse  and  prolonged,  because 
spontaneous  arrest  of  hemorrhage  from  any  considerable  vessel  will  rarely 
take  place  within  the  abdomen. 

Treatment. — ^The  surgeon  endeavors  to  discover  promptly  if  a  wound  of 
the  abdominal  wall  is  or  is  not  penetrating  in  character.  This  fact  may 
be  proved  by  protrusion  of  viscera,  by  the  appearance  of  stomach-contents 
in  the  wound,  or  by  a  flow  of  bile,  urine,  or  feces  from  the  wound.  If  none 
of  the  above  indications  exists,  and  if  there  are  no  signs  of  serious  hemorrhage, 
the  wound  should  be  irrigated  with  hot  salt  solution,  and  should  be  dressed 
with  gauze,  and  every  effort  should  be  made  to  bring  about  reaction. 

When  reaction  is  obtained,  the  wound  should  be  enlarged  layer  by  layer 
until  it  becomes  obvious  whether  the  peritoneum  is  open  or  not.  Madelung, 
of  Strassburg,  points  out  that  incision  layer  by  layer  will  be  of  no  use  in 
settling  the  question  of  penetration  if  the  wound  is  in  the  chest,  the  buttock, 
the  perineum,  or  the  back  of  a  fat  individual.!  If  after  incision  layer  by 
layer  it  becomes  evident  that  penetration  has  not  occurred,  the  wound  should 
be  clo.sed  and  treated  on  general  principles.  If  it  becomes  evident  that  it 
has  occurred,  the  abdomen  should  be  opened  at  the  point  of  penetration, 
and  a  thorough  exploration  of  intra-abdominal  structures  should  be  made 
in  order  to  determine  the  injury  and  be  able  to  treat  it  properl\-. 

In  a  case  still  doubtful  after  incision  layer  by  layer,  do  an  exploratory 

*  Annals  of  Surgery,  March,  1902.  f -'^"ri^l»  of  Surgery,  Sept.,  1897. 


702  Diseases  and   Injuries  of  the  Abdomen 

laparotomy  in  the  middle  line.  It  is  impossible  to  affirm  from  the  appear- 
ance of  the  wound  and  from  the  symptoms  that  visceral  injury  has  not  oc- 
curred; hence,  in  every  penetrating  wound  in  civil  practice  perform  explora- 
tory laparotomy. 

In  every  case  in  which  it  is  evident  that  penetration  has  occurred  laparot- 
omy is  necessary  in  order  to  detect  and  correct  intra-abdominal  injury,  and 
clean  the  peritoneum  by  flushing  with  hot  salt  solution.  If  viscera  protrude, 
they  must  be  washed  off  with  hot  salt  solution  and  covered  with  hot  sterile 
pads,  and  after  the  patient  has  reacted  the  wound  should  be  enlarged,  the 
condition  of  the  contents  of  the  abdomen  investigated,  hemorrhage  arrested, 
wounds  properly  treated,  and  the  viscera  returned. 

It  is  customary  to  flush,  the  belly  with  hot  salt  solution,  some  of  the  fluid 
being  allowed  to  remain.  This  proceeding  mechanically  cleanses  the  perito- 
neum, removes  blood-clots,  and  strongly  combats  shock.  It  is  not  absolutely 
necessary  to  flush  out  the  belly  unless  a  considerable  hemorrhage  has  occurred 
or  feces  or  stomach- contents  have  been  extra vasated.  If  extravasation  of 
stomach-contents  or  feces  has  occurred,  not  only  should  flushing  be  practised, 
but  evisceration  should  be  carried  out;  the  fouled  intestine  should  be  wiped  off 
with  gauze  pads  wet  with  hot  salt  solution,  and  be  wrapped  in  hot  moist  towels; 
the  peritoneal  fossae  should  be  rubbed  with  gauze  pads  and  the  space  between 
the  liver  and  diaphragm  should  be  carefully  wiped. 

A  wound  of  the  stomach  should  be  sutured;  a  wound  of  the  bowel  may  be 
sutured,  or  resection  and  anastomosis  or  resection  and  end-to-end  suturing  may 
be  required.  Visceral  injuries  are  treated  by  appropriate  means.  In  a 
punctured  wound  or  a  gunshot-wound  of  the  intestine,  rectal  insufflation  of 
hydrogen  gas  may  disclose  the  nature  of  the  injury,  but  evisceration  may  be 
required. 

After  the  completion  of  intra-abdominal  manipulations  the  surgeon  re- 
stores any  protruding  bowel. 

Drainage  is  required  when  the  contents  of  the  stomach  or  the  intestines  have 
escaped,  when  hemorrhage  is  severe,  or  when  the  liver,  pancreas,  kidney,  or 
spleen  is  found  to  be  damaged.  The  peritoneum  may  be  sutured  with  a  con- 
tinuous suture  of  catgut,  and  the  muscles,  fascia,  and  skin  with  interrupted 
sutures  of  silkworm-gut,  or  through-and-through  sutures  of  silkworm-gut  may 
be  used.  Active  stimulation  and  artificial  heat  are  needed  immediately  after 
the  operation  to  combat  shock.  In  many  cases  intravenous  infusion  of  hot 
normal  salt  solution  is  of  great  value.  It  may  be  given  both  during  and  after 
operation.  Enteroclysis,  or  high  rectal  injection  of  hot  sahne  fluid,  is  useful. 
So  is  hypodermoclysis,  or  the  subcutaneous  injection  of  hot  salt  solution.  The 
after-treatment  consists  of  rest,  avoidance  of  food  by  the  stomach  for  forty- 
eight  hours,  and  the  administration  of  brandy  and  water  from  time  to  time. 
For  two  days  the  patient  should  be  fed  by  the  rectum.  On  the  appearance  of 
the  first  sign  of  peritonitis,  forty-eight  hours  or  more  after  the  operation,  give 
a  saline  cathartic.  It  is  not  wise  to  purge  during  the  first  forty-eight  hours 
after  the  operation,  unless  a  Murphy  button  was  used.  When  there  is  no 
sign  of  peritonitis,  a  purge  should  not  be  given  until  the  fourth  day.  After 
forty-eight  hours  liquid  food  can  usually  be  given  by  the  stomach.  Solid  food 
may  be  given  after  seven  or  eight  days,  but  the  patient  must  not  leave  his  bed 
until  the  wound  is  firmly  united,  because  of  the  danger  of  ventral  hernia.     A 


Gunshot-wounds   of  the   Pregnant  Uterus  703 

support  should  be  worn  for  a  long  time.  E.  D.  Fenner  *  reports  39  stab 
wounds  of  the  abdomen  operated  upon  in  the  Charity  Hospital  of  New 
Orleans.     There  were  9  deaths  (23.07  per  cent.). 

Qunshot=WOunds  of  the  Abdomen. — The  bullet  may  penetrate  from 
the  front,  the  side,  the  back,  the  chest,  or  the  perineum.  If  a  bullet  has  pene- 
trated, it  may  or  it  may  not  have  produced  visceral  damage.  A  pistol-bullet 
or  the  bullet  of  a  sporting-rifle  usually  does;  a  projectile  of  a  modern  military 
rifle  may  not  or  may  produce  wounds  which  can  be  recovered  from  without 
operation.  A  urinary  examination  should  be  made  promptly  to  see  if  blood 
is  present. 

In  gunshot  wounds  of  the  belly  shock  is  usually  due  to  hemorrhage,  and  in 
civil  practice  certainly  prompt  operation  is  indicated.  The  incision  is  made 
through  the  belly  even  when  the  shot  entered  the  back.  In  some  cases  the 
opening  is  made  through  the  wound;  in  others  it  is  not;  but  in  every  case  the 
wound  is  explored  and  cleaned.  After  opening  the  abdomen  our  first  duty 
is  to  arrest  hemorrhage,  our  next  is  to  look  for  perforations  of  the  viscera  and 
mesentery  and  close  them.  If  the  anterior  wall  of  the  stomach  is  perforated, 
close  the  opening  and  examine  the  posterior  wall  through  an  opening  made  in 
the  gastro-cohc  omentum.  If  a  posterior  perforation  is  found,  close  it  and 
insert  posterior  drainage  into  the  lesser  peritoneal  cavity.  As  a  rule,  an  in- 
testinal perforation  can  be  closed,  but  occasionally  considerable  intestine  re- 
quires resection.  If  the  bullet  is  encountered  it  is  removed,  but  a  prolonged 
search  for  it  should  never  be  made.  Finally  the  abdominal  cavity  is  cleansed, 
drainage  is  provided  for,  and  the  abdominal  wound  is  closed. 

E.  D.  Fenner  f  reports  113  gunshot-wounds  of  the  abdomen,  operated 
upon  in  the  Charity  Hospital  of  New  Orleans;  there  were  78  deaths  (69  per 
cent.).  • 

Military  surgeons  have  shown  that  wounds  inflicted  by  the  modern  hard- 
jacketed  projectile  are  not  so  apt  to  involve  fatal  hemorrhage  and  disastrous 
complications;  in  fact,  such  wounds  are  often  recovered  from  w'ithout  opera- 
tion, and  sometimes  with  an  entire  absence  of  serious  symptoms.  Again,  it  is 
difficult  or  impossible  to  treat  such  cases  as  in  civil  practice,  even  were  it  de- 
sirable. In  fact,  in  military  practice  the  results  are  slightly  better  from  ex- 
pectant treatment,  whereas,  in  civil  practice,  the  reverse  is  true.  Still,  even  in 
war,  if  conditions  permit,  operation  should  be  performed  if  there  is  hemorrhage 
or  obvious  visceral  injury,  or  if  septic  peritonitis  develops. 

Qunshot=wounds  of  the  Pregnant  Uterus.— It  is  rarely  that  both 
walls  are  perforated,  as  the  force  of  the  bullet  is  greatly  lessened  by  the  uterine 
contents.  As  a  rule,  there  is  severe  shock  and  hemorrhage,  and  occasionally 
amniotic  fluid  flows  from  the  wound  of  entrance.  The  intestine  may  also  be 
injured.  As  a  rule,  labor  pains  come  on  soon  after  the  injury.  Gellhorn  % 
has  collected  18  cases.  In  this  series  there  were  12  recoveries.  The  proper 
treatment  early  in  pregnancy,  if  the  wound  is  small,  consists  in  emptying  the 
uterus  and  closing  the  wound.  A  large  wound,  or  anv  wound  late  in  preg- 
nancy, demands  the  Porro  operation. 

*Annal.s  of  Surgery,  Jan.,  1902.  f  Annals  of  Surgery,  Jan.,  1902. 

J  St.  Louis  Med.  Review,  Dec.  2  and  9,  1901. 


704  Diseases  and    Injuries   of   tlie   Abdomen 

Stomach  and  Intestines. 
Foreign  Bodies  in  the  Stomach  and   Intestine.— Foreign  bodies 

of  considerable  size  are  rarely  taken  into  the  alimentary  canal  except  by  chil- 
dren, insane  people,  or  drunkards.  Most  foreign  bodies  swallowed  are  passed 
with  the  feces,  but  some  lodge.  Any  body  which  can  pass  the  esophagus  is 
not  too  large  to  pass  through  the  intestines.  Lodgment  is  an  accident,  not  an 
inevitable  consequence — an  accident  which  is  due  to  the  shape  and  size  of  the 
body.  A  foreign  body  may  lodge  in  the  stomach.  In  some  cases  there  are  no 
symptoms.  In  other  cases  symptoms  are  violent.  The  severity  of  the  symp- 
toms depends  upon  the  shape  and  character  of  the  body. 

In  some  cases  it  is  possible  to  feel  the  body  from  without.  A  metal  body 
in  the  stomach  will  deflect  a  magnetic  needle  held  over  the  viscus  (Polaillon). 
Many  foreign  bodies  can  be  skiagraphed.  It  is  not  wise  to  attempt  to  recover 
the  body  by  inducing  vomiting.  In  some  cases  gastrotomy  is  necessary. 
When  a  foreign  body  has  been  swallowed,  the  usual  treatment  is  as  follows: 
a  purgative  should  never  be  given  to  expedite  the  passage  of  a  foreign  body, 
because  increased  peristalsis  means  increased  danger  of  impaction  or  of  per- 
foration. Endeavor  to  encrust  the  foreign  body,  and  thus  lessen  the  danger  of 
perforation,  by  feeding  with  bread  and  milk  only  for  several  days,  and  at  the 
end  of  this  period  give  a  mild  laxative.  An  exclusive  diet  of  mush  or  of  mashed 
potatoes  has  been  suggested.  Pain  is  relieved  by  opium.  A  foreign  body 
rarely  lodges  in  the  duodenum,  but  may  lodge  lower  down,  and  may  cause 
ulceration,  perforation,  abscess,  or  intestinal  obstruction.  Operation  may  be 
necessary  in  such  cases. 

Carcinoma  of  the  Stomach. — Innocent  tumors  and  sarcomata  oc- 
casionally attack  the  stomach,  but  they  are  infinitely  rare  in  comparison  with 
primary  cancer.  This  disease  is  unusual  before  the  age  of  forty  and  is  prac- 
tically never  seen  before  the  age  of  thirty.  It  is  more  common  in  men  than 
in  women,  the  proportion  being  as  5  to  4.  In  a  very  few  instances  cancer 
has  been  found  to  have  arisen  from  an  ulcer.  The  forms  of  cancer  met 
with,  set  forth  in  their  order  of  frequency,  are,  according  to  Osier,  epithelioma, 
encephaloid,  scirrhus,  and  colloid.  Cancer  may  be  limited  to  the  body  of 
the  stomach  (either  curvature  or  either  wall),  the  pyloric  end,  or  the  cardiac 
end;  but  it  may  involve  two  of  these  regions,  or  almost  the  entire  stomach, 
or,  being  multiple,  may  be  found  in  many  parts.  It  is  usually  fatal  in  from 
four  months  to  two  years,  and  most  patients  die  within  one  year.  In  60 
per  cent,  of  cases  the  pylorus  is  involved.  In  over  half  of  the  cases  of  cancer 
of  the  pylorus  there  is  no  important  lymphatic  involvement  (McArdle).  In  in- 
vestigating any  gastric  disorder,  follow  Ma}-()'s  advice,  and  study  the  history, 
the  size  and  situation  of  the  stomach,  determine  the  existence  and  situation  of 
pain  and  tenderness,  the  presence  of  a  tumor,  and  if  the  passage  of  food  is  in- 
terfered with. 

Symptoms. — Examine  with  care  a  y)atient  in  whom  cancer  is  suspected. 
In  unusual  cases  it  produces  no  symptoms  until  it  has  lasted  for  some  time 
and  has  attained  a  large  size.  In  nearly  all  cases  it  does  produce  symptoms. 
The  disease  comes  on  gradually,  usually  with  indigestion  and  physical  weak- 
ness. The  patient  has  persistent  dragging  pain,  which  is  increased  by  eating 
and  yjressure,  and  attacks  of  vomiting  are  frequent.     After  a  short  time  the 


Carcinoma   of   the   Stomach  705 

patient  becomes  very  weak  and  excessively  anemic,  and  it  is  often  possible 
to  feel  a  tumor  in  the  stomach.  Blood  examination  shows  diminution  of  red 
corpuscles  and  hemoglobin,  and  absence  of  any  increase  of  leukocytes  after 
a  full  meal.  The  vomiting  of  gastric  cancer  is  at  first  only  occasional,  but  as 
tlie  case  progresses  it  becomes  more  and  more  frequent.  Vomiting  soon  after 
eating  occurs  when  the  cardiac  region  is  involved;  vomiting  an  hour  or  so  after 
eating  occurs  when  the  pyloric  end  is  involved.  When  the  body  of  the  organ 
is  the  seat  of  disease,  vomiting  may  be  absent.  The  vomited  matter  is  often 
mixed  with  a  small  amount  of  altered  blood  (coffee-ground  vomit).  In  most 
cases  free  hydrochloric  acid  is  not  found  in  the  stomach,  but  lactic  acid  is  found 
and  Oppler's  bacillus  can  often  be  detected.  If  the  cancer  is  not  ulcerated, 
free  hydrochloric  acid  will  probably  be  found;  if  it  is  ulcerated,  it  will  usually  be 
absent.*  Free  hydrochloric  acid  may  be  absent  from  the  stomach  because  of 
atrophy  of  glands,  cessation  of  secretion,  or  neutralization  by  the  products  of 
the  cancerous  area.  Free  hydrochloric  acid  may  be  absent  when  cancer  does 
not  exist.  I  have  noted  its  absence  in  two  cases  of  cicatricial  stenosis  of  the 
pylorus. 

Distend  the  stomach  with  gas  or  fluid  and  map  out  its  outlines.  Feel  for  a 
tumor.  A  tumor  can  usually  be  felt  if  it  involves  the  greater  curvature,  or 
anterior  wall,  and  a  large  tumor  of  the  pylorus  can  be  palpated,  but  in  other 
regions  the  tumor  can  rarely  be  felt.  Give  a  test-meal,  siphon  off  the  contents 
of  the  stomach,  and  examine  for  free  hydrochloric  acid,  lactic  acid,  and 
Oppler's  bacilli.  Ewald's  test-breakfast  is  usually  employed.  It  consists  of  a 
dry  roll  and  three-fourths  of  a  pint  of  weak  tea  or  warm  water.  It  is  given  on 
an  empty  stomach.  After  an  hour  the  stomach-tube  is  introduced.  The  fluid 
is  removed  by  a  pump  or  by  abdominal  compression. 

Cancer  of  the  cardiac  end  interferes  with  the  entrance  of  food  into  the 
stomach,  and  in  such  a  case  the  stomach  is  shrunken  and  the  esophagus  is 
dilated  immediately  above  the  growth.  In  cancer  of  the  pylorus  the  food  is 
partially  or  completely  arrested  as  it  passes  to  emerge  from  the  stomach,  and 
the  stomach  becomes  much  dilated.  The  vomited  matter  in  a  case  of  cancer 
rarely  contains  recognizable  fragments  of  the  growth,  but  fluid  with  which 
the  stomach  has  been  irrigated  may  contain  pieces  which  can  be  identified 
as  cancer  (Rosenbach). 

In  cancer  of  the  stomach  the  general  course  of  the  temperature  is  normal, 
but  there  are  occasional  deviations  to  below  or  above  normal.  In  many  cases 
the  urine  contains  albumin,  indican,  acetone,  and  casts.  Occasionally 
cancer  of  the  stomach  produces  spasm  of  the  esophagus.  I  have  seen  this 
in  two  cases.  Cancer  of  the  stomach  is  apt  to  involve  secondarily  adjacent 
lymph-glands,  or  organs  or  other  structures,  especially  the  liver;  in  fact, 
the  liver  is  involved  in  30  per  cent,  of  the  cases  (Welch).  Occasionally  there 
is  enlargement  of  the  supraclavicular  glands  of  the  left  side.  Metastases  are 
usual  and  early,  but  in  cancer  of  the  pylorus  over  half  the  cases  show  no 
distinct  lymphatic  involvement.  In  many  doubtful  cases  exploratory  incision 
is  justifiable. 

Treatment. — The  medical  treatment  consists  in  milk-diet,  and  the  use  of 
morphin  and  of  lavage  if  the  pylorus  or  body  of  the  stomach  is  diseased.  Per- 
form lavage  as  follows:  The  tube  for  lavage  should  be  long  enough  to  extend 

*Reissner.  in  Miinchen.  med    Woch.,  Dec.  3,  1901. 
45 


7o6  Diseases  and   Injuries  of   the  Abdomen 

about  three  feet  out  of  the  mouth  when  the  other  end  is  in  the  stomach,  it 
should  be  flexible,  should  have  an  opening  in  the  stomach-end  and  another 
opening  on  the  side  about  one  inch  above  the  stomach-end.  The  tube  should 
be  greased  with  glycerin.  The  patient  sits  down,  throws  the  head  back,  opens 
the  mouth  widely,  and  is  directed  to  take  deep  breaths  at  regular  intervals. 
The  tube  is  carried  into  the  pharynx,  the  patient  is  ordered  to  make  efforts  to 
swallow  it,  and  the  tube  is  thus  taken  into  the  stomach.  About  one  quart  of 
fluid  is  poured  into  the  funnel-hke  end  of  the  tube,  and  just  before  the  tube 
empties  itself  of  the  last  of  the  water  the  funnel  is  lowered  and  the  fluid  runs 
out.  This  proceeding  is  repeated  till  the  fluid  becomes  clear.  The  best  fluid 
to  use  is  a  solution  of  bicarbonate  of  sodium,  a  teaspoonful  of  the  salt  to  a 
quart  of  warm  water.  Lavage  should  be  practised  before  breakfast,  and 
sometimes  also  at  bed-time. 

The  indications  jor  operation  are  well  set  forth  by  Macdonald:  They  are 
progressive  aggravation  of  symptoms  in  spite  of  a  rigid  diet  and  medical 
treatment,  loss  of  gastric  mobility,  progressive  diminution  of  gastric  peris- 
talsis, progressive  diminution  of  free  hydrochloric  acid,  emaciation  even 
under  forced  feeding,  progressive  reduction  of  hemoglobin  to  65  per  cent,  or 
under,  and  moderate  leukocytosis.* 

Surgical  treatment  aims  to  remove  the  growth,  or  to  obviate  the  effect 
of  obstruction  at  one  of  the  orifices  of  the  stomach. 

In  cancer  of  the  body  of  the  stomach,  if  the  growth  is  not  extensive,  e.x- 
cision  may  be  performed ;  if  it  is  extensive,  it  is  useless  to  attempt  it  unless  the 
growth  is  absolutely  non-adherent.  Schlatter,  of  Zurich;  Brigham,  of  San 
Francisco;  Richardson,  of  Boston;  Macdonald,  of  San  Francisco;  Boeckel, 
of  France;  and*  De  Carvalho,  of  Brazil,  and  others  have  successfully  re- 
moved the  entire  stomach  and  attached  the  esophagus  to  the  small  intestine. 
In  these  cases  digestion  was  satisfactorily  performed  after  removal  of  the 
stomach.  Very  rarely  will  cases  be  found  suitable  for  such  a  radical 
proceeding.  The  case  suitable  for  this  treatment  is  one  in  which  the  entire 
stomach  is  involved  in  the  growth,  in  which  there  is  no  obvious  glandular  in- 
volvement, and  in  which  the  stomach  is  not  adherent  but  is  freely  movable. 
In  limited  cancer  of  the  body  of  the  stomach  perform  partial  gastrectomy. 
In  cancer  of  the  cardiac  orifice  of  the  stomach  the  surgeon  usually  keeps  the 
passage  open  as  long  as  possible  by  the  frequent  passage  of  a  tube,  and  through 
this  tube  introduces  liquid  food.  Sometimes  a  small  tube  is  introduced  and 
permanently  retained.  When  it  becomes  difficult  to  introduce  a  tube,  gas- 
trostomy may  be  performed.  As  a  matter  of  fact,  in  most  cases  gastrostomy  is 
done  as  a  last  resort,  and  it  is  scarcely  worth  doing  in  cancer  of  the  cardiac  end 
of  the  stomach.  It  is  far  more  useful  in  cancer  of  the  esonhagus.  In  cancer 
of  the  pylorus  limited  in  extent  and  without  lymphatic  involvement,  pylorec- 
tomy  may  be  performed;  but  in  cancer  which  has  widely  infiltrated  the  coats  of 
the  stomach  and  has  involved  the  lymphatic  glands,  gastro-enterostomy  is 
performed  as  a  palliative  measure,  the  patient  during  the  rest  of  his  life  sub- 
sisting upon  liquid  or  semiliquid  foods  and  submitting  to  frequent  irrigation  of 
the  stomach  to  remove  food-residue.  In  cases  of  irremovable  cancer  it  is 
usually  best  to  create  the  opium-habit. 

The  most  .successful  of  all  the  above  operations  is  pylorcctomy  or  partial 

*John  B.  Muryjhy,  in  Chicago  Med.  Recorder,  June  15,  1902. 


Peptic   Ulcer  of  the   Stomach  707 

gastrectofny.  There  are  in  literature  43  cases  which  have  survived  three 
years  or  over  (Macdonald).  Mayo  reported  21  gastro-enterostomies  for  cancer 
with  4  deaths.  The  greatest  prolongation  of  hfe  was  nineteen  months.  His 
experience  makes  him  question  if  the  operation  is  worth  doing  in  malignant 
disease. 

Sarcoma  of  the  Stomach. — Of  recent  years  it  has  been  proved  that 
sarcoma  is  more  common  than  was  once  supposed.  There  are  over  60  cases 
on  record.  It  can  occur  at  any  age,  but  is  more  usual  in  early  life  than  is  car- 
cinoma. It  has  been  estimated  by  Wm.  T.  Howard  *  that  37.7  per  cent,  of 
cases  are  under  the  age  of  forty,  and  11.44  per  cent,  are  under  the  age  of 
twenty.  The  yjylorus  is  involved  in  about  one-fourth  of  the  cases.  In  most 
cases  the  posterior  wall  and  greater  curvature  are  involved.  Howard  says 
there  is  a  diffuse  growth  in  21.31  per  cent,  of  cases  and  that  the  cardiac  end  is 
involved  in  only  4.9  per  cent,  of  cases.  Sarcoma  arises  in  the  submucous 
coat.  Any  form  of  sarcoma  may  arise.  It  causes  stenosis  in  less  than  one- 
tenth  of  the  cases.  There  is  no  se.\  p)redisposition  in  sarcoma,  as  there  is  in 
cancer. 

Symptoms. — A  tumor  forms,  grows  rapidly,  and  often  attains  a  large  size, 
and  not  unusually  actually  causes  a  projection  of  the  abdominal  wall.  If  it 
ulcerates,  there  will  be  hematemesis,  but  it  often  does  not  ulcerate,  and  bleed- 
ing is  much  rarer  than  in  carcinoma.  Not  unusually  this  growth  arises  in  a 
person  under  forty,  and  sometimes  in  one  of  less  than  twenty  years  of  age. 
Stenosis  is  uncommon.  The  liver  is  involved  secondarily  in  only  11.47  per 
cent,  of  cases  (Howard),  metastases  are  more  rare  than  in  carcinoma,  free  hy- 
drochloric acid  is  usually  absent  from  the  gastric  contents,  and  microscopic 
examination  of  washings  from  the  stomach  may  detect  fragments  of  sarcoma. 
Certain  diagnosis  is  impossible  without  exploratory  incision.  Howard  esti- 
mates the  average  duration  of  life  to  be  from  nine  to  ten  months. 

Treatment. — If  the  liver  is  free  and  if  there  are  no  metastases,  partial 
gastrectomy  or  complete  gastrectomy  may  be  advisable.  If  there  is  pyloric 
stenosis,   gastro-enterostomy   may  be   performed. 

Peptic  Ulcer  of  the  Stomach.— Ulcer  of  the  stomach  is  a  con- 
dition due  to  digestion  of  a  portion  of  the  stomach-wall  by  very  acid  gastric 
juice,  the  destroyed  portion  having  been  the  seat  of  lowered  vitality.  The 
reason  for  the  lowered  vitality  of  the  gastric  mucous  membrane  is  uncertain. 
Thrombosis  has  been  suggested  as  a  cause,  but  it  is  rare  in  gastric  ulcer. 
Embolism  is  assigned  by  some  as  a  cause,  but  emboli  are  seldom  found  bv 
pathologic  examination.  Some  observers  blame  infection;  others  direct 
damage  to  the  mucous  membrane,  but  the  question  is  involved  in  uncertainty. 
What  does  seem  to  be  certain  is  that  anemia  strongly  predisposes  to  the  forma- 
tion of  very  acid  gastric  juice  (hyperchlorhydria)  and  to  ulceration. 

Ulcers  are  more  common  in  females  than  in  males,  and  are  more  frequent 
in  young  women  than  in  those  of  middle  or  advanced  age.  Men  about  forty 
and  women  between  twenty  and  thirty  are  particularly  liable.  There  is  usually 
a  single  ulcer,  but  in  some  cases  there  are  two  or  more.  The  ulcer  may  heal 
or  may  perforate."  The  most  common  seats  of  ulcer  are  the  posterior  wall  and 
lesser  curvature,  especially  in  the  pyloric  region.  Only  2  per  cent,  of  ulcers  on 
the  posterior  wall  perforate,  as  they  tend  to  form  adhesions  to  adjacent  struc- 

*Jour.  Am.  Med.  Assoc,   Feb.  8,  1902. 


7o8  Diseases  and   Injuries  of   the  Abdomen 

tures  (Alderson).  Ulcers  on  the  anterior  wall  are  unusual,  do  not  tend  to 
form  adhesions,  and  are  apt  to  perforate.  Disorder  of  menstruation  may 
develop  ulcer,  so  may  tight  lacing,  and  habitually  bending  o\'er,  as  in  making 
shoes.  Chlorosis  is  associated  with  ulcer  in  many  cases.  Traumatism  and 
swallowing  corrosive  liquid  may  lead  to  ulceration.  Alderson  believes  that 
alcoholism,  syphilis,  and  mental  anxiety  may  lead  to  the  condition.  Ulcers 
due  to  syphilis  and  tubercle  are  not,  be  it  remembered,  peptic  ulcers. 

Symptoms. — Acid  dyspepsia  exists,  associated  with  much  flatulence.  In 
most  cases,  though  not  in  all,  food  aggravates  the  condition.  In  many  of  these 
patients  vomiting  occurs  about  two  hours  after  eating.  The  vomited  matter 
contains  much  hydrochloric  acid.  Hemorrhage  from  the  stomach  occurs  in 
about  one-half  of  the  cases.  The  blood  may  be  brought  up  with  food,  and  is 
then  black  and  clotted,  or  may  be  vomited  clear  and  in  large  amount.  In 
hemorrhage  from  an  acute  ulcer  a  pint  or  two  may  be  ejected  in  a  few  minutes, 
and  such  a  patient  presents  all  of  the  general  symptoms  of  dangerous  hemor- 
rhage. In  some  cases  blood  from  the  stomach  is  passed  by  the  bowels  in  part 
or  wholly.  A  very  large  hemorrhage  may  occur,  and  yet  the  bleeding  never  be 
repeated,  or  a  large  hemorrhage  may  be  followed  by  another  or  be  the  first 
of  three  or  of  a  series.  In  a  great  many  cases  after  a  large  hemorrhage  there 
is  no  further  bleeding  or  there  are  subsequently  a  few  small  hemorrhages. 
Small  hemorrhage  may  recur  indefinitely  and  may  after  a  time  eventuate  in 
a  large  hemorrhage.  In  chronic  small  hemorrhages  recurring  over  a  long 
period  the  condition  is  due  to  the  erosion  of  small  vessels  which  cannot  contract 
and  retract  because  they  are  imbedded  in  fibrous  tissue.  A  large  hemorrhage 
may  be  due  to  the  erosion  of  a  large  vessel,  but  is  often  produced  by  the  ex- 
istence of  a  great  number  of  erosions  of  the  mucous  membrane,  erosions  per- 
haps so  numerous  that  blood  seems  to  pour  from  every  portion  of  mucous 
surface.  In  a  sudden  acute,  violent  hemorrhage  there  will  probably  be  no 
history  of  antecedent  stomach  trouble.  In  ulcer  paroxysmal  pain  exists, 
which  is  usually,  but  not  invariably,  aggravated  by  taking  food.  The  pain 
is  very  violent  in  the  abdomen,  and  also  passes  to  the  back,  being  located  be- 
tween the  eighth  and  ninth  dorsal  vertebrae. 

In  gastric  ulcer  it  is  usual  to  find  tenderness  developed  by  abdominal 
pressure. 

If  the  ulcer  does  not  cicatrize,  but  progresses,  causing  pain  and  hemorrhage, 
the  patient  becomes  thinner,  more  anemic,  weak,  and  even  exhausted. 

It  is  certain  that  many  cases  of  gastric  ulcer  are  unrecognized ;  in  fact,  as 
Habershon  says,  diagnosis  is  rarely  made  unless  hemorrhage  exists,  and  in 
certain  latent  cases  both  vomiting  and  bleeding  are  ab.sent.  It  is  believed  that 
latent  ulcers  are  even  more  common  than  are  ulcers  causing  symptoms. 

A  gastric  ulcer  may  cicatrize  and  thus  be  cured,  but  the  cure  of  the 
ulcer  may  prove  the  ruin  of  the  stomach  by  producing  stenosis  of  one  of  the 
stomach-orifices  or  hour-glass  contraction  of  the  body  of  the  stomach.  An 
ulcer  may  perforate.  A  perforation  may  be  acute;  that  is,  the  ulcer  sud- 
denly breaks  open  when  the  stomach  contains  food  or  liquid,  and  the  con- 
tents of  the  stomach  are  yjoured  into  the  free  peritoneal  cavity.  If  a  per- 
foration occurs  when  the  stomach  is  empty  or  nearly  empty,  there  is  no  escape 
of  .stomach-contents  or  the  escape  of  only  a  small  amount,  and  the  opening  may 
be  quickly  closed  by  adhesions  or  by  a  piece  of  omentum.     In  what  is  known 


Peptic   Ulcer   of  the   Stomach  709 

as  a  chronic  perforation  the  break  takes  place  into  a  box  of  preformed  ad- 
hesions, the  extruded  gastric  contents  are  circumscribed  by  these  adhesions, 
the  general  peritoneal  cavity  is  not  invaded,  but  circumscribed  suppuration  is 
inaugurated.* 

Perforation  is  usuallybrought  about  by  muscular  effort  and  is  most  common 
after  a  full  meal.  ''The  severity  of  the  symptoms  depends  upon  several  con- 
ditions: the  previous  state  of  health,  the  size  and  number  of  the  perforations, 
the  condition  of  the  stomach,  whether  full  or  almost  empty,  the  bacterial 
virulence  of  its  contents,  and  the  occurrence  of  vomiting,  "f  The  situation  of 
the  ulcer  has  some  influence  on  the  symptoms.  ''  If  in  the  fundus,  at  the 
cardiac  end,  or  in  the  body  of  the  stomach,  an  acute  infection  of  the  whole 
peritoneal  cavity  rapidly  follows;  if  the  ulcer  be  at  the  pylorus  or  in  the  first 
portion  of  the  duodenum,  the  fluid  is  directed  down  the  right  side  of  the  abdo- 
men, owing  to  the  hillock  formed  by  the  transverse  mesocolon  at  the  pyloric  end 
of  the  stomach"  (Moynihan).  In  such  a  case  the  fluid  may  gravitate  toward 
the  right  iliac  region  and  the  condition  may  be  mistaken  for  appendicitis.  In 
one  such  case  I  operated,  believing  that  appendicitis  existed.  Alderson  calls 
attention  to  the  fact  that  the  sudden  perforation  of  an  ulcer  may  be  mistaken 
for  poisoning,  and  he  cites  the  death  of  the  Duchess  of  Orleans  in  1670. 

Acute  perforation  can  usually  be  certainly  diagnosticated  if  the  case  is  seen 
early.  Perforation  causes  sudden  and  violent  epigastric  pain,  greatly  in- 
creased by  swallowing  fluids,  by  vomiting,  and  by  pressure.  This  pain  may 
radiate  throughout  the  abdomen,  but  the  chief  tenderness  is  in  the  region  of  the 
stomach.  The  collapse  is  usually  profound.  In  some  cases  death  takes  place 
quickly,  but  as  a  rule  reaction  occurs  and  peritonitis  develops.  Vomiting  is  rare 
after  rupture.  When  it  does  occur,  it  does  much  harm  by  increasing  shock 
and  by  ejecting  gastric  contents  into  the  peritoneal  cavity.  Vomiting  of  blood 
is  very  unusual.  Rigidity  exists  and  it  is  most  marked  in  the  upper  portion  of 
the  abdomen.  The  area  of  liver-dulness  is  in  many  cases  diminished  or  ob- 
literated. Such  an  emergency  has  usually  but  not  invariably  been  preceded 
by  positive  and  prolonged  symptoms  of  gastric  disorder. 

Treatment. — Medical  Treatment  of  Noyi-perjorated  Ulcer. — Rest  in  bed. 
Rectal  feeding  for  a  time,  followed  by  the  use  of  a  bland  diet.  Lavage  twice 
a  day.  To  some  cases  Carlsbad  salts  are  given  (Ziemssen),  to  others  silver 
nitrate,  bismuth  subnitrate,  or  oxalate  of  cerium.  If  pain  is  severe,  opium 
is  required. 

Surgical. — In  a  chronic  ulcer  if  the  patient  grows  worse  in  spite  of  careful 
dietetic  and  medical  treatment,  if  hemorrhage  has  been  profuse  or  if  there  have 
been  frequent  distinct  hemorrhages,  if  the  pain  is  violent,  or  if  tenderness  is 
marked,  open  the  abdomen  and  inspect  the  stomach.  An  ulcer  mav  be  re- 
moved by  an  elliptical  incision  in  the  long  axis  of  the  stomach,  the  coats  being 
sutured  by  the  usual  method.  I  have  e.xtirpated  one  chronic  ulcer  with  satis- 
factory results.  In  some  cases  gastro-enterostomy  leads  to  the  cure  of  chronic 
ulcer.  In  an  acute  and  violent  hemorrhage  threatening  life  the  proper  course 
to  pursue  is  somewhat  uncertain.  It  is  not  proper  to  operate  for  one  hemor- 
rhage, because  the  chances  are  it  will  not  be  repeated.     .Again,  the  chance  of 

*  See  paper  by  B.  G.  A..  Moynihan,  Brit.  Med.  Jour.,  Jan.  31,  1903. 
t  Moynihan,  in  Brit.  Med.  Jour.,  Jan.  31,  1903. 
X  Provincial  Med.  Jour.,  Dec.  2,  1895. 


7IO  Diseases  and   Injuries  of   the  Abdomen 

arresting  such  a  hemorrhage  by  operation  is,  on  the  whole,  poor.  If  the  bleed- 
ing is  from  a  distinct  ulcer,  we  may  succeed  in  excising  or  in  ligating.  As  a  rule, 
however,  the  bleeding  is  not  from  a  distinct  point  but  from  a  multitude  of 
excoriations.  In  the  light  of  our  present  knowledge  we  may  lay  down  the 
following  rule :  Do  not  operate  for  one  acute  hemorrhage.  Simply  bring  about 
reaction  by  gentle  means,  let  the  patient  take  bits  of  ice,  and  give  suprarenal 
extract  by  the  stomach.  If  the  bleeding  recurs  once  or  twice  in  comparatively 
trivial  amounts,  do  not  operate;  but  if  it  recurs  violently,  we  should  advise 
operation.  The  surgeon  opens  the  abdomen  while  hot  salt  solution  is  being 
thrown  into  a  vein.  The  stomach  is  opened,  the  clot  washed  out,  and  a  search 
made  for  the  source  of  the  blood.  If  it  is  found  that  the  blood  comes  from  an 
area  of  ulceration,  this  area  should  be  extirpated  or  ligated.  If  it  is  found  that 
the  bleeding  comes  from  a  multitude  of  excoriations  and  that  the  stomach  is,  as 
Moynihan  expresses  it,  "weeping  blood,"  we  can  do  nothing  but  gastro- 
enterostomy, which  in  such  a  condition  is  of  uncertain  value.  In  perforation 
bring  about  reaction  from  shock  and  open  the  abdomen.  When  the  abdomen 
is  opened,  there  is  an  escape  of  odorless  gas,  and  food  or  fluid  may  be 
discovered  in  the  peritoneal  cavity.  The  perforation  is  sought  for  and  some 
surgeons  recommend  excision.  I  do  not  believe  that  excision  is  necessary. 
The  ulcer  should  be  buried  or  overlaid  with  stomach-wall  by  two  layers  of 
Halsted  sutures.  The  abdominal  cavity  is  irrigated  with  hot  salt  solution  and 
the  space  between  the  liver  and  diaphragm  is  sponged  out  with  a  gauze  pad 
wet  with  hot  salt  solution.  If  the  case  is  operated  many  hours  after  the  per- 
foration, or  if  the  peritoneum  was  badly  soiled,  drainage  must  be  used,  but 
even  in  other  cases  it  safest  to  use  it.  Of  late  a  number  of  cases  have 
been  successfully  operated  upon.  Moynihan  estimates  that  35-40  per  cent, 
of  acute  perforations  recover  after  operation. 

Cicatricial  stenosis  of  the  orifices  of  the  stomach  results  from 
the  healing  of  an  ulcer,  the  swallowing  of  a  corrosive  substance,  or  traumatism 
from  a  foreign  body.  Constriction  of  the  cardiac  orifice  is  indicated  by  grad- 
ually increasing  diii&culty  in  swallowing.  After  a  time  the  esophagus  above 
the  stricture  dilates  or  pouches;  the  fluid  food  passes  into  the  stomach,  but  the 
solid  food  lodges  in  the  esophageal  pouch  and  is  soon  regurgitated.  The  site 
of  the  stricture  is  located  by  a  bougie,  and  by  having  the  patient  swallow  while 
auscultating  over  the  esophagus  and  cardiac  end  of  the  stomach.  If  the  con- 
striction be  malignant,  the  patient  will  be  found  to  be  beyond  middle  life,  the 
vomit  is  occasionally  bloody,  emaciation  is  rapid  and  decided,  and  occasionally 
the  supraclavicular  glands  are  enlarged.  A  tumor  of  the  cardiac  end  of  the 
stomach  can  seldom  be  palpated.  If  the  constriction  be  cicatricial,  the  history 
will  indicate  the  cause.  Constriction  of  the  pyloric  orifice  causes  retention  of 
food  and  dilatation  of  the  stomach.  Dyspeptic  symptoms  will  be  found  to 
have  been  long  present.  A  tube  passed  into  the  stomach  permits  of  the  in- 
jection of  fluid  so  as  to  fiU  the  stomach.  When  the  fluid  runs  out  it  contains 
portions  of  undigested  food,  which  was  perhaps  eaten  days  before,  and  meas- 
urement of  the  liquid  shows  that  the  capacity  of  the  stomach  is  enormously 
increased.  If  hydrogen  be  forced  through  the  tube,  the  outline  of  the  distended 
stomach  is  at  once  made  clear.  The  usual  method  of  distending  the  stomach 
is  by  a  Seidlitz  powder:  two  solutions  are  made;  the  bicarbonate  solution  is 
swallowed   at   once,  and   the    tartaric   solution   is  taken   afterward  in   small 


Perigastric   Adhesions  yii 

amounts  at  a  time.  Percussion  over  the  distended  stomach  indicates  the 
size  of  the  viscus. 

In  malignant  disease  of  the  pylorus  a  tumor  may  often  l^e  made  out;  there 
are  tenderness  and  considerable  persistent  pain,  great  cachexia  and  emacia- 
tion, absence  of  free  hydrochloric  acid  from  the  gastric  juice,  diminution  of  red 
corpuscles  and  hemoglobin,  and  no  increase  of  white  corpuscles  after  a  full 
meal.  There  is  sometimes  enlargement  of  the  supraclavicular  glands.  Vom- 
iting of  bloody  fluid  occurs  in  40  per  cent,  of  cases.  Illumination  of  the 
stomach  by  the  gastrodiaphanoscope  may  aid  the  diagnosis,  the  area  of  malig- 
nant grov^'th  interfering  -w'lih.  the  transmission  of  light.  In  cicatricial  stenosis 
of  the  pylorus  there  may  be  paroxysms  of  pain,  there  is  no  tenderness,  emacia- 
tion is  not  so  rapid  in  onset,  and  the  supraclavicular  glands  are  never  enlarged. 
Vomiting  occurs,  but  the  ejected  matter  is  not  bloody. 

Treatment. — Cicatricial  cardiac  stenosis  requires  dilatation  with  bougies 
and  the  maintenance  of  the  restored  cahber.  If  dilatation  from  above  is 
unsatisfactory,  perform  a  gastrotoniy,  push  a  small  bougie  from  the  mouth 
into  the  stomach,  tie  a  string  to  the  bougie,  draw  the  string  through  the 
stricture,  use  the  string  as  a  saw  to  cut  the  fibrous  bands,  pass  a  full-sized 
bougie,  close  the  wound  in  the  stomach,  and  maintain  the  cahber  of  the 
cardiac  orifice  by  the  repeated  passage  of  dilating  instruments.  If  no  instru- 
ment can  be  passed  through  the  stricture  from  above,  perform  a  gastrotoniy, 
introduce  an  instrument  from  below  and  pass  it  into  the  mouth,  tie  a  string 
to  it,  draw  the  string  into  the  stomach,  and  use  Abbe's  string-saw.  If  no 
instrument  can  be  passed  from  below,  convert  the  gastrotomy  into  a  gas- 
trostomy. In  malignant  stenosis  of  the  cardia  gastrostomy,  if  performed  at 
all,  should  be  performed  early.  Cicatricial  pyloric  stenosis  was  once  treated 
by  a  gastrotomy  and  digital  divulsion  of  the  stricture  (Loreta's  operation); 
but  this  operation  is  obsolete,  experience  having  shown  that  recontraction 
is  inevitable.  Pyloroplasty  is  advocated  by  many  surgeons.  This  is  known 
as  the  Heineke-Mikuhcz  operation.  Occasionally  the  symptoms  are  not 
relieved  by  pyloroplasty,  a  condition  which  renders  gastro-enterostomy 
necessary.  Mayo  points  out  that  in  such  cases  pyloroplasty  fails  because 
the  pylorus  is  on  a  higher  level  than  the  gastric  pouch  and  the  degenerated 
muscle  of  the  stomach  is  unable  to  lift  the  food  from  the  pouch  to  the  pylorus 
and  the  symptoms  of  gastric  dilatation  and  retardation  of  the  passage  of 
food  into  the  duodenum  are  not  relieved.  Gastro-enterostomy  is  a  very 
satisfactory  operation,  and  usually  effects  a  cure.  Malignant  stenosis  is 
treated  by  pylorectomv  or  gastro-enterostomy.  (See  under  these  heads 
respectively.) 

Perigastric  Adhesions.— That  perigastric  adhesions  are  frequently 
responsible  for  stomach  pain  and  digestive  difficulty  is  undoubted.  Such 
adhesions  often  arise  in  cases  of  protracted  ulceration  of  the  stomach  or 
duodenum.  A  common  cause  of  perigastric  adhesions  is  gall-stone  disease. 
Tuberculous  peritonitis  causes  dense  adhesions.  In  some  cases  the  adhesions 
are  traumatic,  in  some  are  due  to  syphihs,  in  many  the  cause  is  uncertain 
(Fred.  D.  Bird,  "Intercolonial  Med.  Jour,  of  Australasia."  Dec.  20,  1900). 
Adhesions  may  cause  blocking  or  kinking  of  the  pylorus,  or  may  glue  the 
stomach  to  the  parietal  peritoneum  or  to  some  adjacent  viscus.  In  Fenwick's 
table  of  123  cases,  he  finds  that  the  adhesions  usually  cause  the  stomach  to 


712  Diseases  and   Injuries   of   the  Abdomen 

adhere  to  the  pancreas  or  to  the  hver.  The  formation  of  adhesions  in  cases 
of  gastric  ulcer  is,  in  many  instances,  conservative,  serving  to  prevent  perfora- 
tion or  to  prevent  extravasation  if  perforation  of  the  stomach-wall  occurs. 

Symptoms. — The  symptoms  are  variable.  In  some  cases  the  adhesions 
produce  httle  or  no  trouble;  but  in  the  majority  of  cases  they  cause  definite 
symptoms,  and  sometimes  the  condition  becomes  one  of  absolute  disable- 
ment. The  symptoms  may  be  due  to  blocking  of  the  pylorus,  a  condition 
that  is  followed  by  gastric  dilatation.  They  may  be  due  to  dragging  upon 
the  adhesions,  when  the  stomach  contracts  during  digestion,  or  when  peris- 
talsis occurs  in  an  adherent  piece  of  intestine. 

The  usual  symptom  is  pain,  frequently  of  a  violent  character.  The  pain 
comes  on  in  paroxysms,  and  recurs  over  and  over  again,  it  may  be  for  years. 
H.  Hale  White*  points  out  that  in  these  cases  there  is  usually  some  pain  persist- 
ing, which  is  now  and  then  increased  into  violent  paroxysms;  and  that  the  only 
other  condition  that  produces  persistent  pain  with  violent  exacerbations  is 
cancer.  In  adhesion-dyspepsia,  however,  there  is  no  distinct  loss  of  weight; 
the  condition  may  exist  in  youth,  as  well  as  in  middle  age  or  old  age;  it  is 
not  increased  by  taking  food;  and  it  very  rarely  causes  death.  If  there  is 
a  history  of  antecedent  gall-stone  disease  or  of  ulcer  of  the  stomach,  it  is 
possible  to  make  the  diagnosis  without  exploratory  operation.  Even  in  other 
cases,  the  condition  may  sometimes  be  diagnosticated;  because,  although 
there  are  these  attacks  of  violent  pain,  there  is  no  tenderness.  In  rare  cases, 
the  adhering  and  matting  together  with  inflammatory  exudate  produces  a 
palpable  mass.  In  doubtful  cases  of  chronic  and  disabling  stomach-disease, 
an  exploratory  operation  should  be  performed;  if  adhesions  exist,  they  will 
then  become  manifest. 

Treatment. — In  some  cases,  simply  dividing  an  adhesion  effects  a  cure; 
in  other  cases,  it  is  necessary  to  make  extensive  separation  of  adherent  struc- 
tures, covering  the  raw  surface  with  omental  grafts.  In  serious  adhesions 
about  the  pylorus,  gastro-enterostomy  is  usually  the  proper  operation. 

Bilocular    Stomach    (Hour=glass    Stomach).  — Some    few  cases 

are  congenital,  but  the  majority  are  acquired  and  result  from  adhesions 
produced  by  the  healing  of  an  ulcer.  In  hour-glass  stomach  with  a  large 
opening  between  the  two  sacs  there  may  be  no  symptoms.  W^ien  the  opening 
is  small,  the  symptoms  resemble  those  of  pyloric  stenosis.  The  sac  toward 
the  cardia  is  frequently  much  dilated.  G.  G.  Cumston  f  points  out  that 
in  a  congenital  bilocular  stomach  an  ulcer  is  apt  to  form  at  the  seat  of  con- 
striction. 

Symptoms. — The  diagnosis  of  cancer  is  often  made.  The  protracted 
chronic  gastritis  has  caused  free  hydrochloric  acid  to  disappear  and  acids 
of  fermentation  are  usually  found.  The  patient  vomits  from  time  to  time, 
bringing  up  food  which  was  eaten  a  day  or  two  before,  proof  that  food  is 
retained  in  the  stomach  and  not  fligested.  Occasionally  l>Iood  is  vomited. 
There  is  pain  and  the  patient  is  harassed  with  foul-smelling  eructations. 
Emaciation  is  pronounced.  Cumston  points  out  that  in  a  thin  belly  dis- 
tention of  the  stomach  may  make  the  condition  evident;  further,  that  if 
water  is  thrown  into  the  stomach  only  a  part  returns,  and  when  the  stomach 
is  emptied  as  much  as  possible  by  a  tube  a  splashing  sound  can  still  be  elicited 

*  Lancet,  Nov.  30,  1901.  f  Med.  News,  Dec.  7,  1901. 


Physical   Signs   of   Dilated   Stomach  713 

in  the  stomach  because  the  pyloric  pouch  is  not  empty.     One  cause  of  death 
is  torsion  on  the  axis.  * 

Treatment. — The  diagnosis  becomes  certain  only  after  exploratory  ope- 
ration, and  exploration  also  enables  the  surgeon  to  decide  with  certainty 
as  to  what  operation  should  be  performed.  Cumston  gives  us  the  following 
suggestions: 

1.  In  rare  cases  resect  the  stricture  and  suture  the  pouches. 

2.  If  there  is  trivial  ulceration  or  a  slight  scar,  do  an  operation  upon 
the  constriction  exactly  similar  to  pyloroplasty. 

3.  The  best  operation  in  most  cases  is  gastro-gastrostomy — that  is,  anas- 
tomosis of  the  cardiac  pouch  to  the  pyloric  pouch;  but  this  cannot  be  done 
if  the  pyloric  pouch  is  small.     Then  do  gastro-enterostomy. 

Other  operations  are : 

4.  Gastro-duodenostomy. 

5.  Gastro-jejunostomy. 

6.  Gastrolysis.  t 

Chronic  Dilatation  of  the  Stomach. — A  dilated  stomach,  roughly 

speaking,  is  one  which  can  contain  more  than  1.5  quarts  (Ewald).  Some 
few  cases  of  dilatation  result  directly  from  atrophy  of  the  muscular  coat, 
brought  about  by  drinking  quantities  of  liquid,  especially  beer;  chronic 
catarrh  of  the  stomach;  and  conditions  such  as  cancer,  tuberculosis,  dia- 
betes, etc.  The  common  cause  of  dilatation  is  constriction  of  the  pylorus. 
In  order  to  force  food  by  the  pyloric  narrowing  more  force  is  necessary  than 
is  required  in  a  normal  state  of  affairs  and  the  stomach  muscle  hypertro- 
phies. This  muscular  hypertrophy  is  compensatory,  and  dilatation  does  not 
occur  so  long  as  the  muscle  is  efficient.  But  finally  the  pyloric  opening 
becomes  so  narrow  that  compensation  fails,  the  stomach-contents  accumu- 
late, and  the  stomach  dilates. 

S5rmptoms  of  Dilated  Stomach. — There  is  annoying  hunger  unless  cancer 
exists.  Thirst  is  complained  of.  At  intervals  of  a  day  or  two  the  patient 
vomits  enormous  quantities,  and  portions  of  food  may  be  identified  which 
were  eaten  several  davs  before.  The  vomited  matter  is  sour  and  foul-smelling, 
contains  numbers  of  yeasts  and  much  fermentative  acid,  but  rarely  free  hydro- 
chloric acid.  In  some  cases  vomiting  occurs  two  or  three  hours  after  each  meal. 
The  patient  suffers  from  foul  gaseous  eructations.  There  are  progressive 
emaciation,  constipation,  scantiness  of  urine;  sometimes  cramp  in  the  legs, 
belly,  and  arms;  tetany  may  occur,  insomnia  is  the  rule,  cardiac  palpitation 
occurs,  and  there  is  dyspnea,  particularly  at  night. 

Physical  Signs  of  Dilated  Stomach. — The  epigastric  region  is  hollow 
and  the  left  side  of  the  abdomen  is  more  prominent  than  the  right.  The 
outline  of  the  greater  curvature  of  the  stomach  can  be  distinguished.  If  the 
stomach  contains  air,  percussion  gives  a  tympanitic  note;  if  it  contains  fluid, 
a  dull  note.  When  it  is  partly  full  of  fluid,  by  altering  the  position  of  the 
patient  we  can  show  by  percussion  that  the  fluid  changes  its  position.  In  a 
doubtful  case  give  a  light  meal  in  the  evening,  and  in  the  morning,  before 
the  patient  has  eaten,  introduce  a  tube  and  remove  any  material  contained 
in  the  stomach.  The  presence  of  undigested  food  points  to  dilatation. 
*  Cumston,  in  Med.  News,  Dec.  7,  1901.  t  Med.  News,  Dec.  7,  1901. 


714  Diseases  and  Injuries  of  the  Abdomen 

The  motor  power  of  the  stomach  can  be  tested  as  follows  : 

Klemperef s  Test. — Wash  out  the  stomach.  Introduce  100  c.c.  of  olive 
oil  by  means  of  the  tube.  After  two  hours  withdraw  the  oil.  The  stomach 
cannot  absorb  oil,  and  if  the  amount  withdrawn  is  subtracted  from  the  amount 
introduced,  the  difference  is  the  amount  which  passed  the  pylorus.  If  the 
condition  is  normal,  not  more  than  from  20  to  40  c.c.  should  be  found  in  the 
stomach  after  two  hours. 

The  Salol  Test  of  Ewald. — Salol  is  not  decomposed  in  the  stomach,  but 
in  the  intestine  is  broken  up  into  phenol  and  salicylic  acid.  Salicylic  acid  is 
absorbed  and  salicyluric  acid  soon  appears  in  the  urine.  If  salol  cannot  reach 
the  intestine,  salicyluric  acid  will  not  appear  in  the  urine.  If  salol  reaches 
the  intestine  more  slowly  than  normal,  sahcyluric  acid  will  appear  after 
a  longer  interval  than  when  there  is  no  pyloric  block  to  retard  the  emptying 
of  the  stomach.  In  a  normal  person  salicyluric  acid  is  found  in  the  urine 
in  from  three-fourths  of  an  hour  to  an  hour  after  swallowing  a  dose  of  salol. 
In  stenosis  of  the  pylorus  it  appears  much  later.  The  test  is  made  as  follows: 
The  bladder  is  emptied  and  the  patient  is  given  three  capsules,  each  con- 
taining gr.  v  of  salol.  The  patient  is  directed  to  pass  water  every  half  hour 
until  he  has  done  so  four  times.  Each  sample  voided  is  examined  for  sali- 
cyluric acid  by  adding  neutral  chlorid  of  iron.  If  salicyluric  acid  is  present, 
a  violet  color  is  noted. 

To  Test  the  Absorptive  Power  of  the  Stomach. — The  absorptive 
power  of  the  stomach  can  be  tested  by  giving  the  patient  a  capsule  containing 
gr.  i^  of  iodid  of  potassium.  Normally  it  should  be  found  in  the  saliva  in 
from  ten  to  fifteen  minutes.  When  absorption  is  deficient,  it  may  not  appear 
for  an  hour  or  longer.  In  order  to  test  for  it,  moisten  starch  paper  with 
sahva  and  touch  the  moist  paper  w-ith  a  drop  of  fuming  nitric  acid.  If  iodin 
is  present,  a  blue  color  develops. 

While  the  diagnosis  of  dilatation  of  the  stomach  can  be  certainly  made, 
the  determination  of  the  cause  may  require  an  exploratory  operation. 

Treatment. — Cases  not  due  to  pyloric  obstruction  are  much  improved 
by  lavage,  regulated  diet,  use  of  an  abdominal  belt,  electricity,  aperients, 
and  other  agents  called  for  by  symptoms. 

In  all  cases  where  there  is  pyloric  obstruction,  in  many  doubtful  cases, 
and  in  cases  in  which  medical  treatment  fails,  exploratory  operation  is  indi- 
cated. In  dilatation  without  pyloric  obstruction  some  surgeons  advocate 
gastroplication.  If  pyloric  obstruction  exists  the  surgeon  may  elect  to  do 
pylorectomy,  pyloroplasty,  or  gastro-enterostomy,  the  method  selected  de- 
pending on  the  condition  discovered.  If  gastroptosis  exi.sts,  gastropexy  or 
Beyea's  operation  may  be  performed. 

Acute  Dilatation  of  the  Stomach. — This  condition  may  arise 
in  the  course  of  chronic  dilatation  or  when  no  previous  dilatation  existed. 
The  cau.se  is  uncertain.  It  is  said  to  be  due  to  degeneration  of  the  gastric 
muscle  in  the  course  of  specific  fevers,  to  paresis  arising  in  the  course  of 
chronic  gastritis,  and  to  the  drinking  of  a  quantity  of  effervescing  liquid. 
The  surgeon  sees  it  from  kinking  or  sudden  blocking  of  the  pylorus  or  duo- 
denum— in  the  course  of  sepsis  and  during  shock.  It  is  occasionally  a  fatal 
sequence  of  abflominal  operations,  particularly  operations  upon  the  gall- 
bladder and  bile-ducts. 


Intestinal    Obstruction 


715 


Symptoms. — There  is  the  sudden  onset  of  violent  vomiting,  pain,  fre- 
quently cyanosis,  the  same  physical  signs  met  with  in  chronic  dilatation  and 
collapse.     Death  occurs  in  most  cases. 

Treatment. — ^^'a5h  out  the  stomach  at  frequent  intervals,  give  no  food 
by  the  mouth,  and  combat  shock  and  sepsis  by  proper  methods. 

Qastroptosis.  —  In  this  condition  the  stomach  has  undergone  dis- 
placement downward,  the  greater  curvature  in  many  cases  being  but  little 
above  the  pubic  symphysis  and  the  lesser  curvature  being  between  the  ensi- 
form  cartilage  and  the  umbilicus.  This  condition  is  far  more  common  in 
women  than  in  men,  and  is  especially  common  in  women  who  have  had 
many  children.  It  may  be  produced  by  tight  lacing  and  may  follow  mova- 
bility  of  the  right  kidney,  of  the  liver,  or  of  the  spleen.  It  is  often  associated 
with  enteroptosis  and  is  particularly  prone  to  arise  in  the  anemic  and  tuber- 
culous. 

Symptom.s. — There  may  be  no  symptoms  for  a  long  time,  but  sooner 
or  later  dyspepsia  arises  because  the  stomach  cannot  empty  itself.  The 
stomach  becomes  atonic,  its  secretions  are  scanty  and  altered,  and  while 
the  viscus  may  be  normal  in  size  or  even  shrunken,  it  is  usuallv  dilated. 
The  malposition  can  be  made  out  by  percussion  when  the  stomach  is  dis- 
tended with  air  or  with  fluid. 

Treatment. — Lavage,  regulation  of  diet,  improvement  of  the  general 
health,  and  the  wearing  of  an  abdominal  binder.  If  medical  treatment  fails 
and  the  condition  is  producing  grave  impairment  of  the  general  health,  per- 
form gastropexy  or  Beyea's  operation. 

Intestinal  Obstruction  (Ileus  or  Enterostenosis).— Intestinal  ob- 
struction is  a  condition  in  which  fecal  movement  is  mechanically  impeded 
or  prevented.  It  may  be  either  partial  or  complete.  Acute  obstruction  is 
due  to  a  sudden  narrowing  or  occlusion  of  the  lumen  of  a  portion  of  the 
intestine.  Chronic  obstruction  is  due  to  a  gradual  narrowing  of  the  lumen 
of  a  portion  of  the  intestine,  and  it  may  at  any  time  become  acute.  If  ob- 
struction to  circulation  in  the  wall  of  the  bowel  occurs,  the  condition  becomes 
one  of  strangulation.     Intestinal  obstructions  are  classified*  as  follows: 

I.  Strangulation  by  bands  or  in  apertures,  the  commonest  form,  is  due 
to  peritoneal  adhesions,  but  the  band  may  come  from  the  omentum.  Ob- 
struction may  take  place  by  Meckel's  diverticulum,  a  structure  due  to  per- 
sistence of  the  vitelline  or  omphalomesenteric  duct,  and  coming  oflf  from 
the  ileum  from  twelve  to  thirty-six  inches  above  the  ileocecal  valve.  The 
vitelline  duct  should  be  obliterated  in  the  eighth  week  of  fetal  life.  A  Meckel's 
diverticulum  usually  has  no  mesentery,  is  from  3  to  10  inches  long,  and  arises 
from  tlie  convex  side  of  the  gut.  It  may  hang  free  or  may  be  attached  to 
the  umbilicus  by  its  tip  or  by  a  fibrous  cord  formed  by  the  obliterated  tip. 
In  some  cases  it  remains  open  at  the  umbilicus  (page  719).  In  other  cases 
a  cord  runs  from  the  umbilicus  to  the  gut  or  the  tip  of  the  diverticulum  or 
is  adherent  to  another  portion  of  the  intestine.  The  diverticulum  may  be- 
come strangulated,  may  enter  a  hernial  sac,  may  ulcerate  or  perforate  like 
an  appendix  (W.  Sheen,  in  ''Bristol  Medico-Chir.  Jour.,"  Dec,  iqoi,  gives 
an  admirable  account  of  "Some  Surgical  Aspects  of  Meckel's  Diverticulum"). 
Strangulation  of  the  diverticulum  may  take  place  beneath  an  adherent  ap- 

*  After  Treves,  in  "  Heath's  Dictionary." 


7i6  Diseases  and   Injuries  of  the  Abdomen 

pendix,  a  Fallopian  tube,  a  portion  of  mesentery,  or  the  pedicle  of  an  ovarian 
tumor,  or  it  may  take  place  in  an  omental  or  a  mesenteric  aperture.  Stran- 
<yulation  bv  bands  or  in  apertures  usually  involves  the  ileum,  and  sometimes 
the  colon.  This  form  of  obstruction  is  identical  with  hernia,  except  in  the 
absence  of  an  external  protrusion. 

2.  Volvulus,  or  twisting  of  the  bowel.  The  twist  may  be  about  the 
mesenteric  axis  or  on  the  axis  of  the  bowel  itself,  or  two  intestinal  coils  may 
be  twisted  together.  Volvulus  is  commonest  in  the  sigmoid  flexure.  It  may 
occur  in  a  hernial  sac. 

3.  Intussusception  is  the  invagination  of  a  portion  of  bowel-wall  into  the 
lumen  of  an  adjacent  part.  One-third  of  all  cases  of  obstruction  are  due 
to  this  cause  (Treves).  Most  cases  of  obstruction  in  children  are  due  to 
intussusception.  Pitt  reports  that  in  St.  Thomas's  Hospital,  from  1875  to 
1900  inclusive,  there  were  115  cases  of  intussusception,  and  every  patient 
was  under  fifty  years  of  age.  Gibbon's  patient  was  fifty-eight.  Rutherford 
Morrison  had  a  case  due  to  polypus,  and  the  patient  was  sixty-two  years 
of  age.  There  are  four  varieties:  the  ileocecal,  in  which  the  ileum  and  the 
ileocecal  valve  pass  into  the  cecum  and  colon;  the  colic,  in  which  the  large 
intestine  is  prolapsed  into  itself;  the  ileal,  in  which  the  small  intestine  alone 
is  involved;  and  the  ileocolic,  in  which  the  ileum  prolapses  through  the  ileo- 
cecal valve.  The  first  variety  is  the  commonest.  Intussusception  is  due  to 
active  peristalsis. 

4.  Stricture  oj  the  intestine,  which  may  be  either  cicatricial  or  cancerous. 

5.  Obstruction  by  Tumors  oj  the  Bowel  and  by  Foreign  Bodies. — Tumors 
may  be  innocent  or  malignant.  Foreign  bodies  include,  besides  certain  sub- 
stances that  have  been  swallowed,  gall-stones,  and  enteroliths  or  intestinal 
calculi.  Foreign  bodies  are  apt  to  lodge  in  the  lower  portion  of  the  ileum 
or  in  the  cecum,  and  they  may  cause  ulceration  at  the  seat  of  lodgment.  If 
a  gall-stone  is  sufficiently  large  to  cause  obstruction,  it  cannot  have  passed 
the  duct,  but  must  have  ulcerated  into  the  bowel  from  the  gall-bladder. 
About  three-fourths  of  the  cases  of  gall-stone  intestinal  obstruction  occur  in 
women.  The  stone  is  arrested  at  some  point,  because  a  local  paralysis  of 
the  bowel  has  developed. 

6.  Obstruction  by  tumors,  etc.,  outside  the  bowel,  among  the  causes  of 
which  are  retroflexion  or  retroversion  of  the  womb,  especially  in  pregnancy, 
cysts  or  tumors  of  the  kidneys,  ovaries,  uterus,  etc.,  movable  kidney,  and 
enlarged  spleen.  Obstruction  from  any  of  the  above  causes  takes  place  in 
the  rectum  or  the  sigmoid  flexure. 

7.  Obstruction  jroni  jecal  accumulation  is  due  to  paresis  or  paralysis  of 
the  bowel  and  the  diminution  or  abolition  of  peristalsis.  Obstruction  may 
follow  an  abdominal  f)peration.  Paresis  or  paralysis  arises  in  the  colon. 
Treves  mentions  among  the  rare  forms  of  ()l)struction  kinking  of  the  bowel, 
adhesions  matting  the  bowels  together  or  compressing  the  gut,  and  shrinking 
of  the  mesentery. 

In  addition  to  the  seven  groups  previously  mentioned,  we  should  consider 
post-operative  intestinal  obstruction  and  obstruction  jrom  embolism  or  throm- 
bosis oj  the  mesenteric  vessels.  Obstruction  of  the  mesenteric  vessels  is  liable 
to  occur  when  the  aorta  is  atheromatous,  and  usually  causes  gangrene  of 
the  intestine. 


Symptoms   of   Chronic   Obstruction  717 

Symptoms  of  Acute  Obstruction. — Severe  colic  comes  on  suddenly, 
the  pain  varying  in  intensity,  but  at  no  time  entirely  ceasing.  In  a  suddenly 
arising  intraperitoneal  accident,  whether  it  be  perforation,  acute  obstruction, 
or  acute  strangulation,  there  is  at  first  shock,  from  which  the  patient  usually 
reacts  for  a  time.  In  obstruction  there  is  constipation,  which  soon  becomes 
absolute,  not  even  wind  being  passed ;  vomiting  is  early — first  of  the  contents 
of  the  stomach,  next  of  bilious  matter,  and  finally  of  feces  (stercoraceous) ; 
the  abdomen  becomes  distended  and  tender.  After  reaction  from  shock 
some  fever  may  be  noted,  but  in  any  unrelieved  case  collapse  soon  arises; 
the  temperature  becomes  subnormal;  the  face  Hippocratic;  the  pulse  rapid 
and  feeble.  The  amount  of  urine  passed  is  very  small.  In  obstruction  of 
the  upper  third  of  the  ileum  true  fecal  vomiting  cannot  occur.  If  obstruction 
is  high  up  in  the  small  intestine,  tympanites  does  not  occur.  The  tongue 
is  dry,  the  mind  is  clear,  and  muscular  cramp  may  occur.  Intestinal  peris- 
talsis above  the  obstruction  may  be  detected  through  the  abdominal  wall. 

Symptoms  of  Chronic  Obstruction. — At  intervals  there  arise  attacks 
of  pain  which  become  gradually  more  frequent  and  severe,  and  are  linked 
with  vomiting  and  constipation,  the  vomiting  not  being  stercoraceous  and 
the  constipation  not  being  absolute.  Between  the  painful  seizures  the  patient 
complains  of  constipation  alternating  with  fluid  diarrhea,  distention  of  the 
belly,  some  abdominal  uneasiness,  anorexia,  and  dyspepsia.  The  attacks 
recur  with  increasing  frequency  and  severity,  and  acute  obstruction  may 
arise  or  the  patient  may  be  worn  out  by  pain,  vomiting,  and  want  of  food. 

Diagnosis. — The  determination  of  the  seat  of  lesion  requires  abdominal 
and  rectal  examination.  An  intussusception  may  sometimes  be  felt.  Vaginal 
examination  may  be  demanded.  Pain  is  apt  to  arise  at  the  seat  of  obstruction 
or  to  radiate  from  there.  Palpation  may  detect  a  tumor.  Rectal  insufflation 
of  hydrogen  may  locate  the  obstruction  by  causing  great  distention  below  it. 
Entire  suppression  of  urine,  early  vomiting  which  is  not  truly  stercoraceous, 
absence  of  abdominal  distention,  and  rapid  collapse  mean  obstruction  in 
the  duodenum  or  in  the  jejunum.  Early  vomiting,  which  is  often  stercora- 
ceous in  a  rapidly  progressive  case  with  great  distention  of  the  umbilical 
region,  means  obstruction  of  the  ileum  or  the  cecum.  Distention  of  the 
entire  abdomen  and  of  the  flanks,  linked  with  tenesmus,  with  less  intensity 
of  symptoms,  less  rapidity  of  progress,  and  less  diminution  of  urine  than 
in  the  above-cited  forms,  means  obstruction  low  down  in  the  colon  or  in 
the  rectum.  A  test  for  obstruction  in  the  adult  large  intestine  is  an  injection 
by  a  fountain -syringe;  if  six  quarts  can  be  introduced,  there  is  no  obstruction 
in  the  large  intestine;  if  less  than  four  quarts  can  be  introduced,  there  is 
probably  obstruction  in  the  large  intestine.  The  passage  of  a  sound  in  the 
rectum  is  generally  useless  and  is  often  unsafe.  In  many  cases  the  seat 
of  the  lesion  and  the  cause  of  the  obstruction  can  only  be  determined  by 
exploratory  laparotomy. 

The  determination  oj  the  causative  condition  is  always  difficult  and  is 
often  impossible.  Intussusception  is  the  common  cause  in  children.  A 
sausage-shaped  tumor  can  usually  be  felt  in  the  right  iliac  fossa,  tenesmus 
exists,  and  bloody  mucus  is  passed.  The  abdomen  is  rarely  distended  or 
tender.  \^omiting  occurs,  but  it  is  seldom  stercoraceous.  The  prolapse  may 
sometimes  be  detected  bv  digital  exploration  of  the  rectum.     In  obstruction 


yi8  Diseases  and   Injuries  of  the  Abdomen 

/>£»;;/  bands,  internal  hernia,  etc.,  there  is  a  record  of  antecedent  peritonitis, 
of  a  traumatism,  of  a  violent  effort,  or  of  pelvic  pain.  The  attack  is  sudden 
in  onset,  is  fierce  in  character,  and  is  usually  excited  by  violent  exercise  or 
the  taking  of  food.  Vomiting  is  early  and  intractable,  and  it  soon  becomes 
stercoraceous;  pain  is  violent;  peristalsis  above  the  obstruction  is  forcible; 
tympanites  and  abdominal  tenderness  appear  after  the  attack  has  lasted  for 
some  little  time;  obstruction  is  complete,  no  wind  even  being  passed;  collapse 
soon  arises;  no  tumor  can  be  detected,  and  rectal  examination  is  negative. 
Volvulus,  which  is  usually  located  in  the  sigmoid  ilexure,  is  preceded  by 
constipation.  The  symptoms  come  on  with  explosive  suddenness,  and  rapidly 
attain  great  severity.  Constipation  is  absolute;  vomiting  is  late  and  is  rarely 
stercoraceous;  no  tumor  can  be  detected;  rectal  examination  is  negative; 
abdominal  distention  and  tenderness  are  early  and  pronounced;  peristalsis 
above  the  volvulus  is  vigorous;  collapse  is  not  so  rapid  nor  so  grave  as  in 
the  previously  considered  forms.  Obstruction  by  a  foreign  body  may  some- 
times be  inferred  from  the  history  of  some  such  body  having  been  swallowed. 
The  obstructing  body  may  occasionally  be  felt  during  palpation,  or  may  be 
discovered  with  the  x-rays.  Abdominal  distress  may  exist  for  days  or  weeks 
before  obstruction  occurs.  Vomiting  is  late  and  is  rarely  severe,  but  pain, 
tenderness,  and  distention  are  marked.  In  obstruction  from  gall-stones  there 
will  be  a  record  of  one  or  more  attacks  of  hepatic  colic.  Pain  is  early  and 
acute,  and  vomiting  is  invariable  and  usually  becomes  stercoraceous.  In 
obstruction  from  fecal  accumulation  chronic  obstruction  evolves  into  acute 
obstruction,  pain  and  vomiting  are  late  or  even  absent,  and  the  dough-like 
mass  of  feces  may  often  be  felt  by  rectal  examination  or  by  abdominal  pal- 
pation. In  some  cases  the  fluid  elements  of  the  feces  pass,  but  the  solid 
elements  agglutinate  to  the  walls  of  the  bowel  (the  diarrhea  of  constipation). 
Obstruction  from  stricture  or  from  pressure  comes  on  acutely  after  a  pro- 
longed period  of  disturbance,  during  which  period  attack  after  attack  of 
temporary  obstruction,  complete  or  partial,  takes  place.  A  history  of  blood 
or  pus  in  the  stools  would  indicate  tumor  of  the  bowel;  a  history  of  blood 
or  pus  having  been  absent  would  indicate  pressure  from  without.  In 
junctional  obstruction  there  is  no  local  pain,  no  tenderness,  no  tumor, 
no  tendency  to  collapse,  but  simply  distention  and  absolute  constipation, 
and  possibly  non-fecal  vomiting  occurring  in  a  neurotic  or  hysterical  subject. 
A  phantom  tumor  due  to  a  local  distention  of  the  intestine  from  limited 
muscular  spasm  disappears  under  ether.  Obstruction  of  the  mesenteric 
vessels  causes  abdominal  pain,  but  early  in  the  case  there  is  no  tenderness, 
rigidity,  or  distention.  Moderate  vomiting  may  occur,  there  is  great  rest- 
lessness and  sometimes  bloody  diarrhea.  Obstruction  may  follow  an  ab- 
dominal operation  (post-operative  obstruction) ;  it  may  arise  a  day  or  so  after 
operation;  it  may  arise  in  ten  or  twelve  days  after  operation;  it  may  not 
arise  for  weeks  or  months  (Legeve).  It  may  be  due  to  some  cause  at  the 
.seat  of  operation  (adhesion  of  the  bowel  to  a  raw  surface,  volvulus,  catching 
of  the  intestine  under  adhesions,  etc.).  It  may  be  due  to  some  cause  di.stant 
from  the  seat  of  operation  (displacement  of  intestine,  bands,  etc.).  It  may 
arise  from  paralysis  of  a  portion  of  the  bowel,  which  may  or  may  not  be 
due  to  sepsis.*     It  may  be  due  to  thrombosis  of  a  mesenteric  vessel.     The 

*  Legeve,  Gaz.  des  Il6p.,  Nov.  23,  1895. 


Treatment  of  Intestinal   Obstruction  719 

symptoms  of  post-operative  thrombosis  oj  the  mesenteric  vessels,  according 
to  A.  E.  Maylard,  *  are  as  follows :  Abdominal  pain,  perhaps  colicky  in 
character,  gradual  or  acute  in  onset,  and  as  a  rule  constant.  Early  in  the 
case  there  is  no  abdominal  tenderness,  no  distention,  and  no  rigidity.  The 
pulse  is  rapid,  the  patient  is  extremely  restless,  there  may  be  vomiting,  but 
it  is  never  violent,  as  in  acute  obstruction,  often  there  is  diarrhea,  and  some- 
times bloody  diarrhea.  These  symptoms  become  particularly  significant 
if  there  is  cardiac  or  vascular  disease.  Obstruction  jrom  Meckel's  diver- 
ticulum is  usually  acute,  but  is  sometimes  chronic,  and  occurs  particularly 
in  young  adults  and  children.  It  has  been  stated  that  other  and  visible 
deformities  are  usually  present,  but  in  a  study  of  6g  cases  by  A.  E.  Halsteadf 
this  was  true  of  but  one  case,  in  which  harelip  existed.  In  obstruction  from 
Meckel's  diverticulum  there  is  often  a  history  of  former  mild  attacks  (Halstead). 
Halstead  sums  up  the  symptoms  as  follows:  As  the  obstruction  is  high  up, 
the  abdomen  is  the  shape  of  an  inverted  cone;  early  in  the  attack  there  is 
often  local  meteorism,  especially  under  the  costal  arch  of  the  right  side, 
but  there  is  no  distention  in  the  flanks.  Early,  active  peristalsis  may  be 
visible.  The  tenderness  is  just  to  the  right  of  the  umbilicus,  on  a  level  with 
it  or  below  it.     In  most  cases  there  is  early  fecal  vomiting. | 

Recognition  of  Intestinal  Obstruction  from  Other  Diseases. — Always  ex- 
amine for  a  strangulated  hernia  at  every  hernial  outlet.  If  obstruction  is 
complicated  with  an  irreducible  hernia  above  the  seat  of  lesion,  the  hernia 
will  always  enlarge  and  become  tender  because  of  accumulation  of  feces. 
Functional  obstruction  may  attend  peritonitis  or  may  follow  the  reduction 
of  a  hernia.  Appendicitis  with  peritonitis  may  cause  symptoms  similar  to 
those  of  obstruction;  but  there  are  fever,  a  history  of  pain  in  the  right  iliac 
fossa,  and  the  vomiting  is  not  stercoraceous.  Acute  pancreatitis  produces 
symptoms  so  similar  to  those  of  intestinal  obstruction  that  a  diagnosis 
cannot  always  be  made.  Poisoning  by  arsenic  or  by  corrosive  sublimate 
should  not  be  confounded  with  intestinal  obstruction. 

Prognosis. — Without  surgical  interference  most  cases  of  acute  intestinal 
obstruction  die  within  ten  days,  usually  within  seven  days.  Death  may  be 
due  to  shock,  to  exhaustion,  to  perforation,  to  peritonitis,  or  to  obstruction 
of  respiration  and  circulation  by  tympanites.  Recovery  occasionally  happens 
by  the  formation  of  a  fistula  externally  or  into  another  portion  of  the  bowel. 
In  acute  obstruction  from  foreign  bodies  the  obstructing  body  occasionally 
passes.  Volvulus  and  strangulation  by  bands  are  almost  invariably  fatal 
unless  an  operation  is  performed.  In  intussusception  recovery  occasionally 
follows  the  sloughing  away  of  the  prolapsed  gut,  but  stricture  almost  in- 
evitably results  from  this  rare  event.  Functional  obstruction  gives  a  good 
prognosis.  The  prognosis  of  chronic  obstruction  depends  upon  the  causative 
lesion.  It  does  not  threaten  life  immediately  to  anything  like  the  degree 
that  acute  obstruction  does. 

Treatment. — In  any  abdominal  case  in  which  the  diagnosis  is  uncertain 
and  the  patient  is  shocked,  give  an  enema  of  brandy  and  hot  water,  wrap 
the  patient  in  blankets,  surround  him  with  hot-water  bottles,  and  study 
the  development  of  symptoms  and  signs.     In  half  an  hour,  as  a  rule,  reaction 

*  Brit.  Med.  Jour.,  Nov.   16,  1901.  t  .-Vniials  of  Surgery,  April,  1902. 

J  Annals  of  Surgery,  April,  1902. 


720  Diseases  and   Injuries  of   the  Abdomen 

will  be  brought  about,  and  a  probable  diagnosis  may  be  made  (Greig  Smith). 
In  acute  obstruction  it  is  usually  customary  to  empty  the  stomach  by  lavage 
and  to  evacuate  the  rectum  by  means  of  copious  injections  given  while  the 
patient  is  in  the  knee-chest  position.  Hutchinson's  method  of  taxis  and 
massage  is  uncertain,  and  is  as  liable  to  inflict  harm  as  to  confer  benefit. 
Some  surgeons  apply  constant  compression  to  the  abdomen  by  means  of 
straps  of  adhesive  plaster.  Puncture  of  the  intestine  with  an  aseptic  hypo- 
dermatic needle  introduced  obhquely  to  relieve  gaseous  distention  is  a  de- 
cidedlv  dangerous  proceeding.  The  passage  of  a  small  tube  from  the  anus 
to  the  sigmoid  flexure  will  empty  the  colon  of  gas  if  no  obstruction  intervenes. 
In  intussusception  give  no  food  by  the  stomach;  administer  opium  and  bella- 
donna to  arrest  peristalsis,  wash  out  the  rectum  with  copious  injections,  give 
an  anesthetic,  and  insufBate  hydrogen  gas  or  carbonic  acid  gas  in  order  to  dis- 
tend the  bowel.  Some  surgeons  treat  intussusception  by  forcing  air  into  the 
rectum  by  means  of  an  ordinary  bellows,  and  others  inject  water  by  a  fountain- 
svringe,  the  reservoir  standing  at  a  height  of  three  feet.  D'Arcy  Power 
believes  in  the  value  of  hydrostatic  pressure  in  intussusception  in  children. 
He  states  that  the  child  should  be  anesthetized  and  the  large  intestine  filled 
gradually  with  hot  saline  fluid,  the  reservoir  not  being  raised  more  than 
three  feet  above  the  patient.  The  fluid  should  be  retained  for  ten  minutes. 
The  author  is  of  the  Opinion  that  whereas  it  is  justifiable  to  try  to  reduce 
by  gaseous  or  hydrostatic  pressure  during  the  first  twenty-four  hours  of  the 
attack,  early  operation  gives  a  better  prognosis  and  is  safer  and  more  certain. 
After  the  first  twenty-four  hours  it  is  not  justifiable  to  use  gaseous  or  hydro- 
static pressure  because  ulcer  or  gangrene  may  exist.  Pressure  cannot  be 
accurately  regulated,  and  if  the  bowel  is  much  damaged  may  lead  to  rupture. 
If  the  case  is  not  seen  until  after  the  first  day,  or  if  injections  have  been  used 
and  have  failed,  laparotomy  should  certainly  be  performed. 

Frederick  Holme  Wiggin  has  made  a  study  of  the  reported  cases  of 
laparotomy  for  infantile  intussusception,  and  considers  that  operation  done 
within  the  first  forty-eight  hours  will  give  a  mortality  of  22.2  per  cent.*  (see 
Operation  for  Intussusception). 

In  obstruction  of  the  main  mesenteric  vessels  operation  is  of  no  avail. 
In  obstruction  of  branches  it  may  be  possible  to  resect  the  involved  region 
of  bowel,  a  region  which  is  found  to  be  gangrenous  or  at  least  becoming  so. 
In  obstruction  from  fecal  impaction  use  large  rectal  injections  and 
give  small  repeated  doses  of  salines  or  of  castor  oil.  If  there  are 
signs  of  inflammation,  do  not  give  cathartics,  even  in  small  doses,  but 
give  opium  and  belladonna  to  arrest  vomiting  and  to  relax  spasm.  Im- 
pactions in  the  rectum  can  be  removed  by  the  use  of  a  spoon.  In  acute 
inte.stinal  obstruction,  if  the  symptoms  grow  worse,  do  not  wait,  but  open 
the  abdomen  before  collapse  comes  on  and  find  the  cause  of  the  obstruc- 
tion. If  it  is  a  gall-.stone  or  enterolith,  try  to  crush  it  without  opening  the 
intestine;  if  this  fails,  pu.sh  it  up  a  little  distance,  incise  the  bowel,  remove 
the  stone,  and  close  the  incision  with  Halsted  sutures.  Pilcher  f  reports 
40  cases  operated  upon  for  gall-stone  obstruction  with  21  deaths.  If  there 
is  fecal  obstruction,  break  up  the  masses  by  jircssure  and  push  the  fecal 
plug  down  without  opening  the  bowel.  If  there  is  intussusception,  reduce 
■*  Med.  Record,  Jan.  18,  1896.  f  Med.  News,  Feb.  8,  1902. 


Fecal    Fistula 


721 


the  prolapse  and  shorten  the  mesentery;  but  if  reduction  is  impossible,  per- 
form an  anastomosis  or  a  resection  and  enterorrhaphy,  or  make  an  artificial 
anus.  In  volvulus  untwist  and  shorten  the  mesentery;  but  if  this  is  im- 
possible, treat  as  an  irreducible  invagination.  In  obstruction  from  adhesions 
try  to  separate  them  and  straighten  out  the  bowel,  stitching  healthy  perito- 
neum over  each  raw  spot  to  prevent  recurrence.  Anastomosis  may  be  neces- 
sary. In  flexion  separate  the  intestines,  remove  the  flexion  by  a  V-shaped 
incision,  and  suture  the  wound  in  the  bowel  (Senn).  In  chronic  obstruction 
it  is  often  advisable  to  perform  an  exploratory  laparotomy,  discover  the 
condition,  and  determine  what  is  to  be  done  to  correct  it.  Some  tumors 
external  to  the  bowel  may  be  removed.  Growths  in  the  bowel-wall  may 
be  removed  by  resection  of  the  involved  portion  of  intestine,  or  an  anasto- 
mosis may  be  performed,  or  it  may  be  necessary  to  make  an  artificial  anus. 
In  obstruction  from  Meckel's  diverticulum  that  structure  may  be  found 
twisted,  the  gut  near  it  may  be  kinked  or  twisted,  or  the  diverticulum  may 
act  as  a  band,  the  bowel  being  caught  under  it  or  kinked  over  it.  Intussus- 
ception of  the  gut  below  it  sometimes  occurs;  so  does  invagination  of  the 
mucous  membrane  of  the  diverticulum;  so  does  chronic  inflammation  and 
cicatricial  narrowing  of  the  diverticulum  or  gut  (Halsted).  The  diverticu- 
lum may  be  gangrenous,  perforated,  or  cystic. 


Fig.  364. — Fecal  fistula  :   a,  Direction  of  fecal 
flow  ;  b,  b,  belly-wall. 


Fig.  365. — Artificial  anus,  showing  spur: 
a,  Spur;  5, /J,  belly-wall  ;  c,  direction  of  fecal 
flow. 


After  opening  the  abdomen  the  surgeon  must  be  guided  by  conditions. 
The  diverticulum  should  be  removed,  just  as  the  appendix  is  removed  in 
appendicitis,  and  complications  relating  to  the  gut  must  be  dealt  with.  Post- 
operative obstruction  coming  on  soon  after  a  surgical  operation  is  often  not 
recognized  for  a  time,  and  the  surgeon  will  be  in  doubt  as  to  whether  he 
is  dealing  with  peritonitis  or  intestinal  paresis.  When  in  doubt  wash  out 
the  stomach  with  warm  salt  solution,  administer  salines  in  small  doses  fre- 
quently repeated,  employ  enemata,  and  give  two  or  three  doses  of  atropin 
at  intervals  of  two  hours.  Each  dose  should  be  gr.  -g-^-y.  Atropin  is  given 
with  the  idea  that  it  increases  peristalsis  and  contracts  blood-vessels.  It  is 
probably  merely  sedative,  relaxes  spasm,  and  is  useless  if  strangulation  ex- 
ists. If  these  measures  are  not  quickly  followed  by  the  passage  of  flatus 
or  feces,  open  the  abdomen;  never  wait  for  the  advent  of  stercoraceous 
vomiting  (see  Legeve). 

Fecal  Fistula. — A  fistula  is  an  abnormal  opening  in  the  intestine 
through  which  gas  or  a  portion  of  the  feces  escapes  (Fig.  364).  If  all  the 
intestinal  contents  escape  through  the  opening,  it  is  called  an  artificial  anus 
(Fig.  365,  Senn).  A  surgeon  may  make  a  fistula  deliberately  (intentional 
fistula).  A  fistula  mav  be  the  product  of  disease  or  injurv  (accidental  fistula). 
46  ■ 


722  Diseases  and  Injuries  of  the  Abdomen 

♦ 

Senn  enumerates  the  following  causes  of  accidental  fistula:  wounds,  injury 
of  the  intestine,  intestinal  ulceration,  intestinal  strangulation,  foreign  bodies 
in  the  intestinal  canal,  malignant  tumors,  actinomycosis,  pelvic  and  abdominal 
abscess,  appendicitis,  injury  of  the  bowel  during  an  abdominal  operation, 
the  application  of  ligatures,  catching  by  sutures,  and  the  employment  of 
drainage-tubes. 

Treatment. — Many  fistulae  close  spontaneously.  This  can  only  be  hoped 
for  if  the  opening  is  quite  small,  if  the  general  health  of  the  patient  is  good, 
if  the  cause  has  passed  away,  if  the  fistula  is  not  lined  with  mucous  mem- 
brane, and  if  there  is  no  spur  (spur  is  shown  at  a,  Fig.  365).  In  most  cases 
of  fistula  not  high  up  it  is  well  to  give  Nature  a  chance  to  effect  a  cure,  and 
not  lO  be  in  a  hurry  to  operate.  The  part  is  cleansed  frequently  with  peroxid 
of  hydrogen,  the  patient  is  kept  recumbent,  food  is  given  which  does  not 
leave  much  residue,  pads  of  gauze  with  pressure  are  apphed,  and  the  bowels 
are  kept  regular. 

If  the  track  is  fined  with  granulations,  it  may  be  touched  with  lunar 
caustic;  if  it  is  lined  with  mucous  membrane,  the  actual  cautery  should  be 
apphed;  any  collection  of  pus  which  exists  should  be  drained.  If  these 
methods  fail,  an  operation  must  be  performed.  The  fistula  may  be  sutured 
by  extraperitoneal  manipulation  (Greig  Smith) ;  it  may  be  covered  with  skin 
(Dieffenbach) ;  the  spur  may  be  removed  by  means  of  a  clamp;  or  resection 
may  be  performed.  In  most  cases  it  is  best  to  incise  a  button  of  skin  around 
the  opening,  temporarily  suture  the  fistula,  open  the  peritoneal  cavity,  deliver 
the  bowel,  and  suture  carefully  (Senn's  method).  In  some  cases  partial 
exclusion  of  the  fistulous  part  is  necessary,  the  bowel  being  divided  above 
the  fistula,  the  end  near  the  fistula  sutured,  and  the  other  end  anastomosed 
to  the  bowel  below  the  fistula.  In  other  cases  complete  exclusion  may  be 
performed  (page  814). 

L'lcer  of  the  Bowel. — In  typhoid  fever  and  in  dysentery  ulceration 
occurs.  An  ulcer  may  be  due  to  tuberculosis  or  cancer.  An  ulcer  of  the 
duodenum  is  due  to  the  same  causes  as  an  ulcer  of  the  stomach.  An  ulcer 
of  the  jejunum  sometimes  develops  after  the  performance  of  gastro-jejunos- 
tomy  for  gastric  ulcer.  Curling's  ulcer  is  a  chronic  ulcer  of  the  duodenum 
following  a  bum  of  the  cutaneous  surface.  An  ulcer  may  heal,  and  by 
causing  thickening  and  constriction  produce  chronic  intestinal  obstruction. 
It  may  perforate,  causing  collapse  and  subsequent  peritonitis. 

Peptic  Ulcer  of  the  Duodenum. — Occurs  usually  in  that  portion 
of  the  duodenum  which  is  above  the  opening  of  the  bile-duct;  in  other  words, 
only  in  the  region  acted  on  by  the  acid  fluid  from  the  stomach.  Reversing 
the  rule  in  gastric  ulceration,  duodenal  ulceration  is  more  common  in  men 
than  in  women.  It  may  occur  at  any  period  of  life,  from  early  youth  to 
extreme  old  age.  An  indurated  chronic  ulcer  may  exist,  and  this  may  heal 
and  produce  cicatricial  stenosis.  An  acute  ulcer  is  apt  to  perforate.  Just 
as  chronic  gastric  ulcer  may  be  latent,  no  symptoms  ever  being  observed, 
so  may  chronic  duodenal  ulcer  Vje  latent.  Usually  there  is  pain  coming  on 
about  one  hour  after  taking  food,  and  located  in  the  epigastric  or  right  hypo- 
chondriac region.  In  one-third  of  the  cases  there  is  hematemesis,  and 
sometimes  there  is  blood  in  the  stools.  Severe  hemorrhage  is  much  rarer 
than   in   gastric  ulcer.     Moynihan  *  mentions  the  following  complications: 

*  Lancet,  Dec.  14,  1901. 


Perforated   Typhoid   Ulcer  723 

Severe  hemorrhage;  perforation;  periduodenitis;  cancer;  and  cicatricial  con- 
traction involving  the  bile-duct. 

Perforating  ulcer  is  more  common  than  we  once  thought.  Moynihan 
gathered  49  cases  from  literature  and  added  2  of  his  own.  In  the  great 
majority  of  cases  perforation  of  the  duodenum  cannot  be  differentiated  from 
perforation  of  the  stomach  by  a  study  of  the  symptoms,  but  in  some  cases 
the  symptoms  resemble  appendicitis.  In  most  cases  there  is  a  sudden  onset 
of  violent  abdominal  pain,  vomiting,  shock,  rapid  pulse,  and  tenderness  of 
the  epigastric  or  right  hypochondriac  region.  As  a  rule,  after  a  few  hours 
the  patient  reacts  from  shock.  Sheild's  case  got  better  in  four  hours  and 
walked  some  distance  to  the  hospital.*  Lucy's  case  got  better  a  short  time 
after  the  onset,  walked  home,  and  attended  to  a  horse,  but  then  became 
rapidly  worse.  The  improvement  is  apparent,  not  real,  and  is  only  temporary. 
The  symptoms  quickly  become  worse,  and  when  they  become  worse,  besides 
the  pain  and  tenderness  and  rapid  pulse,  there  will  be  occasional  vomiting, 
rigidity  of  the  abdomen,  usually  an  elevated  or  normal  temperature,  and 
possibly  diminution  of  the  area  of  liver-dulness. 

Treatment. — In  chronic  ulcer  operate  if  the  symptoms  are  not  amended 
by  rigid  diet  and  medication;  if  severe  hemorrhage  occurs;  if  cicatricial  con- 
traction interferes  with  the  passage  of  food  through  the  bowel  or  bile  into 
the  duodenum.  Moynihan  refers  to  four  cases  of  chronic  ulcer  operated 
upon,  and  all  recovered. 

In  perforation  operation  is  performed  as  soon  as  the  patient  rallies  from 
the  primary  shock.  Operation  is  not  performed  in  shock  unless  hemorrhage 
is  thought  to  exist.  The  ulcer  is  inverted  by  two  rows  of  silk  sutures.  Some 
surgeons  do  not  drain,  but  I  would  feel  it  safer  to  drain.  B.  G.  A.  Moynihan f 
gathered  49  operations  for  perforated  ulcer  with  8  recoveries. 

Perforated  Typhoid  Ulcer.  —  Perforation  occurs  in  about  i  case 
out  of  100.  Perforation  in  a  typhoid  ulcer  is  usually  effected  rapidly, 
a  large  opening  is  formed,  and  a  considerable  quantity  of  fecal  matter  is 
passed  into  the  peritoneal  cavity.  Severe  pain,  a  nervous  chill,  and  marked 
leukocytosis  indicate  that  perforation  is  beginning  to  occur.  This  stage  is 
known  as  the  preperforative  stage  (Gushing).  When  perforation  occurs, 
violent  pain  develops.  As  a  rule,  there  is  tenderness,  rapid  pulse,  costal 
respiration,  abdominal  rigidity,  vomiting,  and  shock.  Usuallv  there  is 
temporary  reaction  from  shock,  the  subnormal  temperature  giving  way  to 
a  normal  or  to  an  elevated  temperature.  The  vomiting  in  some  cases  be- 
comes stercoraceous.  There  is  constipation  and  sometimes  dulness  on 
percussing  the  flanks.  The  face  is  Hippocratic.  The  patient  may  die  of 
the  preliminary  shock  or  may  react  and  die  subsequently  of  blood-poisoning. 

Treatment. — Death  is  practically  certain  without  operation.  Operation 
should  save  about  one-fifth  of  the  cases.  Operation  should  not  be  done 
in  shock,  but  rather  as  soon  as  reaction  is  established.  In  many  cases  a 
general  anesthetic  should  not  be  gixen,  but  a  local  anesthetic  shoukl  be 
employed.  The  incision  should  be  made  in  the  right  iliac  region  and  the 
colon  should  be  first  located  and  then  the  end  of  the  ileum.  By  locating 
the  colon  we  obtain  a  fixed  point  from  which  to  begin  our  search  for  per- 
foration, and  b}'  opening  in  the  iliac  region  we  come  down  at  once  onto  the 

*  Lancet,  March  29,  1902.  t  Lancet,  Dec.  14,  1901. 


724  Diseases  and  Injuries  of  the  Abdomen 

perforated  gut  in  the  vast  majority  of  cases.  When  a  perforation  is  found 
it  is  inverted  with  two  layers  of  Halsted  sutures.  It  is  not  wise  to  excise 
the  ulcer.  If  the  bowel  is  very  badly  damaged  resection  can  be  consid- 
ered, but  it  is  usually  wiser  to  make  a  temporary  artificial  anus.  After  find- 
ing a  perforation  and  closing  it,  examine  to  see  if  there  are  others.  Close 
everv  perforation,  and  if  a  point  is  found  where  the  thinning  of  the  bowel- 
wall  indicates  that  perforation  is  liable  to  occur,  protect  this  point  by  in- 
verting the  area  of  ulceration  by  sutures.  Clean  the  peritoneum  by  evis- 
cerating, wrapping  the  intestines  in  hot  towels,  wiping  out  peritoneal  cavity 
and  wiping  particularly  the  peritoneal  fossas,  the  space  between  the  liver 
and  diaphragm,  and  the  pelvis.  The  bowels  are  wiped  off  and  returned  to 
the  belly  and  quarts  of  hot  salt  solution  are  used  to  flush  the  cavity.  Leave 
the  wound  open  and  insert  strands  of  iodoform  gauze  to  afford  drainage. 
Sometimes  make  suprapubic  drainage  and  sometimes  make  a  drain  incision  in 
the  right  kidney  pouch.  I  have  operated  four  times  for  typhoid  perforation 
with  a  uniformly  unfortunate  result.  Two  cases  died  of  shock.  In  one  case 
the  perforation  was  not  found,  but  was  discovered  post-mortem  in  the  he- 
patic flexure  of  the  colon.  One  case  improved  greatly,  lived  for  eight  days, 
developed  another  perforation,  and  died  of  shock.  The  necropsy  show-ed 
that  the  sutured  perforation  was  soundly  closed. 

Primary  Intestinal  Tuberculosis. — According  to  Kocher,  there  are 
80  cases  on  record.  He  reported  29  cases  to  the  Swiss  Medical  Congress 
in  1892.  Primary  tuberculosis  is  very  rare,  whereas  secondary  tuberculosis 
is  common.  The  exact  propriety  of  rigidly  regarding  such  cases  as  primary 
is  doubtful.  Kocher's  cases  came  from  tuberculous  stock,  and  suffered  in 
infancy  from  enlarged  glands,  pleurisy,  or  bronchitis,  and  that  surgeon  says 
that,  in  all  probability,  there  had  for  some  time  been  somewhere  in  the  body 
a  latent  tuberculous  focus,  and  from  this  focus  came  the  bacteria  which 
attacked  the  intestine.  Primary  tuberculosis  begins  with  the  formation 
of  multiple  ulcers,  chiefly  in  the  cecum.  The  symptoms,  as  a  rule,  are  shght, 
attacks  of  pain  occurring  now  and  then,  and  stricture  gradually  developing. 
The  urine  shows  the  diazo  reaction  (Kocher).  In  some  cases  of  intestinal 
tuberculosis  there  is  enormous  tumor-like  thickening  (hyperplastic  tubercu- 
losis). 

Treatment. — In  the  first  stage  the  proper  treatment  is  excision  of  ulcerated 
areas,  possibly  excision  of  the  cecum.  Later,  if  stricture  is  causing  chronic 
obstruction,  an  operation  may  be  performed  to  give  relief. 

Malignant  Tumor  of  the  Intestine. — Sarcoma  is  very  rare,  but  does 
sometimes  arise,  particukirly  in  young  persons,  and  it  enlarges  very  rapidly. 
It  is  most  prone  to  attack  the  large  intestine  Jopson  and  White*  report 
I  ca.se  and  also  collect  22  others.  The  mesenteric  glands  frequently  enlarge. 
Cancer  is  not  uncommon,  attacking  especially  the  middle  aged.  It  is  most 
common  in  the  neighborhood  of  the  ileocecal  valve  and  in  the  sigmoid  flexure. 
Ewald  collected  1148  ca.ses  of  cancer  of  the  intestine.  In  64  cases  the  cecum 
was  involved;  in  24  cases  the  ileum  was  involved.  It  i)roduces  pain  at  the  seat 
of  growth,  and  after  a  time  constipation,  or  constipation  alternating  with 
diarrhea,  and  Anally  intestinal  obstruction.  In  some  cases  the  symptoms 
appear  suddenly,  acute  obstruction  taking  place  or  intussusception  occurring. 
*Am.  Jour.  Med.  Sciences,  Dec,  1901. 


Appendicitis  725 

It  is  usually  possible  to  palpate  the  tumor,  which  is  hard  and  immovable. 
The  patient  wastes  rapidly  and  is  apt  to  occasionally  pass  blood  at  stool. 
The  growth  does  not  enlarge  very  rapidly  and  glands  are  not  involved  early. 
In  some  cases  the  supraclavicular  glands  enlarge.  In  more  than  one-half  of 
the  cases  which  die  of  intestinal  cancer  there  is  no  lymphatic  infection.* 

Treatment. — Early  in  the  case  exploratory  laparotomy  should  be  per- 
formed, followed  if  possible  by  excision  with  end-to-end  approximation.  This 
is  done  for  either  cancer  or  sarcoma.  It  may  be  possible  to  remove  enlarged 
glands.  In  cancer  of  the  cecum  extirpate  the  cecum  and  implant  the  end 
of  the  ileum  into  the  side  of  the  colon  (Wm.  J.  Mayo).  If  excision  is  im- 
possible, the  growth  should  be  sidetracked  by  performing  lateral  anastomosis. 
In  advanced  cancer  of  the  large  bowel,  if  resection  is  impossible,  make  an 
artificial  anus  above  the  tumor  (cancer  of  rectum,  page  865). 

Appendicitis. — Appendicitis,  which  is  an  inflammation  of  the  vermi- 
form appendix  of  the  cecum,  is  almost  invariably  the  primary  lesion  of  all  of 
those  various  conditions  known  as  typhlitis,  perityphhtis,  paratyphhtis,  etc. — 
terras  which  no  longer  imply  pathological  entities,  and  are  in  most  instances 
well  relegated  to  obscurity.  It  was  recognized  by  some  observers  many  years 
ago  that  such  a  disease  existed,  but  the  majority  of  the  profession  did  not  grasp 
the  fact.  In  1750  Mestevier,  of  France,  reported  a  case  of  perforative  ap- 
pendicitis with  peritonitis. t  In  181 2  a  perforated  appendix  was  shown  to  the 
Medico-Chirurgical  Society  of  London,  and  in  1835  Southam  reported  an 
appendiceal  abscess  (Manley).  In  1849  Hancock  reported  an  appendiceal 
abscess.  In  1827  Dr.  L.  Mellier  described  appendicitis,  and  named  among 
its  symptoms  fixed  pain  in  the  right  iliac  fossa  and  colic.  This  brilliant  in- 
vestigator was  years  ahead  of  his  contemporaries.  He  reported  cases  of  un- 
doubted appendicitis  verified  by  autopsy,  described  gangrene,  perforation, 
associated  peritonitis,  and  appendiceal  concretions.  His  original  article, 
Manley  tells  us,  is  in  the  "Journal  of  Medicine,  Surgery,  and  Pharmacv" 
for  1827,  Second  Series,  no.  |  Mellier  said:  "If  it  were  possible  to  establish 
with  certainty  the  diagnosis  of  this  affection,  we  could  see  the  possibility  of 
curing  the  patient  by  operation.  We  shall  perhaps  some  day  arrive  at  this 
result. "  §  In  spite  of  Mellier's  writings,  the  profession  adhered  for  half  a 
century  to  the  view  of  Dupuytren,  put  forth  in  1833,  that  abscesses  in  the  iliac 
region  take  origin  from  the  cecum  and  not  from  the  appendix.  Dr.  Reginald 
Fitz,  of  Boston,  in  1886  persuaded  the  world  that  the  appendix  is  the  real  seat 
of  most  inflammations  in  the  right  iliac  fossa.  The  appendix  is  a  long  and 
narrow  diverticulum  (musculomembranous  in  structure)  which  comes  from 
the  posterior  and  internal  part  of  the  head  of  the  colon,  and  which  has  no 
physiological  function  (in  herbivora  and  rodents  it  is  a  functionallv  active 
organ).  The  structure  of  the  appendix  is  similar  to  the  structure  of  the  colon, 
except  that  the  muscular  structure  is  ill  developed  and  trivial  in  amount. 
Lockwood  points  out  that  there  is  an  extensive  lymph  system  in  the  appendix, 
and  that  the  submucous  and  subperitoneal  tissues  communicate  by  numerous 
gaps  in  the  muscles.  ||     This  structure  has  a  poor  blood-supply,  and  in  conse- 

*  Wm.  J.  ^Nlayo,  Jour.  Am.  Med.  Assoc,  Oct.  19,  1901. 

tjour.  Med.  et  Chir.,  1760.  J  Thomas  H.  Manley,  Med.  Record,  July  iq.  1902. 

?  See  R.  J.  Lee  Morrill's  article  in  the  Amer.  Med. -Surg.  Bull.,  Dec.  I9,  1S96. 

II  Brit.  Med.  Jour.,  Jan.  27,  1900. 


726  Diseases  and   Injuries  of  the  Abdomen 

quence  gangrene  occurs  from  rather  trivial  causes.  It  is  supphed  by  a  branch 
from  the  superior  mesenteric  artery.  In  women  there  is  sometimes  an  ad- 
ditional supply  by  a  vessel  running  in  the  appendiculo-ovarian  ligament.  The 
nerves  are  derived  from  the  superior  mesenteric  plexus.  The  appendix 
averages  about  four  and  a  half  inches  in  length,  but  varies  in  .size  between  the 
limits  of  I  inch  and  9  inches,  and  its  diameter  is,  as  a  rule,  about  equal  to  that 
of  a  No.  9  Enghsh  bougie;  its  canal  is  narrow  and  is  partly  closed  by  the  valve 
of  Gerlach  (Talamon).  The  appendix  enters  the  cecum  at  its  posterior 
internal  part,  which  is  usually  the  seat  of  the  most  intense  pain  in 
inflammation,  and  corresponds  to  a  point  on  the  surface  two  inches  from  the 
anterior  superior  spine  of  the  ilium,  on  a  line  drawn  from  the  umbihcus  to  the 
iliac  spine,  which  is  known  as  "  McBurney's  point. "  The  free  part  of  the 
appendix  in  one-third  of  all  persons  is  in  relation  with  the  posterior  surface  of 
the  cecum;  in  almost  one-third  of  all  persons  it  is  fixed  in  the  iliac  fossa,  so  that 
if  perforation  occurs  the  contents  will  be  voided  in  the  retroperitoneal  tissue 
(iliac  abscess).  In  some  cases  it  is  external  to  the  cecum;  in  some  it  passes 
downward,  and  in  some  inward.  It  is  important  to  remember  that  the  ap- 
pendix may  be  met  with  in  the  most  unexpected  situations.  When  the  ascend- 
ing colon  is  displaced  the  diverticulum  may  be  upon  the  left  side.  It  is  not 
unusual  to  find  its  tip  in  the  middle  line,  up  toward  or  adherent  to  the  gall- 
bladder, or  in  the  pelvis.  In  about  two-thirds  of  all  cases  the  appendix  is  com- 
pletely covered  with  peritoneum;  in  one-third  of  all  cases  it  is  in  contact,  in 
some  part  of  its  length,  with  cellular  tissue  (Talamon).  Robinson  has  called 
attention  to  the  fact  that  the  appendix  is  frequently  in  contact  with  the  psoas 
muscle  in  men,  and  may  be  bruised  by  this  muscle.  In  10,000  autopsies  the 
appendix  is  said  to  have  been  absent  five  times.  In  most  cases  where  surgeons 
have  been  unable  to  find  the  appendix  it  was  not  absent  but  was  covered  with 
peritoneum.     Occasionally  the  appendix  is  found  in  a  hernial  sac. 

Etiology  and  Pathology. — Appendicitis  is  very  rare  in  infants.  I 
operated  unsuccessfully  on  a  male  three  years  of  age  for  gangrenous  appen- 
dicitis. Savage  operated  unsuccessfully  on  a  baby  sixty-one  days  and  Weiss 
operated  unsuccessfully  on  a  child  twenty  months  old.*  J.  P.  Crozer  Grif- 
fith! has  collected  15  cases  in  children  under  two  years  of  age.  One  of  these 
patients  was  three  months  of  age.  Nine  of  the  15  were  operated  upon,  with 
7  recoveries.  In  4  of  the  cases  the  appendix  was  in  the  scrotum.  In  2  cases 
a  diagnosis  of  intus-susception  was  made.  Appendicitis  is  common  at  any 
period  beyond  childhood,  being  more  frequent  in  young  and  middle-aged 
people  than  in  the  aged.  It  is  about  four  times  as  common  in  males  as  in 
females.  It  is  more  common  in  summer  than  in  other  seasons  and  in  warm 
countries  than  in  cold  or  temperate  climes.  Appendicitis  is  a  bacterial  disease. 
It  is  produced  occasionally  by  pus  cocci,  but  most  commonly  by  the  action  of 
the  bacterium  coli  commune  of  Escherich.  The  colon  bacilli,  which  normally 
inhabit  the  appendix,  are  harmless  when  the  appendix  is  healthy,  but  become 
active  for  harm  when  the  diverticulum  is  bruiserl,  obstructed,  irritated  by  the 
presence  of  uric  acid,  or  congested  Ijecause  of  chilling  of  the  cutaneous  surface 
of  the  body.  When  non-traumatic  inflammation  occurs  swelling  of  the  mucous 
membrane  occludes  the  opening  into  the  colon,  and  Ihe  Iimien  of  the  ap])endix 

*  Manley,  in  Merl.  Record,  July  9,  1902. 

I  University  of  Penna.  Med.  Bull.,  Oct.,  1902. 


Appendicitis  727 

dilates  and  fills  up  with  a  thick  mucopurulent  fluid.  Ulcers  sometimes  form, 
which  may  only  involve  the  mucous  membrane,  may  pass  deeply  into  the  coats, 
or  may  even  perforate.  Dieulafoy  *  maintains  forcefully  that  appendicitis 
is  due  always  to  the  conversion  of  the  appendix  into  a  closed  cavity,  but  cases 
are  met  with  which  disprove  this  assertion.  \'arious  conditions  may  bring 
about  this  transformation.  Partial  obstruction  may  be  caused  by  calculi, 
which  are  composed  of  stercoral  material  and  hordes  of  bacteria  mixed  with 
salts  of  Ume  and  magnesia.  These  calcuh  are  not  formed  in  the  colon,  but  are 
formed  in  the  appendix.  The  theory  that  concretions  form  in  the  colon,  and 
are  forced  into  the  appendix  by  peristalsis,  has  been  very  largely  abandoned. 
Dieulafoy  speaks  of  the  condition  as  appendicular  lithiasis,  and  says  it 
has  a  tendency  to  run  in  family  lines,  and  has  a  kinship  with  gout  and  rheu- 
matism. Obstruction  may  be  caused  by  local  infection  of  a  catarrhal  area, 
by  the  formation  of  a  fibrous  stricture,  or  by  several  causes  acting  in  unison. 
The  presence  of  a  concretion  is  always  dangerous.  It  is  frequently  associated 
with  ulceration,  either  as  cause  or  effect.  It  is  a  mass  of  virulent  bacteria. 
It  may  lead  to  perforation  or  gangrene.  Talamon  taught  that  the  appendix 
resents  the  presence  of  the  concretion,  reflex  contraction  of  the  muscular  coat 
taking  place,  which  is  accompanied  by  violent  pain  (appendicular  colic).  The 
muscular  structure  is  so  rudimentary  that  it  does  not  .seem  probable  that  at- 
tempts at  contraction,  even  should  they  arise,  would  produce  violent  pain  and 
di.stant  symptoms.  Pozzi  believes  that  appendicular  colic  may  be  caused  by 
torsion  or  bending  of  the  appendix,  or  malposition  of  the  diverticulum,  and 
holds  that  pain  may  arise  when  there  is  no  lesion  in  the  appendix  and  no  in- 
flammation of  the  peritoneum  or  pericecal  structures. t  ^^'hat  is  called  ap- 
pendicular cohc  is  really  inflammation  of  the  appendix  without  involvement 
of  the  peritoneum.  The  term  appendicular  colic  has  led  to  much  injudicious 
conservatism,  and,  as  Lockwood  shows,  if  an  appendix  is  removed  from  an 
individual  who  suft"ers  from  attacks  of  appendicular  colic,  it  will  usually  be 
found  that  the  diverticulum  is  inflamed  or  the  lumen  contains  a  concretion. 
Foreign  bodies,  such  as  pins,  fish-bones,  nails,  buttons,  date-stones,  cherry- 
stones, and  grape-seeds,  may  enter  the  appendix,  but  they  do  so  far  less  often 
than  is  generally  supposed,  most  alleged  grape-seeds  from  the  appendix  being 
fecal  concretions.  Fitz  found  concretions  in  15  cases  out  of  300.  Ranvier 
collected  the  records  of  459  post-mortems,  and  found  reported  179  fecal  con- 
cretions and  16  foreign  bodies.  Appendicitis  due  to  a  foreign  body,  such  as  a 
grape-seed  or  a  pin,  is  known  as  traumatic;  appendicitis  in  which  a  concretion 
is  the  assumed  cause  is  known  as  stercoral.  A  foreign  bod}"  ma}"  produce  in- 
stant perforation.  If  impaction  of  a  foreign  body  or  concretion  occurs,  the 
orifice  of  the  appendix  is  closed,  the  circulation  is  soon  cut  oft",  the  secretions 
are  retained-,  the  coats  become  congested,  the  diverticulum  enlarges  enor- 
mously, microbes  multiply  with  great  rapidity,  and  the  wall  of  the  congested 
appendix  inflames  and  may  become  gangrenous  or  ulcerated,  and  is  finally  per- 
forated. Interference  with  the  blood-supply  of  the  appendix  will  predispose 
to  appendicitis.  This  may  be  brought  about  by  twists,  bruises,  adhesions, 
concretions,  pressure,  or  bands;  and  the  psoas  muscle  may  play  a  part  in  the 
production  of  these  conditions.  In  women  appendicitis  is  occasionally  secon- 
dary to  tubo-ovarian  disease.     Appendicitis  is  rarer  in  women  than  in  men, 

*  Progres  medicale,  No.  11,  1896.  "I"  Piogres  medicale.  No.  19,  1S96. 


728  Diseases  and   Injuries  of   the  Abdomen 

probably  because  in  many  females  the  appendix  has  a  better  blood-supply  than 
in  males,  the  additional  supply  coming  through  the  folds  of  the  appendiculo- 
ovarian  ligament.  In  women  disease  of  the  uterus  or  adnexa  frequentl)^  pre- 
cedes or  actually  causes  appendicitis.  Catarrhal  conditions  of  the  intestine, 
habitual  constipation,  and  indigestion  with  flatulence  predispose  to  appen- 
dicitis. In  fact,  in  a  great  majority  of  cases  there  has  been  a  more  or  less  pro- 
longed history  of  diarrhea  or  constipation,  and  flatulent  indigestion  before  the 
development  of  acute  appendicitis.  An  acute  attack  of  appendicitis  frequently 
arises  after  the  eating  of  a  large  and  indigestible  meal,  especially  if  such  a  meal 
is  taken  late  at  night.  Bolting  the  food  and  eating  large  meals  at  irregular 
hours  predispose.  It  seems  probable  that  catarrhal  appendicitis  may  result 
from  extension  of  a  catarrh  of  the  colon,  and  may  also  in  rare  cases  arise  from 
external  traumatism.  In  most  cases,  however,  in  which  appendicitis  seems  to 
be  produced  by  a  blow,  the  injury  simply  awakened  a  sleeping  dog  and  stirred 
into  activity  an  appendix  already  diseased.  If  before  perforation  the  appendix 
adheres  to  the  cellular  tissue  behind  the  cecum,  cellulitis  or  abscess  without 
peritonitis  may  result.  When  appendicitis  goes  on  to  perforation,  there  is 
always  some  peritonitis;  but  if  the  steps  to  perforation  are  gradual,  and  if  the 
causative  organism  is  the  colon  bacillus,  the  peritonitis  may  be  local,  and  will 
sometimes  by  formation  of  adhesions  make  a  barrier  between  the  appendix 
and  the  peritoneal  cavity  before  perforation  occurs.  When  perforation  takes 
place  suddenly  diffused  septic  peritonitis  is  inevitable.  When  the  causative 
organism  is  the  streptococcus  general  peritonitis  is  very  apt  to  arise.  Peritonitis 
may  arise  without  perforation  by  contiguity  of  structure  or  by  migration  of 
bacteria  through  the  congested  walls  of  an  obstructed  appendix.  In  some  cases 
perforation  takes  place  into  the  peritoneal  cavity,  but  pus  is  circumscribed  by 
matting  together  of  the  intestines  with  plastic  exudate.  The  appendix  may 
become  gangrenous  very  rapidly  or  after  some  time.  A  case  of  appendicitis 
in  which  gangrene  and  perforation  come  on  very  quickly  is  spoken  of  as 
fulminating  appendicitis.  In  some  cases,  if  the  perforation  is  very  small  and 
the  appendix  is  swathed  in  lymph,  or  if  perforation  does  not  occur,  the  in- 
flammation may  subside.  Perforation  rarely  occurs  from  liquid  pressure  or 
from  the  pressure  of  a  concretion;  it  is  generally  due  to  ulceration  produced  by 
the  action  of  micro-organisms.  Appendicitis  which  subsides  may  at  any  time 
recur,  and  the  life  of  the  patient  is  under  constant  menace.  An  enormous 
number  of  people  have  had  appendicitis.  Toft  recorded  500  autopsies,  and  in 
36  per  cent,  of  them  there  were  positive  signs  of  past  attacks.  The  disease  is 
occasionally  unsuspected  during  life.  These  facts  prove  that  the  disease  may 
subside  without  the  aid  of  surgery. 

Forms  of  Appendicitis. — In  what  is  known  as  appendicular  colic  the 
appendix  is  temporarily  obstructed  because  of  transitory  inflammatory  swelling 
of  the  mucous  membrane  of  the  outlet,  and  the  stercoral  contents  are  retained 
in  the  diverticulum.  The  peritoneal  covering  is  not  involved  in  the  inflamma- 
tion. This  condition  is  called  by  Fergusson  "constipation  of  the  appendix." 
If  not  relieved,  it  will  eventuate  in  appendicitis  with  involvement  of  the  perito- 
neum. It  is  an  unfortunate  term,  sometimes  used  as  an  excuse  for  avoiding 
operation.     In  such  cases  a  concretion  is  frequently  or  usually  present. 

Simple  parietal  or  ralarrhal  appendicitis  is  not  limited  to  the  mucous  mem- 
brane; hence  the  term  catarrhal  is  not  strictly  correct.     The  vessels  of  the 


APPENDICITIS. 


Plate  8. 


Various  forms  of  appendicitis  (from  drawings  by  Dr.  M.  H.  Richardson):  i.  Obstruction  from 
stenosis  of  appendix.  2.  Dilatation  of  distal  end  of  appendi.v  ;  perforation  by  a  fecal  concretion. 
3.  Gangrene  of  nearly  the  whole  of  the  appendix  ;  fecal  concretion  in  lumen. 


Appendicitis  729 

appendix  are  distended  with  blood,  the  lumen  at  the  intestinal  end  becomes 
partially  or  completely  obstructed,  the  epithelium  desquamates  from  numerous 
glands,  the  mucosa  ulcerates,  and  the  lumen  of  the  appendix  becomes  filled 
with  a  mixture  of  mucus,  bacteria,  and  portions  of  organic  matter.  Bacteria 
enter  the  lymph-spaces  of  the  wall  of  the  appendix,  and  pass  rapidly  from  the 
submucous  to  the  subperitoneal  tissues.  Within  forty-eight  hours  after  the 
mucous  coat  begins  to  inflame  the  peritoneal  coat  will  probably  be  involved. 
This  inflammation  may  undergo  resolution  and  the  patient  get  well  or  events 
may  result  disastrously.  The  appendix  may  thicken  and  ulceration  take  place. 
Suppuration  or  gangrene  may  occur,  perforation  may  take  place,  or  pyemia, 
with  abscess  of  the  liver,  may  arise.  The  acute  condition  may  pass  into 
chronic  appendicitis,  or  ulcerations  of  the  mucosa  may  remain;  the  mucous 
crypts  may  be  filled  with  bacteria;  a  concretion  may  exist;  cicatricial  con- 
tractions may  occur;  in  any  one  of  these  conditions  the  patient  is  in  danger  of  a 
fresh  attack  at  any  time.  In  a  catarrhal  inflammation  secondary  to  catarrh  of 
*  the  colon  the  case  may  be  chronic  from  the  beginning.  If  the  lumen  of  the 
appendix  is  gradually  and  completely  obliterated,  the  condition  is  denominated 
obliterative  appendicitis  (Senn).  This  progressive  obliteration  may  result 
from  repeated  attacks  of  inflammation  or  may  be  simply  a  degenerative  change. 
Recurrent  appendicitis,  it  has  been  said,  may  be  due  to  inordinate  size  of  the 
mouth  of  the  appendix,  making  of  this  diverticulum  a  drag-net  for  foreign 
bodies;  but  it  is  more  probable  that  it  is  due  to  smallness  of  the  opening,  so 
that  it  quickly  closes  from  slight  swelling  and  converts  the  appendix  into  a 
closed  vase  filled  with  septic  material.  Suppurative  appendicitis  is  due  to 
purulent  infiltration  of  the  walls.  Pus  in  the  lumen  is  not  purulent  appen- 
dicitis. Pus  may  form  about  the  appendix,  a  condition  known  as  appendiceal 
or  appendicular  abscess.  Gangrenous  appendicitis  is  a  moist  or  septic  gan- 
grene, due  to  interference  with  the  circulation  and  to  tissue-destruction  by  the 
action  of  micro-organisms.  Perforations  occur,  and  they  are  often  multiple. 
The  entire  appendix  may  slough  off.  Interference  with  circulation  may  be 
caused  by  an  obstruction,  by  a  bend  or  twist  or  bruise  of  the  appendix,  or  by  the 
action  of  virulent  organisms  on  an  appendix  whose  tissue-resistance  is  lowered 
by  injury  or  disease.  In  gangrenous  cases  the  vessels  of  the  meso-appendix  are 
usually  obstructed  by  thrombi  or  the  changes  of  arteritis  (Van  Cott).  In  rare 
instances  appendicitis  is  due  to  tuberculous  ulceration, in  other  cases  to  typhoid 
ulceration,  and  genuine  appendicitis  may  arise  during  typhoid  fever. 

Fowler  suggests  the  following  classification  of  cases  of  appendicitis:  (i) 
endo-appendicitis;  (2)  parietal  appendicitis;  (3)  peri-appendicitis;  (4)  para- 
appendicitis. 

As  a  matter  of  fact,  appendicitis  is  always  one  disease,  which  varies  in 
intensity,  and  it  is  useless  to  divide  it  into  a  great  number  of  symptomatic 
groups. 

Symptoms  and  Signs. — In  what  is  known  as  appendicular  colic  the  patient 
suffers  from  disorder  of  digestion  and  occasionally  has  a  brief  attack  of  abdom- 
inal pain  associated  with  trivial  and  temporary  tenderness  in  the  right  iliac 
fossa.  The  colicky  pain  is  about  the  umbilicus  and  right  iliac  fossa;  there  is 
often  nausea  and  usually  constipation.  This  condition,  if  not  soon  relieved,  is 
followed  by  the  evidences  of  peritoneal  inflammation.  The  symptoms  of 
genuine  appendicitis  are  as  follows :     In  some  cases  the  disease  seems  to  begin 


730  Diseases   and   Injuries   of   the  Abdomen 

suddenly,  but  in  the  vast  majority  of  cases  for  a  few  hours  or  a  day  or  two  there 
are  distinct  premonitory  symptoms,  among  which  are  constipation  and  diarrhea, 
flatulence,  nausea,  and  even  vomiting,  anorexia,  dyspepsia,  coated  tongue, 
weakness,  general  gastro-intestinal  uneasiness,  colicky  pain  about  the  um- 
bilicus, and  the  development  of  tenderness,  a  sense  of  weight,  soreness  or 
actual  pain  in  the  right  iliac  fossa.  The  acute  symptoms  suddenly  appear 
after  the  premonitory  symptoms  have  lasted  a  variable  time,  and  the  acute 
symptoms  very  frequently  appear  in  the  early  hours  of  the  morning.  The 
tongue  is  coated  and  usually  dry.  Great  thirst  is  often  complained  of.  The 
face  is  expressive  of  pain,  or  later,  in  a  severe  case,  becomes  Hippocratic.  The 
posture  assumed  for  greater  ease  is  one  of  recumbency  with  the  right  thigh  and 
knee  or  both  thighs  and  knees  partly  flexed.  Leukocytosis  is  usually  present 
(see  remarks  on  Diagnosis).  Respirations  in  acute  appendicitis  are  shallow 
and  thoracic.  The  development  of  acute  pain  is  usually  the  most  prominent 
symptom.  The  pain  is  at  first  located  about  the  umbilicus  or  through  the 
abdomen  in  general,  this  distant  or  generalized  pain,  according  to  Treves, 
corresponding  to  the  distribution  of  the  superior  mesenteric  plexus.  Usually,  in 
from  twelve  to  twenty-four  hours  the  pain  becomes  localized  in  the  right  iliac 
fossa,  and  associated  with  tenderness  and  hyperesthesia  of  the  skin.  The  usvial 
location  of  the  pain  in  the  right  iliac  fossa  depends  on  the  fact  that  the  appendix 
is  usually  placed  in  that  region.  Occasionally  when  the  appendix  crosses  the 
belly  the  pain  is  located  on  the  left  side,  and  occasionally,  for  like  reasons,  in  the 
gall-bladder  region,  the  right  loin,  or  the  pelvis.  If  the  pain  of  appendicitis 
is  violent,  the  patient  presents  some  evidences  of  shock.  Nausea  is  the  rule 
in  appendicitis;  vomiting  usually  occurs  early  in  the  case,  and  in  children  is 
often  violent  and  persistent.  But  in  adults,  after  the  early  hours  of  the  attack, 
vomiting  occurs,  as  a  rule,  occasionally  or  not  at  all,  although  nausea  is  com- 
plained of.  If  vomiting  persists,  it  points  to  diffusing  peritonitis,  to  pus- 
formation,  or  to  intestinal  obstruction  unless  it  results  from  the  administration 
of  morphin.  There  is  usually  constipation  in  acute  appendicitis,  although 
diarrhea  occasionally  occurs.  As  a  rule,  in  appendicitis  there  is  fever,  not 
ushered  in  by  a  chill,  but  the  temperature  mounting  in  the  course  of  a  few  hours 
to  102°  or  103°  F.  or  even  higher.  In  a  very  mild  case  the  temperature  remains 
elevated  for  a  day  or  two  and  then  falls  to  normal.  In  severe  cases  it  is  apt  to 
remain  elevated  for  a  longer  period,  but  it  is  always  to  be  borne  in  mind  that  in 
very  grave  appendicitis  there  may  be  very  little  elevation  of  temperature,  no 
elevation,  or  actually  a  subnormal  temperature.  In  gangrenous  cases,  and  in 
cases  in  which  a  large  perforation  suddenly  forms,  and  when  general  peritonitis 
develops  there  is  usually,  for  a  time  at  least,  a  subnormal  tem])erature.  A 
sudden  drop  of  temperature  indicates,  as  a  rule,  a  ])eritoncal  calamity.  The 
pulse  in  appendicitis  is  in  most  cases  rapid.  A  very  rapid  pulse  (over  no) 
is  significant  usually  of  a  .severe  case,  and  the  auguries  are  especially  ominous 
if  the  pulse  is  rapid  but  the  temperature  is  normal  or  subnormal.  Occasion- 
ally, however,  a  slow  pulse  exists,  even  in  the  worst  ca.ses. 

Examination  of  the  abdomen  discovers,  early  in  the  ca.sc,- general  al)dom- 
inal  rigidity;  but  usually  in  the  course  of  twenty-four  hours  or  more,  tlie 
general  rigidity  passes  away,  the  abdomen  distends  more  or  less,  and  rigidity  of 
the  lower  half  of  the  right  belly  becomes  evident  and  persists.  If  general 
peritonitis  begins  early,  general  abcltjminal  rigidity  docs  not  abate  or  pass  away. 


Appendicitis  73 1 

If  general  peritonitis  begins  later,  general  abdominal  rigidity,  which  was  pres- 
ent at  first  but  which  passed  away,  returns.  Rigidity  may  not  exist  in  the 
very  beginning  of  appendicitis — in  a  case  in  which  the  appendix  is  retrocecal 
or  pelvic  and  in  some  abscess  cases. 

A  symptom  almost  invariably  present  in  appendicitis  is  tenderness.  In 
some  cases  the  tenderness  is  diffuse;  in  most  it  is  localized,  or  at  least  most  acute, 
in  the  right  iliac  fossa.  The  point  where  tenderness  is  usually  most  acute  is  a 
spot  about  2  inches  internal  to  the  anterior  superior  spine  of  the  ilium  on  a  line 
drawn  from  that  bony  point  to  the  umbilicus.  This  is  known  as  "  McBurney's 
point,  '•  and  ov^erlies  the  usual  point  of  origin  of  the  appendix.  In  some  cases, 
however,  the  greatest  point  of  tenderness  is  nearer  the  gall-bladder;  in  others 
in  the  loin;  in  others  toward  the  umbilicus,  in  the  mid-line,  or  on  the  opposite 
side;  in  others  in  the  rectum.  The  seat  of  greatest  tenderness  depends  on  the 
situation  of  the  appendix,  and  it  is  usually  at  McBurney's  point  because  this 
usually  overlies  the  origin  of  the  appendix.  The  lesson  is  that  in  appendicitis 
there  is  a  point  of  tenderness  or  of  greatest  tenderness  in  a  region  which  the  ap- 
pendix could  occupy.  If  tenderness  exists  on  the  right  side  and  then  develops  in 
the  left  side  severe  spreading  peritonitis  usually  exists  (W.  Meyer).  When  the 
appendix  becomes  gangrenous,  local  tenderness  may  for  a  time  disappear,  be- 
cause the  peritoneum  of  the  involved  region  has  become  anesthetic;  later,  how- 
ever, it  returns,  spreads,  and  may  become  general.  In  view  of  the  fact  that 
tenderness  in  the  right  iliac  fossa  is  often  demonstrable  in  tubal  and  ovarian 
disease,  the  sign  in  males  "is  of  greater  significance  than  in  females"  (A.  H. 
Tubby,  on  "Appendicitis,"  Medical  Monograph  Series).  Pressure  upon  the 
left  side  will,  in  some  cases,  cause  pain  in  the  right  iliac  region.  When 
rigidity  abates  or  disappears  the  case  may  go  on  to  cure,  but  sometimes  a  mass 
becomes  evident  in  the  right  iliac  fossa.  The  mass,  of  variable  shape,  is  at 
first  hard,  and  if  of  any  considerable  size  is  dull  on  percussion.  In  some  cases, 
when  no  mass  is  palpable  through  the  abdominal  wall,  rectal  examination  de- 
tects one.  This  mass  may  be  agglutinated  bowel  and  omentum  or  a  collection 
of  coagulated  inflammatory  exudate.  It  may  gradually  disappear  or  an 
abscess  may  form.  The  evidences  of  general  peritonitis  are:  great  distention 
because  of  intestinal  paresis,  general  abdominal  tenderness,  rectal  tenderness, 
very  rapid  pulse,  hiccough,  persistent  vomiting  which  may  become  regur- 
gitation, and  as  Meyer  points  out,  percussion  dulness  over  the  right  iliac 
region  or  entire  lower  abdomen. 

In  some  cases  the  symptoms,  at  first  trivial,  become  grave.  In  some 
all  the  symptoms  are  violent  from  the  beginning,  the  attack  tends  to  linger, 
and  is  followed  by  persistent  soreness  of  the  appendix  and  harassing  digestive 
disturbances.  Any  case  of  appendicitis  may  become  suddenly  desperately 
grave  because  of  perforation  or  gangrene,  and  in  any  case  general  peritonitis 
may  dev^elop.  After  sudden  perforation  or  rapid  gangrene  the  temperature 
falls,  hiccough  begins,  abdominal  distention,  pain,  and  tenderness  become 
marked  and  general,  and  the  pulse  becomes  very  rapid.  In  some  cases 
these  grave  symptoms  are  present  almost  from  the  start  (fulminating  cases). 
A  sudden  perforation  produces  collapse,  and,  if  reaction  takes  place,  general 
peritonitis  arises.  Peritonitis,  be  it  remembered,  may  arise  without  either 
perforation  or  gangrene.  If  pus  forms,  it  may  be  unlimited  by  adhesion. 
In  such  cases  there  is  the  rapid  onset  of  fatal  peritonitis  and   septicemia. 


732  Diseases  and   Injuries  of   the  Abdomen 

Pus  may  be  limited  by  adliesions  and  be  practically  extraperitoneal.  In 
such  a  case  a  lump  is  felt  in  the  right  ihac  region,  but  dusky  discoloration 
and  edema  of  skin  very  seldom  exist.  The  surgeon  does  not  wait  for  fluctua- 
tion before  he  makes  a  diagnosis.  In  an  abscess  case  there  are  usually 
irregular  fever  and  sweating,  but  rigbrs  do  not  occur.  Hawkins  says  we 
should  always  suspect  pus  if  the  symptoms  continue  after  the  sixth  day, 
and  particularly  when  the  symptoms  abate  and  suddenly  increase  between 
the  seventh  and  tenth  days.  A  limited  collection  of  pus  may  be  liberated 
into  the  peritoneal  cavity  by  rupture  of  the  abscess-wall.  Such  a  rupture 
may  be  caused  by  pressure  or  muscular  effort;  rupture  is  fohowed  at  once 
by  shock  and  later  by  diffused  peritonitis.  An  abscess  may  rupture 
externally,  or  into  the  vagina,  intestinal  tract,  or  bladder.  It  is  desirable,  if 
possible,  to  locate  the  situation  of  the  appendix,  and  this  is  usually  deter- 
mined by  locating  the  seat  of  swelling  and  of  greatest  tenderness.  The  sur- 
geon should  not  lose  sight  of  the  fact  that  the  appendix  may  be  found  in 
the  most  unexpected  situations.  In  every  case  a  rectal  or  vaginal  exami- 
nation should  be  made,  in  order  to  detect  swelhng  and  tenderness,  and 
thus  determine  if  the  inflammation  took  origin  in  or  has  come  to  involve 
the  pelvic  region.  Pain  at  the  end  of  micturition  points  to  involvement 
of  the  vesical  peritoneum.*  In  cases  where  there  is  not  localized  swell- 
ing and  tenderness, — for  instance,  in  gangrenous  or  perforative  appendicitis 
with  general  peritonitis, — "diagnostic  localization"  is  impossible  (Van  Hook). 

Terminations  and  Prognosis. — Acute  appendicitis  may  terminate  in 
death,  in  complete  recovery,  or  in  a  condition  of  lowered  vitality  during 
the  existence  of  which  acute  attacks  are  almost  certain  to  occur.  Sometimes 
after  and  sometimes  without  an  antecedent  acute  attack  the  patient  develops 
persistent  soreness  and  tenderness  in  the  right  iliac  region.  Between  the 
attacks  of  recurrent  appendicitis  there  may  be  soreness,  tenderness,  and 
gastro-intestinal  disturbance,  or  there  may  be  no  evident  trouble  whatever; 
yet,  even  in  the  latter  case,  there  may  be  an  ulcer  or  ulcers  of  the  mucous 
lining.  If  a  patient  has  once  had  appendicitis,  he  will  always  be  liable  to 
suffer  from  another  attack  if  the  appendix  has  not  been  removed.  The 
liability  becomes  almost  a  certainty  if  the  intestinal  end  of  the  appendix 
is  narrowed  or  if  the  lumen  is  obstructed  at  any  point,  if  a  concretion  exists, 
or  if  there  is  an  area  of  ulceration  or  of  desquamating  epithelium.  After 
an  attack  the  appendix  may  remain  enlarged  and  tender;  exercise  or  indis- 
cretion in  diet  may  cause  it  to  become  tender,  or  the  patient  may  have  occa- 
sional attacks  of  colicky  pain.  If  any  of  the  above  conditions  exi.st,  another 
attack  may  be  confidently  anticipated  if  operation  is  not  performed.  In 
such  cases  the  appendix  can  usually  be  palpated.  The  method  of  palpation 
proposed  by  Robert  T.  Morris  is  very  useful. f     It  is  a])])]ied  as  follows: 

The  surgeon  stands  to  the  right  of  the  patient  and  u.ses  three  fingers 
of  the  right  hand  to  feel  with  and  three  fingers  of  the  left  hand  to  press  with. 
Morris  insists  that  no  muscular  effort  should  be  used  by  the  hand  which 
feels.  The  feeling  fingers  are  pressed  by  the  other  fingers  beneath  the  margin 
of  the  right  rectus  muscle  on  a  level  with  the  umbilicus,  and  are  drawn  toward 
the  patient's  right  side,  and  the  colon  will  be  felt  to  roll  under  the  fingers. 

*Van  ITof.k,  in  Jour.  Am.   Med.  Assoc,  t'cb.  20,  1897. 
I  See  Medical  Record,  Sept.   17,  1898. 


Appendicitis  733 

The  process  is  repeated  several  times  until  the  end  of  the  cecum  is  reached. 
The  appendix  is  sought  for  by  rolling  the  cecum  from  side  to  side  with  the 
finger-tips,  and  working  toward  the  proximal  end  of  the  appendix.* 

Adhesions  may  form  as  a  result  of  appendicitis,  general  peritonitis  may 
arise,  the  appendix  may  slough  or  become  perforated,  or  abscess  may  ensue 
upon  local  peritonitis.  Lymphangitis  of  the  appendix  may  accompany, 
and  septic  phlebitis  and  abscess  of  the  liver  may  follow,  appendicitis. 

Among  other  possible  consequences  of  appendicitis  may  be  mentioned 
pyemia,  subphrenic  abscess,  empyema,  inflammation  of  the  parotid  gland, 
and  thrombosis  of  the  right  iliac  vein.  A  positive  prognosis  of  any  case 
of  appendicitis  is  an  absolute  impossibility.  The  futvire  of  every  case  is 
cloudy  with  uncertainty,  and  the  most  that  can  be  attained  in  the  field  of 
prediction  is  a  scientific  guess  of  more  or  less  probability.  All  surgeons 
have  seen  apparently  hopeless  cases  recover,  and  have  observed  cases  with 
the  most  trivial  symptoms  grow  progressively  worse  or  suddenly  develop 
a  fatal  complication.  Further,  after  one  attack,  other  attacks  are  very  apt 
to  arise.  The  medical  man  who  estimates  that  80  or  90  per  cent,  of  cases 
get  well  without  operation  has  probably  dealt  with  many  catarrhal  cases, 
and  he  certainlv  is  optimistic  as  to  freedom  from  future  attacks,  because, 
as  stated  before,  recovery  from  an  attack  does  not  of  necessity  mean  freedom 
from  the  disease.  In  appendicitis  there  may  be  delusive  evidences  of  improve- 
ment; for  instance,  the  abatement  of  pain  and  the  lessening  of  fever  being 
regarded  by  the  patient  himself  as  indubitable  signs  of  improvement,  may 
in  reality  be  indicati\'e  of  gangrene.  In  spite  of  the  previously  mentioned 
difficulties  and  obscurities,  we  can  in  the  majority  of  cases  decide  with  a 
reasonable  probability  of  accuracy  whether  or  not  the  patient  is  becoming 
worse.  In  a  delusive  improvement  some  signs  and  symptoms  improve, 
but  all  do  not;  and  in  endeavoring  to  form  a  prognosis,  all  the  signs  and 
symptoms  must  be  noted  and  weighed:  pain,  tenderness,  rigidity,  distention, 
nausea  and  vomiting,  delirium,  intestinal  obstruction,  shock,  the  tem- 
perature, the  rapidity  of  the  pulse,  the  blood  examination,  etc.  If  (///  these 
elements,  not  only  some  of  them,  point  to  improvement,  we  may  be  reason- 
ably confident  that  improvement  is  really  taking  place.  If  only  some  of  them 
point  to  improvement,  we  will  in  many  cases  be  altogether  uncertain  as 
to  the  significance  of  the  change. 

Diagnosis. — The  diagnosis  is  not  invariably  certain,  as  many  light- 
hearted  operators  seem  to  believe.  It  is  frequently  far  from  easy  and  is 
sometimes  altogether  impossible  without  exploratory  operation.  Sonnenburg 
maintains  that  we  can  diagnosticate  the  pathological  condition  of  the  in- 
flamed appendix.  Personally,  I  am  unable  to  do  this  with  any  certainty, 
although  I  always  try,  and  am  often  right  and  just  as  often  wrong. 

In  attempting  to  make  a  diagnosis,  besides  the  ordinary  e.xamination 
of  the  abdomen  a  rectal  or  vaginal  examination  should  be  made,  associated 
in  many  cases  with  bimanual  palpation.  If  an  appendix  is  enlarged  and 
an  individual  has  a  thin  abdomen  which  is  not  rigid,  it  is  often  possible  to 
palpate  the  appendix.  Sometimes  it  can  be  felt  after  the  administration 
of  ether  when  it  could  not  be  detected  before.  In  an  acute  case  forcible 
or  prolonged  palpation  is  always  unjustifiable,  as  it  may  force  an  ulcer  to 

*  Robert  T.  iMonis,  in  Medical  Record,  Sept.   17,  1S9S. 


734  Diseases  and  Injuries  of  the  Abdomen 

perforate,  or  may  rupture  an  abscess,  and  the  information  gained  is  not 
of  sufficient  importance  to  justify  the  risk.  In  a  chronic  case  information 
of  great  vakie  may  be  obtained  and  there  is  no  real  risk  in  the  maneuver. 

The  disease  may  be  confused  with  a  number  of  different  conditions. 
It  sometimes  is  confused  with  typhoid  fever;  in  fact,  an  early  typhoid  fever 
associated  with  marked  abdominal  pain  gives  a  picture  very  similar  to  that 
furnished  by  appendicitis. 

In  typhoid  fever  the  temperature  is  usually  distinctly  higher  than  that 
commonly  encountered  in  appendicitis.  Maurice  H.  Richardson  *  tells  us 
that  in  every  case  in  which  typhoid  is  suspected,  operation  is  not  justifiable 
on  the  hypothesis  of  existing  appendicitis,  unless  there  is  local  pain  and 
localized  tenderness  in  the  appendix  region,  associated  with  definite  mus- 
cular resistance  or  distinct  rigidity;  and  that  operation  should  be  postponed 
in  a  case  in  which  the  constitutional  signs  are  severe  and  the  local  signs 
are  difficult  to  detect;  but  when  there  are  pain,  tenderness,  and  rigidity, 
with  or  without  distention,  operation  must  be  performed,  even  when  one 
recognizes  the  possibility  of  the  existence  of  typhoid  fever.  Richardson 
lays  down  the  following  rule:  Soft  abdomen  plus  high  temperature  suggests 
typhoid,  even  if  there  is  pain  and  tenderness.  In  appendicitis  there  is  usually 
leukocytosis;  in  typhoid  leukocytosis  is  absent,  except  when  perforation  is 
imminent.  I  have  seen  the  operation  performed  twice  for  supposed  appen- 
dicitis when  the  condition  in  each  case  was  found  to  be  early  typhoid  fever. 

Acute  intestinal  obstruction  is  sometimes  confused  with  acute  appendi- 
citis, and  the  mistake  is  particularly  likely  to  occur  if  the  obstruction  is  due 
to  intussusception.  In  acute  obstruction,  as  in  appendicitis,  the  pain  is 
first  appreciated  about  the  umbihcus;  but  in  acute  obstruction  it  remains 
in  that  region,  does  not  pass  to  and  localize  itself  in  the  right  iliac  fossa, 
and  is  not  associated  with  tenderness  of  the  right  iliac  fossa.  In  obstruction 
the  vomiting  is  persistent;  in  appendicitis,  except  in  the  beginning,  it  is 
usually  trivial  and  often  absent,  although  in  children  it  may  be  violent 
and  persistent.  In  acute  obstruction  shock  is  much  more  pronounced 
than  in  appendicitis,  and  early  and  great  distention  of  the  abdomen  is 
noted.  The  temperature  of  obstruction  is  usually  subnormal;  while  in 
appendicitis,  at  least  in  the  majority  of  cases,  the  temperature  is  distinctly 
elevated.  Further,  in  acute  intestinal  obstruction  the  constipation  is  absolute, 
except  in  cases  of  intussusception.  In  children,  intussusception  is  capable 
of  particularly  confusing  the  diagnosis,  because,  after  the  first  day,  it  is  by 
no  means  unusual  to  have  distinct  fever  in  this  condition,  and  occasionally 
a  tumor-like  mass  is  found  in  the  right  iliac  fossa;  but  in  intussusception  the 
tumor  does  not  remain  fixed,  but  alters  its  position;  it  is  movable;  and  the 
patient  usually  suffers  from  tenesmus  and  the  passage  of  bloody  mucus. 
One  should  bear  in  mind  that  in  acute  appendicitis  associated  with  septic 
peritonitis,  acute  obstruction  may  exist;  and  that  the  diagnosis  of  obstruction 
may  be  made  without  recognizing  the  appendicitis. 

Lesions  of  the  kidney  are  sometimes  mistaken  for  appendicitis,  but  in 
renal  colic  the  pain  runs  into  the  groin  and  testicle  of  that  side,  and  occasion- 
ally passes  flown  the  front  of  the  thigh  or  into  the  rectum;  and  if  any  tender- 
ness exists,  it  is  found  in  the  loin  or  in  the  groin,  rather  than  in  the  right 
*  Bcston  Med.  and  Surg.  Jour.,  Jan.  9,  1902. 


Appendicitis  735 

iliac  fossa.  Besides  this,  there  are  other  symptoms  of  kidney  trouble.  The 
urine  may  contain  blood  or  pus,  and  there  may  be  a  history  of  difficult  or 
of  frequent  urination;  though  one  should  bear  in  mind  that  in  appendicitis 
with  an  appendix  attached  to  the  bladder,  there  may  also  be  a  record  of 
urinary  difficulties.  An  .v-ray  picture  may  exhibit  a  calculus  in  the  ureter 
or  kidney,  and  a  movable  kidney  is  distinctly  palpable.  In  ordinary  renal 
colic  there  is  vomiting  in  the  beginning,  just  as  in  the  beginning  of  appen- 
dicitis. In  movable  kidney  the  vomiting  is  often  more  violent  and  pro- 
longed than  is  common  in  appendicitis.  Movable  kidney  and  appendicitis 
may  exist  coincidently. 

Gall-bladder  difficulties,  too,  mav  be  confounded  with  appendicitis.  I 
have  operated  upon  a  case  of  cholecystitis,  under  the  supposition  that  it 
was  one  of  appendicitis;  and  upon  a  case  of  appendicitis  with  the  appendix 
adherent  to  the  gall-bladder,  in  the  belief  that  the  condition  was  cholecvstitis. 
In  an  inflammation  of  the  gall-bladder,  with  a  distended  gall-bladder,  hanging 
low  down,  and  with  muscular  rigidity,  the  distinction  is  always  difficult 
and  sometimes  impossible.  In  ordinary  gall-stone  colic  the  condition  is 
usually  sudden  in  onset;  it  is  characterized  by  pain  in  the  epigastric  region, 
passing  toward  the  shoulder-blade  and  the  shoulder,  the  pain  being  most 
acute  and  becoming  more  or  less  localized  in  the  region  of  the  gall-bladder; 
and  there  is  always  tenderness  over  the  gall-bladder  region.  In  gall-bladder 
colic  the  vomiting  is  violent  and  continuous. 

The  perforation  of  a  gastric  ulcer  or  of  a  duodenal  ulcer  mav  be  diag- 
nosticated as  appendicitis.  In  perforation  of  a  gastric  ulcer  there  is  usually 
a  history  of  previous  difficulty  with  the  stomach;  though  this  is  not  always 
the  case.  The  onset  of  perforation  is  sudden,  with  much  greater  shock 
than  is  characteristic  of  the  onset  of  appendicitis.  The  pain  is  violent  and 
the  pain  and  rigidity  and  tenderness  are  in  the  epigastric  region. 

Among  other  conditions  that  may  be  confused  with  appendicitis  may 
be  mentioned  malignant  disease  of  the  cecum,  tuberculosis  of  the  cecum, 
acute  tuberculous  peritonitis,  twisting  of  the  pedicle  of  an  ovarian  tumor, 
tubal  disease,  extra-uterine  pregnancy,  membranous  colitis,  perinephric  ab- 
scess, tuberculous  abscess  of  the  loin  or  of  the  groin,  and  abscess  from  hip- 
joint  disease. 

In  reaching  a  diagnosis  in  doubtful  cases  of  appendicitis,  I  believe  that 
the  blood-count  is  often  of  service.  It  is,  of  course,  not  to  be  maintained 
that  the  diagnosis  of  appendicitis  may  be  made  by  counting  the  blood;  but 
the  blood-count  may  furnish  evidence  that,  when  added  to  the  other  signs 
and  symptoms,  may  be  of  great  importance.  In  nearlv  everv  case  of  appen- 
dicitis the  hemoglobin  is  diminished  by  at  least  30  per  cent.  In  a  catarrhal 
appendicitis  or  in  an  interstitial  appendicitis  the  leukocytosis  is  trivial;  but 
in  cases  of  abscess  or  of  gangrene  of  the  appendix  the  leukocvtes,  as  a  rule, 
rise  from  fifteen  to  twenty  thousand.  It  is  to  be  remembered,  however, 
that  when  the  patient  is  profoundly  septic,  the  systemic  condition  is  so  de- 
pressed that  leukocytosis  is  impossible;  hence,  leukocytosis  maybe  absent  in 
trivial  catarrhal  cases  or  in  grave  cases  with  overwhelming  general  sepsis. 
This  latter  condition,  however,  is  extremely  rare.  The  blood-count  will  not 
help  one  in  making  the  differentiation  between  appendicitis  and  an  inflam- 
matory disorder  of   the  pelvis  or  abdomen,  but  will  aid   one  in   making  a 


736 


Diseases   and  Injuries   of  the  Abdomen 


diagnosis  from  typhoid  fever,  intra-abdominal  or  pelvic  neuralgia,  and  mova- 
ble kidney  (see  J-  C.  DaCosta,  Jr.,  study  of  ii8  cases:  "Am.  Jour.  Med. 
Sciences,"  Nov.,  1901). 

Appendicitis  in  Children. — The  disease  is  more  common  than  was  once 
thought  (page  726).  The  onset  is  usually  sudden  and  the  symptoms  as 
a  general  thing  are  violent.  Vomiting  is  usually  more  violent  and  prolonged 
than  in  adults.  Abscess  seems  especially  prone  to  form,  but  general  peri- 
tonitis is  by  no  means  uncommon.  Occasionally  in  young  children  pneu- 
monia begins  with  symptoms  which  seem  to  point  to  appendicitis,  and  an 
attack  of  appendicitis  may  begin  with  pulmonary  inflammation.  I  have 
seen  two  cases  in  which  pneumonia  was  ushered  in  by  abdominal  pain. 
Appendicitis  in  Pregnant  Women. — Appendicitis  is  not  common  during 

pregnancy.  When  it  does 
occur,  it  is  more  dangerous 
than  in  the  non-pregnant. 
In  about  40  per  cent,  of 
cases  abortion  occurs,  and 
usually  the  child  dies  from 
infection.  In  some  cases 
of  successful  operation 
pregnancy  continues  to 
term.  The  diagnosis  is 
often  very  difficult  because 
of  the  enlarged  uterus. 

Tnberciiloiis  Appendi- 
citis. —  Acute  s}'mptoms 
may  develop  resembling 
acute  appendicitis.  There 
is  usually  a  history  point- 
ing to  stenosis,  the  stenosis 
existing  at  the  ileocecal 
valve.*  There  is  always 
great  thickening  and  an 
abscess  of  large  size  is  apt 
to  form  (Fig.  115).  The 
cecum  usually,  but  not 
Chronic  cases,  with  pal- 


Fig.  366. — Tuberculous  appendix  witii  perforation  and  abscess. 


always,  is  involved  in   the  tuberculous  process 
pable  enlargement,  are  .sometimes  mistaken  for  cancer 

Treatment. — If  the  diagnosis  were  always  certain  from  the  beginning, 
and  if  the  cases  were  seen  at  the  very  start  by  a  surgeon,  immediate  operation 
in  every  case  would  be  eminently  proper.  If  this  plan  could  l>e  followed, 
the  mortality  from  appendicitis  would  be  extremely  small.  At  this  early 
stage  the  peritoneum  is  free  from  infection,  and  the  appendix  can  be  rapidly 
anfl  easily  removed  without  risk  oi  infecting  the  peritoneum.  Unfortunately, 
this  plan  cannot  be  habitually  followed.  As  a  rule,  when  the  ]:)hysician 
first  sees  the  case  the  a])pcndirular  peritoneum  is  inflamed,  and  the  surgeon 
usually  sees  the  case  at  even  a  later  jjcriod  than  the  physician.  At  this 
time  the  barriers  of  leukocytes  are  being  heaped  up  to  limit  the  spread  of 

*  Andrews,  Annals  of  Surgery,  Dec,  1901. 


Appendicitis  737 

infection,  and  delicate  encompassing  adhesions  are  usually  being  formed. 
Operation  at  this  stage  may  be  imperatively  necessary,  because  of  the  rapid 
spread  and  dangerous  nature  of  the  process;  but  when  operation  is  not  done, 
in  most  cases  at  least  a  temporary  limitation  will  be  secured  and  the  case 
will  go  on  to  an  interval.  Operation  in  this  period  is  always  dangerous; 
operation  in  an  interval  is  safe.  In  many  instances  it  is  wiser  to  avoid  operat- 
ing when  the  case  is  first  seen,  and  it  is  proper  to  wait  for  an  interval.  The 
period  in  which  the  surgeon  usually  sees  the  case  for  the  first  time  is  said 
by  McBurney  to  be  "too  late  for  an  early  operation  and  too  early  for  a  late 
operation."  Those  who  say,  "operate  as  soon  as  the  diagnosis  is  made," 
operate  as  a  rule  in  this  dangerous  period,  and  in  this  period  I  do  not  believe 
that  every  case  should  be  promptly  cut.  Many  cases,  it  is  true,  must  be 
operated  on  as  soon  as  seen,  irrespective  of  the  duration  of  the  disease.  We 
must  operate  promptly  if  the  pulse  is  small  and  well  above  100;  if  there 
is  persistent  vomiting;  if  there  is  delirium;  if  intestinal  obstruction  exists; 
if  a  chill  has  occurred;  if  the  pain  and  rigidity  are  very  marked;  if  a  mass 
can  be  felt  in  the  right  iliac  fossa  or  by  rectal  examination;  if  there  is  marked 
abdominal  distention;  if  there  are  evidences  of  pus-formation;  if  the  patient 
is  growing  worse;  if  there  is  or  has  been  shock;  or  if  the  pain  suddenly  passes 
away  without  the  use  of  opiates. 

In  an  ordinary  mild  case,  in  which  none  of  the  above-named  conditions 
or  symptoms  exist,  it  is  best  to  defer  operation.  Those  who  advocate  operating 
upon  every  case  consider  such  delay  reprehensible  and  dangerous,  point  out 
that  even  in  apparently  mild  cases  gangrene  or  perforation  may  quickly 
occur,  and  cite  striking  cases  to  emphasize  their  belief.  There  is  much 
force  in  this  view  and  it  must  not  be  hastily  rejected.  The  choice,  however, 
is  not  between  a  dangerous  delay  and  a  safe  operation,  but  is  rather  between 
a  dangerous  delay  and  a  dangerous  operation.  It  is  a  question  of  two  dan- 
gers, and  each  side  chooses  the  danger  which  seems  to  it  the  least.  Richard- 
son's elaborate  study  of  750  cases,  showing  a  mortality  of  18  per  cent,  in 
operations  for  acute  appendicitis,  determines  us  in  the  practice  of  the  more 
conserv^ative  plan. 

In  an  ordinary  mild  case  of  appendicitis  the  patient  is  purged  by  means 
of  Epsom  or  Rochelle  salt.  This  practice  was  begun  because  of  the  belief 
that  inflammation  of  the  appendix  is  associated  with  fecal  impaction  in  the 
head  of  the  colon.  This  belief  has  been  exploded,  but  the  treatment  is 
still  u.sed,  because  experience  shows  that  it  is  beneficial.  If  the  condition 
of  the  stomach  prevents  the  administration  of  salines,  high  enemas  should 
be  given. 

Opium  is  never  given.  In  the  first  place,  it  is  not  needed,  for  if  the  pain 
is  .so  violent  as  to  absolutely  demand  opium,  operation  should  be  performed. 
In  the  second  place,  opium  masks  the  symptoms,  makes  the  patient  feel 
comfortable,  and  gives  the  physician  an  unfortunate  and  ill-founded  sense 
of  security.  The  pain  about  the  umbilicus,  if  severe,  can  be  distinctly  and 
safely  relieved,  by  the  administration  of  thirty  minims  of  chloroform  every 
half  hour  until  three  doses  are  taken.  When  tenderness  can  be  demonstrated 
in  the  right  iliac  fossa  an  ice-bag  should  be  applied. 

The  case  should  be  seen  again  within  six  hours.  We  are  accustomed 
to  follow  McBurnev's  rule,  which  is  as  follows:  If  on  seeing  the  patient 
47 


738  Diseases  and   Injuries  of  the  Abdomen 

again,  six  hours  after  the  first  visit,  the  patient  is  worse,  operate  at  once. 
If  he  is  no  worse,  there  is  no  pressing  danger. 

If  in  twelve  hours  after  tlie  beginning  of  the  attack  the  symptoms  are 
not  intensified,  they  will  soon  begin  to  abate;  if  the  symptoms  have  become 
worse  during  this  time,  operate.  If  in  twenty-four  hours  after  the  beginning 
of  the  attack  the  severity  of  the  symptoms  lessens,  it  is  usually  possible  to 
wait  for  an  interval;  but  if  during  the  second  twenty-four  hours  the  abate- 
ment in  the  severity  of  symptoms  has  not  gone  on  and  there  is  doubt 
as  to  the  condition,  operate  at  once.*  If  operation  is  not  performed,  the 
patient  is  restricted  to  a  liquid  diet  and  the  bowels  are  moved  daily  by  salines. 

If  pus  is  present,  some  surgeons  delay  operation  in  the  hope  that  firm 
adhesions  will  form  around  the  pus,  and  that  the  necessary  operation  will 
simply  be  the  opening  of  an  abscess.  I  do  not  believe  it  is  safe  to  delay 
operation  in  a  pus  case.  The  pus  may  become  limited,  but  it  may  instead 
pass  up  toward  the  liver  or  down  into  the  pelvis.  Delay  is  fraught  with 
peril. 

When  the  attack  has  subsided,  and  about  three  weeks  or  more  have 
passed,  the  appendix  can  be  removed  with  remarkable  safety.  After  a 
patient  has  had  two  or  more  attacks  of  appendicitis  all  surgeons  agree  that 
the  appendix  should  be  removed. 

If  only  one  attack  has  occurred,  there  may  never  be  another,  and  the 
question  arises,  Should  the  appendix  be  removed  after  one  attack?  We 
do  not  know  that  a  man  has  really  recovered  after  purely  medical  treatment. 
Many  cases  reported  as  cured  by  medical  means  have  subsequently  required 
operation.  As  Lockwood  puts  it,|  "To  say  that  a  man  with  appendicitis 
has  been  cured  by  medical  means  is  in  many  cases  equivalent  to  saying  that 
a  man  with  a  stone  in  his  bladder  has  recovered  from  calculus  after  the  cure 
of  a  cystitis  by  rest  in  bed." 

Even  after  a  first  attack,  if  the  appendix  remains  tender  or  becomes 
tender  after  exercise,  or  if  attacks  of  cohcky  pain  occur,  operate. 

In  some  cases  a  single  attack  of  appendicitis  is  followed  by  persistent 
dyspepsia  and  ill  health,  and  in  such  cases  operation  should  be  performed. 
In  the  majority  of  cases,  after  even  one  well-marked  attack,  operation  is 
necessary.  It  is  always  necessary  after  two  attacks  (see  Operation  for  Appen- 
dicitis). 

Appendicitis  in  a  child  is  treated  exactly  as  in  an  adult.  Appendicitis 
in  a  pregnant  woman  is  treated  as  in  the  non -pregnant.  Early  operation  is 
particularly  indicated,  and  it  is  not  proper  to  induce  premature  labor. 

When  operating  upon  a  woman,  bear  in  mind  that  ovarian,  tubal,  or 
uterine  disease  may  have  preceded,  actually  caused,  or  resulted  from  the 
appendicitis;  examine  the  adnexa  and  remove  them  if  necessary. 

An  operation  for  tuberculous  appendicitis  is  rather  apt  to  be  followed 
by  a  fecal  fistula.  An  ordinary  laparotomy  is  sometimes  followed  by  cure, 
but  the  rule  of  operating  should  be,  when  possible,  to  remove  the  appendix 
and  resect  the  diseased  bowel.  Andrews  J  mentions  as  expedients  suited 
to  special  cases:  total  exclusion;  partial  exclusion;  lateral  anastomosis  and 
the  formation  of  an  artificial  anus. 

*  For  McBurney's  views,  see  N.  \'.  Polyclinic,  Jan.  15,  1897. 

I  Brit.  Med.  Jour.,  Jan.  27,  1900.  \.  Annals  of  Surgery,  Dec,  1901. 


Enteroptosis,    or  Glenard's   Disease  739 

Splanchnoptosis. — This  condition  is  due  to  relaxation  of  the  abdominal 
walls,  which  permits  the  viscera  to  move  downward.  The  prolapse  may 
involve  all  of  the  abdominal  viscera,  one  of  them,  or  several  of  them.  Pro- 
lapse of  the  stomach  is  known  as  gastroptosis  (page  715);  prolapse  of  the 
liver  as  hepatoptosis  (page  753);  prolapse  of  the  spleen  as  splenoptosis 
(page  771);  prolapse  of  the  kidney  as  nephroptosis  (page  934);  and  prolapse 
of  the  intestines  as  Glenard's  disease. 

The  causative  relaxation  of  the  abdominal  walls  is  most  common  in 
women,  but  is  by  no  means  confined  to  that  sex.  It  may  be  produced  by 
ascites,  pregnancy,  muscular  effort,  febrile  maladies,  or  wasting  diseases.  In 
some  cases  no  cause  can  be  assigned.  Such  a  relaxed  abdomen  may  be 
thin;  but  is  not  unusually  thick,  the  fascial  strands  and  muscular  fibers 
are  stretched,  thinned,  and  separated,  the  belly  bulges  downward  and  for- 
ward, and  a  viscus  or  the  viscera  follow  because  of  lack  of  support. 

Enteroptosis,  or  Glenard's  Disease. — This  disease  is  a  prolapse  of 
the  intestine.  It  may  be  but  a  part  of  ptosis  or  prolapse  of  all  the  ab- 
dominal viscera ;  it  may  exist  alone ;  it  may  be  associated  with  movable  kid- 
ney, prolapse  of  the  stomach  (gastroptosis),  of  the  liver  (hepatoptosis),  or  of 
the  spleen  (splenoptosis). 

In  Glenard's  disease  the  intestines  occupy  the  lower  portion  of  the  abdo- 
men, and  the  belly  below  the  costal  margins  is  fiat,  is  dull  on  percussion, 
and  the  pulsations  of  the  aorta  are  very  evident.  The  right  portion  of  the 
transverse  colon  begins  to  descend  first,  and  other  portions  of  the  intes- 
tine follow.  The  splenic  and  hepatic  flexures  are  elongated  and  sometimes 
there  is  venous  engorgement  of  dependent  parts  of  the  mesentery  (Lam- 
botte,  in  "Presse  Med.  Beige,"  1901,  Nov.  24).  The  victims  of  this  disease 
are  dyspeptic,  anemic,  and  neurasthenic.  The  condition  may  arise  without 
apparent  cause,  may  be  caused  by  wearing  corsets,  by  falls,  by  blows,  by 
lifting  heavy  weights,  and  by  prolonged  vomiting.  The  dyspepsia  is  due 
to  dragging  on  the  duodenum,  the  tube  becoming  flattened  out  (A.  K.  Stone). 
The  flattening  of  the  duodenum  may  be  followed  by  kinking  of  the  pylorus, 
and  in  such  a  case  the  stomach  dilates,  otherwise  it  does  not  dilate.  Normally 
the  tenth  rib  is  firmly  attached  by  fibrous  tissue  to  the  ninth  costal  cartilage. 
In  enteroptosis  the  tip  of  the  tenth  rib  is  freely  movable  and  obviously  sepa- 
rated from  the  ninth  costal  cartilage  (Stiller 's  sign). 

Treatment. — In  many  cases  medical  treatment  is  of  benefit.  The  fol- 
lowing is  the  usual  plan:  Employ  lavage,  massage,  and  electricity;  order  a 
proper  abdominal  support;  insist  on  regular  exercise,  and  treat  the  anemia 
and  dyspepsia.  If  ptosis  of  the  liver,  spleen,  stomach,  or  kidney  exists, 
operation  may  be  necessary. 

In  enteroptosis  good  results  are  sometimes  obtained  by  attaching  the 
splenic  and  hepatic  flexures  to  the  abdominal  wall  (Lambotte's  operation). 
Robt.  T.  Morris  removes  redundant  peritoneum  and  transversalis  fascia; 
scarifies  and  shortens  the  falciform  and  suspensory  ligaments  of  the  liver; 
rubs  with  gauze  the  upper  surface  of  the  liver  and  the  under  surface  of  the 
diaphragm  and  approximates  the  recti  muscles.  In  two  cases  he  also  anchored 
a  loose  kidney.* 

*  Med.  News,  June  28,  1902. 


740  Diseases  and   Injuries  of  the  Abdomen 

The  Peritoneum. 

Acute  Peritonitis. — Peritonitis,  or  inflammation  of  the  peritoneum, 
is  a  common  and  important  disease. 

Aseptic  irritation  by  a  traumatism  or  a  chemical  irritant  produces  aseptic 
peritonitis,  a  condition  which  is  strictly  limited;  which  may  produce  local 
pain  and  tenderness;  which  may  cause  aseptic  fever  from  the  absorption  of 
fibrin-ferment  and  the  products  of  tissue-change;  which  leads  to  the  formation 
of  temporary  or  permanent  adhesions,  and  which  is,  in  reahty,  a  process  of 
repair. 

Peritonitis,  as  the  term  is  used  by  the  surgeon,  is  always  due  to  bacteria. 
Bacteria  may  reach  the  peritoneal  cavity  by  means  of  an  abdominal  wound 
or  the  entrance  of  foreign  bodies;  by  extravasations  from  the  stomach,  bowel, 
vermiform  appendix,  gall-bladder,  urinary  bladder,  kidney.  Fallopian  tube, 
or  uterus,  or  by  the  passage  of  micro-organisms  through  the  damaged  walls 
of  any  of  these  viscera  or  structures;  by  way  of  an  open  Fallopian  tube; 
from  the  breaking  of  an  abscess  into  the  peritoneal  cavity;  from  areas  of 
necrosis  due  to  volvulus,  strangulation,  or  intussusception  of  the  intestine; 
twisting  of  the  pedicle  of  an  ovarian  tumor,  a  floating  kidney,  or  a  floating 
spleen;  blocking  of  a  mesenteric  vessel  by  a  thrombus  or  an  embolism; 
gangrene  of  the  pancreas  or  spleen,  and  fat-necrosis.*  In  some  cases  the 
peritoneum  may  contain  a  point  of  least  resistance,  and  bacteria  contained 
in  the  blood  reach  this  point  and  produce  infection.  It  used  to  be  thought 
that  cold  could  produce  peritonitis,  but  it  seems  probable  that  it  can  only 
act  by  producing  an  area  of  least  resistance.  The  capacity  of  the  rheumatic 
poison  to  produce  peritonitis  is  doubtful. 

The  peritoneum  is  in  reality  a  great  lymph-sac,  and,  as  Fowler  points 
out,  peritonitis  is  lymphangitis.  "  When  the  peritoneum  is  infected  the 
lymphatics  furnish  an  exudate  which  clots  in  the  lymph-channels,  blocks 
them,  and  limits  or  prevents  absorption.  This  blocking  of  the  lymph-chan- 
nels serves  to  preserve  the  life  of  the  subject,  on  the  one  hand ;  while  a  failure 
in  this  respect,  either  because  of  the  enormous  and  overwhelmingly  rapid 
increase  of  septic  material  and  the  large  size  and  number  of  channels  necessary 
to  destroy  and  obstruct,  on  the  other  hand,  permits  the  destruction  of  the 
organism."!  Absorption  takes  place  most  actively  from  the  region  of  the 
diaphragm,  hence  peritonitis  in  this  region  is  peculiarly  fatal.  Absorption 
takes  place  very  rapidly  from  the  intestinal  region,  although  not  quite  so 
quickly  as  from  the  diaphragmatic  area.  Absorption  takes  place  slowly 
from  the  pelvic  region,  hence  peritonitis  of  this  region  is  much  less  dangerous 
than  is  the  disea.se  in  the  intestinal  region,  and  vastly  less  dangerous  than 
is  the  disease  in  the  diaphragmatic  region  (Fowler). 

Various  bacteria  may  be  responsible  for  peritonitis,  especially  staphy- 
lococci, streptococci,  pneumococci,  and  colon  bacilli.  The  infections  which 
spread  most  rapidly  and  widely  arc  due  to  streptococci.  In  stre[)tococcus 
infection  the  protective  exudate  does  not  coagulate,  barriers  of  leukocytes 
are  not  heaped  up,  encompassing  adhesions  do  not  form,  there  is  rapid  ab- 
sorjjtion    of    toxins,    and    overwhelming    systemic    jxjisoning.     Colon    bacilli 

*  See  Park's  "Surgery  by  American  Autliors." 

f  George  R.  Fowler,  "  iJiffuse  Septic  I'eritonilis,"  iti  Medical  Record,  April  14,  19CO. 


Diffuse    Septic  Peritonitis  74I 

cause  a  very  grave  form  of  peritonitis,  but  less  rapid  and  diffuse  than  that 
caused  by  streptococci — in  fact,  the  process  is  often  encompassed  for  a  time 
bv  coagulated  lymph,  leukocytes,  and  adhesions.  The  omentum  particularly 
is  thickened,  and  is  apt  to  apply  itself  about  the  area  of  infection.  Staphylo- 
cocci and  pneumococci  produce  peritonitis  which  is  more  apt  to  be  limited 
than  that  produced  by  colon  bacilli.  In  most  cases  of  peritonitis  a  mixed 
infection  exists;  for  instance,  colon  bacilli  and  staphylococci  or  colon  bacilli 
and  streptococci.  In  some  apparently  severe  cases  of  acute  peritonitis  cul- 
tures have  remained  sterile. 

Forms  of  Peritonitis. — An  accurate  bacteriological  classification  is  not 
as  yet  possible. 

Peritonitis  can  be  named,  according  to  regions,  pelvic,  subdiaphragmatic, 
etc. ;  it  can  be  divided  pathologically  into  diffuse  septic,  putrid,  hemorrhagic, 
suppurative,  serous,  and  fibrinoplastic  (Senn) ;  it  can  be  classified,  etiologi- 
cally,  into  traumatic,  puerperal,  perforative,  metastatic,  etc.;  and  it  can  be 
divided,  clinically,  into  circumscribed  suppurative,  general  suppurative,  and 
diffuse  septic. 

Circumscribed  Suppurative  Peritonitis. — In  this  condition,  which  is 
frequently  met  v\ith  in  appendicitis,  the  area  of  infection  is  circumscribed 
by  coagulated  exudate,  leukocytes,  and  adhesions,  and  an  abscess  forms. 
After  a  time  distinct  localization  becomes  evident. 

The  symptoms  of  circumscribed  peritonitis  are  pain,  at  first  general  and 
then  local,  tenderness  in  a  particular  region,  muscular  rigidity,  distention, 
vomiting,  rapid  and  often  wiry  pulse,  constipation,  fever,  great  weakness, 
and  dorsal  decubitus  with  the  thighs  flexed.  After  a  time  a  distinct  mass 
can  usually  be  detected  by  palpation,  and  there  may  be  dulness  on  percussion, 
local  rigidity,  irregular  temperature,  sweats,  and  possibly  edema  of  the  belly- 
wall.  An  abscess,  though  limited  for  a  time,  is  always  liable  to  break  through 
its  walls  and  produce  general  peritonitis.  Such  an  accident  may  be  pro- 
duced by  muscular  effort  on  the  part  of  the  patient  or  by  injudicious  pal- 
pation on  the  part  of  the  surgeon;  its  occurrence  is  announced  by  shock, 
and  the  symptoms  of  general  peritonitis  quickly  arise. 

Diffuse  septic  peritonitis  is  apt  to  destroy  life  even  before  the  peritoneum 
presents  any  marked  change.  Death  ensues  from  the  absorption  of  toxic 
alkaloids.  Septic  peritonitis  may  arise  during  puerperality,  through  lym- 
phatic infection;  it  may  be  due  to  infection  from  without  by  an  operation 
or  an  accident;  to  perforation  of  an  ulcer;  to  gangrene  of  a  portion  of  the 
intestine;  to  rupture  of  an  abscess  into  the  peritoneal  cavity;  or  to  migration 
of  micro-organisms  through  a  damaged  wall  of  the  bowel.  Peritonitis  due 
to  perforation  is  called  perforative  peritonitis.  Perforation  is  made  manifest 
by  a  chill,  shock,  or  rapid  collapse.  Gas  may  pass  into  the  peritoneal  cavity, 
and  if  it  does  so  the  area  of  liver-dulness  may  be  lessened  or  abolished. 
Symptoms  and  signs  of  hemorrhage  may  arise.  Diffuse  peritonitis  is  an- 
nounced by  a  very  rapid  pulse,  which  is  at  first  wiry  and  later  gaseous; 
a  temperature  which  may  be  at  times  febrile,  but  which  is  apt  to  be  sub- 
normal or  which  soon  becomes  .so;  diffused  abdominal  pain,  general  tender- 
ness, dry  tongue,  delirium,  persistent  vomiting,  constipation,  and  collapse. 
Rigidity  may  exist,  and  also  intestinal  ob.struction;  often,  but  not  invaria- 
bly, there  is  distention.     In  puerperal  peritonitis  or  septic  peritonitis  from 


742  Diseases  and   Injuries  of  the  Abdomen 

operation  there  is  often  no  severe  pain;  in  perforative  peritonitis  there  is 
acute  pain.     Patients  usually  die  within  five  or  six  days. 

Diffuse  suppurative  peritonitis  differs  clinically  from  diffuse  septic 
peritonitis  in  the  fact  that  it  is  less  apt  to  be  fatal  and  widespread.  In  fact, 
adhesions  may  form  about  an  area  representing  a  considerable  portion  of 
the  peritoneal  cavity.  The  causes  of  both  are  identical.  In  septic  peritonitis 
death  occurs  from  absorption  of  toxins  before  obvious  pathological  changes 
occur  in  the  peritoneum;  in  suppurative  peritonitis  the  microbes  are  fewer, 
are  less  virulent,  or  vital  resistance  is  more  decided,  and  suppuration  follows 
marked  changes  in  the  peritoneum.  In  suppurative  peritonitis  the  pyogenic 
bacteria  are  always  present,  and  there  exists  in  the  peritoneum  a  wound 
or  damaged  area  to  constitute  a  point  of  least  resistance. 

Symptoms. — Chilliness  or  a  rigor  is  common,  followed  by  fever,  the 
temperature  rising  to  102°  or  104°  F.;  pain  is  intense,  and  is  accentuated  by 
motion  and  pressure;  the  attitude  of  the  patient  is  assumed  to  relieve  pain 
(he  lies  upon  his  back,  with  the  shoulders  raised  and  the  thighs  drawn  up) ; 
there  are  vomiting,  obstinate  constipation,  and  rigidity  of  the  abdominal 
walls,  followed  by  distention  when  the  intestine  becomes  paretic  from  septic 
poisoning.  The  pulse  is  rapid;  is  at  first  wiry,  but  may  become  gaseous. 
The  constipation  may  be  due  either  to  tympanitic  distention  or  to  the  shock 
and  toxemia  inhibiting  intestinal  peristalsis.  Vomiting  is  frequent.  In  per- 
foration gas  often  passes  into  the  peritoneal  cavity  and  it  may  obscure  the 
liver-dulness;  in  tympanites  without  perforation  the  liver  is  pushed  up  and 
its  dulness  usually  remains,  but  on  a  higher  level.  Pus  unconfined  by  adhe- 
sions will  gravitate  to  the  most  dependent  part  of  the  peritoneal  cavity.  In 
some  cases  of  suppurative  peritonitis  there  is  no  tympanitic  distention  or 
rigidity;  in  some  cases  there  is  no  fever,  and  a  subnormal  temperature 
may  even  exist. 

Treatment. — In  the  beginning  of  ordinary  peritonitis  without  perforation 
give  a  saline  cathartic,  which  will  empty  the  peritoneal  cavity  of  fluid,  will 
favor  the  ehmination  of  microbes,  and  will  combat  inflammation.  The  old- 
time  remedy  was  opium,  but  Tait  proved  its  inefficiency,  and  showed  that 
it  masked  the  symptoms  and  often  created  a  false  sense  of  security  in  the 
very  midst  of  imminent  dangers.  The  usual  method  of  administering  .salines 
is  to  give  oj  of  Rochelle  salt  and  3j  of  Epsom  salt  every  hour  until  a  free 
movement  occurs.  This  treatment  will  often  cut  short  beginning  perito- 
nitis, and  will  frequently  prevent  peritonitis  after  an  abdominal  operation. 
Administer  an  enema  of  turpentine  at  the  time  the  first  dose  of  the  saline 
is  given.  If  this  treatment  fails,  open  the  belly,  explore  for  the  causative 
condition,  ren>edy  it,  if  possible,  wipe  an  infected  area,  flush  with  gallons 
of  hot  salt  solution,  and  drain.  In  perforative  peritonitis  operate;  do  not 
give  cathartics;  they  will  only  increase  the  extravasation  and  prevent  its 
limitation  by  lymph.  In  typhoid  fever  it  may  be  possible  to  anticipate  per- 
foration by  the  occurrence  of  leukocytosis.  As  soon  as  the  patient  has 
reacted  from  the  shock  of  the  perforation  perform  a  laparotomy,  suture 
the  perforation,  wij>c  and  flu.sh  (nit  the  belly,  and  drain.  In  cleansing,  give 
special  attention  to  Douglas's  jjouch,  and  to  the  space  l^etween  the  liver 
and  diaphragm.  In  rh'ffuse  septic  y)eritonitis  open  the  abdomen  in  the  middle 
line,  explore  for  the  source  of  trouble,  anrl,   if  jjossible,  remove  it.     Make 


Tuberculous   Peritonitis  743 

an  additional  incision  in  the  suprapubic  region  or  through  the  right  kidney 
pouch,  or  in  the  opposite  side  of  the  abdomen.  It  is  frequently  advisable 
to  leave  the  abdominal  wounds  open.  Flush  with  hot  salt  solution  and 
drain.  Some  surgeons  eviscerate  and  wipe  the  intestines  with  moist  gauze 
pads. 

A  circumscribed  abscess  is  treated  as  follows:  Open  the  abscess.  It 
will  be  possible,  if  the  abscess  is  adherent  to  the  abdominal  wall,  to 
open  the  abscess  directly  without  opening  the  peritoneal  cavity.  If  this  is 
not  possible,  after  opening  the  abdominal  cavity  pack  gauze  pads  in  such 
a  manner  about  the  abscess  as  to  prevent  the  diffusion  of  pus  when  the 
abscess  is  evacuated.  After  opening  the  abscess  the  primary  lesion  is 
sought  for  and,  if  possible,  removed.  The  surgeon  should  not,  in  most 
cases,  tear  the  lymph-barriers  in  an  attempt  to  find  the  primary  lesion,  but 
should  rather  let  it  go  undiscovered.  Pack  iodoform  gauze  against  the  in- 
testines to  reinforce  the  barrier  of  lymph  and  insert  a  tube.  It  is  frequently 
advisable  to  leave  the  wound  open  and  drain  with  iodoform  gauze.  Every 
patient  with  peritonitis  requires  stimulants  and  frequent  feeding  with  liquid 
food. 

Tuberculous  Peritonitis. — Tuberculosis  of  the  peritoneum  is  not  very 
common.  In  11 70  autopsies  in  the  Boston  City  Hospital,  tubercle  existed 
in  some  region  in  197,  and  in  14  of  these  the  peritoneum  was  involved.* 
Primary  local  peritoneal  tuberculosis  is  occasionally,  though  very  rarel}',  seen 
by  the  surgeon.  In  a  great  majority  of  cases  of  peritoneal  tuberculosis  other 
distant  structures  are  involved.  In  about  half  of  the  cases  the  lungs  are  in- 
volved. In  28  cases  reported  by  Bottomly,t  not  one  was  primary.  In  every  one 
of  these  cases  the  diagnosis  was  confirmed  by  the  microscope,  by  the  tuberculin 
test,  or  by  autopsy.  In  most  supposed  cases  of  primary  peritoneal  tuberculosis 
another  focus  of  disease  exists,  but  is  not  demonstrable  by  clinical  methods  or 
has  been  overlooked.  The  disease  sometimes  exists  as  a  part  of  a  general 
tuberculosis.  Tuberculous  peritonitis  may  be  only  a  part  of  acute  miliary 
tuberculosis.  Peritoneal  infection  may  follow  a  tuberculous  lesion  of  the  intes- 
tine, the  bacteria  may  enter  by  way  of  the  Fallopian  tube,  the  initial  lesion  may 
be  tuberculous  appendicitis  or  tuberculosis  of  the  mesenteric  glands.  The  germ 
may  lodge  from  the  blood  or  lymph.  The  lymphatic  form  most  commonly 
attacks  the  cecum.  The  disease  is  more  common  among  women  than  men 
and  most  frequently  attacks  those  between  twenty  and  forty  years  of  age,  but 
I  have  seen  it  in  a  child  of  five  and  in  a  colored  man  of  sixty.  There  are  two 
groups  of  cases — the  common  chronic  form  and  the  rarer  acute  condition. 
The  acute  form  begins  suddenly,  and  such  cases,  as  pointed  out  by  Lejars, 
resemble  acute  appendicitis.  In  either  the  acute  or  chronic  condition  it  is 
frequently  the  case  that  pulmonary  phthisis  exists.  Cirrhosis  of  the  liver  is 
sometimes  found  with  tuberculous  peritonitis.  There  are  three  forms  of 
chronic  tuberculous  peritonitis:  the  ascitic,  the  fibrinoplastic,  and  the  caseous,  J 
although  as  a  matter  of  fact  these  so-called  forms  are  only  stages  of  the  same 
disease.  Tuberculous  infection  may  exist  for  some  time  without  causing 
symptoms,  acute  symptoms  may  suddenly  arise,  or  intestinal  obstruction  may 
take    place.     Symptoms    sometimes   develop  quickly  after   pregnancy.     In 

*  Bottomly,  in  Amer.  Med.,  Feb.  15,  1902.  f  Amer.  Med.,  Feb.  15,  1902. 

X  Parker  Syrns,  in  Medical  Record,  April  2,  189S. 


744  Diseases  and   Injuries  of   the  Abdomen 

other  cases  the  symptoms  appear  gradually  and  progressively  grow  more 
positive. 

Symptoms  oj  the  Chronic  Form. — Usually  the  disease  begins  insidiously. 
The  digestion  is  found  to  be  disturbed,  there  is  nausea,  the  bowels  are  out  of 
order,  the  abdomen  is  distended  and  tender,  there  is  occasional  colicky  pain, 
and  the  patient  is  weak,  loses  fiesh  rapidly,  and  becomes  very  anemic.  Fre- 
quently pain  is  the  symptom  which  leads  the  patient  to  seek  advice.  The 
pain  may  be  present  from  the  very  beginning,  it  may  arise  after  malaise  and 
gastro-intestinal  disorder  have  existed  for  some  time,  but  sooner  or  later  it 
will  develop. 

In  many  cases  there  is  ascites,  but  the  amount  of  fluid  is  rarely  very  great. 
In  some  cases  the  fluid  is  serous,  in  some  seropurulent,  in  some  purulent,  and 
in  some  bloody.  Chylous  fluid  occasionally  exists  because  of  fatty  degenera- 
tion of  tuberculous  masses.  Ascites  may  be  either  un  con  fined  or  sacculated  by 
adhesions.  In  some  cases,  and  especially  in  early  youth,  there  is  little  or  no 
ascites,  and  the  condition  is  characterized  by  the  production  of  a  quantity  of 
adhesions  which  bind  coils  of  intestine  to  each  other,  to  the  omentum,  to  the 
stomach,  liver,  and  other  viscera.  In  this  condition,  which  develops  very 
slowly,  small  cavities  are  formed  by  adhesions  and  the  spaces  contain  fluid  and 
bacteria.  This  is  the  most  chronic  form  of  the  disease.  In  any  case  of 
tuberculous  peritonitis  the  mesenteric  glands  may  enlarge.  There  is  usually 
moderate  fever,  but  there  may  be  episodes  of  high  fever  and  protracted  periods 
of  subnormal  temperature,  or  the  temperature  may  be  slightly  elevated  in  the 
evening  and  subnormal  in  the  morning.  When  the  temperature  becomes 
markedly  elevated,  pain,  tenderness,  and  distention  notably  increase.  In 
some  cases  there  is  a  continued  fever  resembling  typhoid.  Tumor-like  forma- 
tions may  be  detected.  These  formations  may  consist  of  indurated  omentum, 
encysted  exudate,  or  enlarged  mesenteric  glands.  If  diarrhea  exists  for  a  long 
period,  there  is  probably  tuberculous  ulceration  of  the  gut. 

In  every  suspected  case  a  bimanual  examination  should  be  made  under 
ether,  in  order  to  discover  if  there  are  any  matted  masses  of  intestine  (Thom- 
son). 

In  many  cases  a  careful  examination  will  detect  tuberculous  disease  of  other 
regions  of  the  body,  particularly  of  the  lungs.  If  tuberculous  disease  of  the 
lungs  or  pleura  is  detected,  if  tuberculous  glands  exist  or  have  been  present,  or 
if  a  nodule  not  due  to  gonorrheal  inflammation  is  palpable  in  the  epididymis, 
or  if  there  are  indurations  in  the  prostate,  the  probability  of  the  presence  of 
tuberculous  peritonitis  is  much  enhanced.  In  many  cases  there  is  dilatation 
of  the  superficial  abdominal  veins.  In  some  cases  tuberculous  peritonitis 
undergoes  spontaneous  cure.  In  the  majority  of  instances  death  ensues  from 
the  tuVjerculous  peritonitis  directly  or  from  associated  or  secondary  disease  in 
other  organs. 

If  an  intraperitoneal  tuberculous  area  caseates,  a  large  cold  abscess  ma\- 
form,  and  such  an  abscess  may  break  into  the  intestine  or  may  be  opened  ex- 
ternally, and  may  be  responsible  for  the  formation  of  a  fecal  fistula. 

In  a  case  of  tuberculous  peritonitis  intestinal  obstruction  may  occur,  the 
gut  getting  caught  by  bands  or  adhesions,  or  becoming  a  rigid  tube  because  of 
the  formation  of  tubercles. 

Symptoms  oj   the  Acute  Form. — This  is  sometimes  mistaken   for  appen- 


Tuberculous    Peritonitis  745 

dicitis.  It  comes  on  rather  suddenly,  but  a  carefully  elicited  history  will 
usually  show  the  previous  existence  of  malaise,  gastro-intestinal  disturbance, 
loss  of  flesh,  and  anemia.  The  symptoms  are  not  so  strictly  localized  to  the 
right  iliac  fossa  as  in  appendicitis.  There  is  abdominal  distention,  a  cer- 
tain amount  of  rigidity,  nausea  and  vomiting,  colicky  pain  which  may  be 
very  severe,  general  abdominal  tenderness,  fever,  and  exhaustion.  It  may 
be  possible  to  palpate  masses  like  tumors,  or  to  feel  nodules  in  the  prostate 
or  epididymis,  or  to  detect  tuberculosis  in  some  other  part. 

Treatment. — In  some  cases  there  is  a  tendency  to  spontaneous  cure,  and  in 
them  medical  treatment  is  of  great  service.  The  patient  should  be  placed 
under  proper  hygienic  conditions,  nutritious  food  and  tonics  should  be  ad- 
ministered, the  abdomen  should  be  counter-irritated  and  massaged,  and  pur- 
gatives should  be  given  frequently.  Guaiacol  applied  daily  to  the  abdomen  is 
often  of  service.  A  mixture  is  made  of  i  part  of  guaiacol  and  5  parts  of  ohve 
oil;  oj  of  this  mixture  is  rubbed  into  the  abdomen,  and  the  part  is  covered  with  a 
piece  of  flannel  held  in  place  by  means  of  a  binder.  If  medical  treatment  is  not 
soon  productive  of  benefit,  the  advisabihty  of  operating  must  be  considered. 
It  is  a  curious  fact,  but  one  confirmed  by  ample  evidence,  that  after  simple 
abdominal  section,  without  the  introduction  of  germicides  and  without  drain- 
age, at  least  30  per  cent,  of  the  cases  recover  from  the  disease  in  from  six 
months  to  one  year.  Some  surgeons  doubt  the  curative  effect  of  operation. 
For  instance,  the  late  Prof.  Fenger  was  strongly  of  the  opinion  that  many 
patients  recover  after  operation,  but  not  as  a  result  of  operation.  In  his 
opinion  they  recover  because  they  were  strong,  free  from  fever,  and  well 
nourished,  and  because  the  disease  tended  to  spontaneous  cure.  He  further 
believed  that  some  died  from  operation  because  the  traumatism  lessens 
the  already  lowered  tissue  resistance.  The  majority  of  surgeons,  however, 
believe  that  operation  in  many  cases  tends  to  cure.  It  is  uncertain  how 
an  operation  tends  to  cure.  It  has  been  thought  that  the  ascitic  fluid  is  a 
culture-medium  for  bacilli,  and  when  it  is  withdrawn  the  bacilli  die,  but 
opposed  to  this  view  is  the  fact  that  aspiration  is  rarely  curative.  It  has 
been  suggested  that  the  operation  brings  numerous  phagocytes  to  the  peri- 
toneum; that  it  stimulates  vital  resistance;  that  it  leads  to  the  exudation 
of  antitoxic  serum.  The  entrance  of  air  seems  to  play  a  definite  and  important 
part  in  effecting  a  cure. 

The  ascitic  cases  are  most  frequently  benefited  by  operation.  In  en- 
cysted fluid  operation  often  cures. 

In  cases  in  which  there  are  numerous  adhesions  operation  is  not  so  hkely  to 
produce  a  cure.  Great  care  should  be  exercised  in  separating  adhesions,  be- 
cause the  bowel  is  apt  to  be  torn  and  a  fecal  fistula  may  result.  It  may  be 
necessary  to  separate  adhesions  or  short-circuit  a  portion  of  gut  to  relieve  ob- 
struction. Drainage  should  not  be  used  unless  a  cold  abscess  exists.  Not 
only  is  drainage  of  no  service,  but  it  is  dangerous;  death  is  more  apt  to  ensue 
in  a  drained  case  and  a  fecal  fistula  will  arise  in  nearly  one-fourth  of  the  cases. 
If  operation  is  performed  for  cold  abscess,  tube-drainage  must  be  used  for  some 
days.  In  a  very  advanced  case,  in  a  case  with  notably  high  temperature,  or 
in  a  case  with  marked  and  advancing  tuberculosis  in  another  region,  an 
operation  should  not  be  performed  except  to  relieve  obstruction  or  drain 
an  abscess.     If  a  patient  does  not   die  within  a  few  months  after  the  opera- 


746  Diseases  and  Injuries  of  the  Abdomen 

tion,  he  will  probably  recover,  and  in  most  cases  operation  secures  at  least  tem- 
porary improvement  (Bottomly).  The  mortality  from  operation  is  i  or  2  per 
cent.  (Fenger). 

Subphrenic  Abscess. — A  subphrenic  abscess  is  a  collection  of  pus 
beneath  the  diaphragm.  The  pus,  as  a  rule,  occupies  a  part  of  the  lesser 
peritoneal  cavity,  in  rare  instances  it  is  extraperitoneal  (when  it  is  of  renal 
origin) ;  in  some  cases  it  is  contained  in  the  area  between  the  diaphragm, 
cardiac  end  of  the  stomach,  and  liver  or  spleen.  It  is  an  unusual  thing  for 
such  an  abscess  to  break  into  the  general  cavity  of  the  peritoneum,  but  it  may 
break  into  the  pleural  sac  (Maydl). 

Causes. — Perforation  of  a  gastric  ulcer,  perforation  of  the  gall-bladder  or 
gall-ducts,  ulceration  of  the  duodenum,  disease  of  the  hver,  spleen,  pancreas, 
intestine,  appendix,  or  kidney,  hydatid  disease,  internal  injury,  metastasis, 
external  injury,  caries  of  rib,  or  disease  of  the  pleura  may  be  responsible  for  a 
subphrenic  abscess  (Maydl).  Charles  A.  Elsberg  *  has  collected  73  cases  of 
subphrenic  abscess  after  appendicitis.  He  points  out  that  the  condition  may 
arise  from  direct  extension  or  by  way  of  the  lymph-channels,  and  may  be 
either  intraperitoneal  or  extraperitoneal;  although  in  the  majority  of  cases  it  is 
intraperitoneal.  In  all  but  seven  of  these  cases  there  was  suppuration  about 
the  appendix.  The  pus  was  thick  and  foul  in  all  the  cases.  In  15  per  cent,  of 
them  gas  was  also  present,  and  in  25  per  cent,  of  these  cases  the  diaphragm  was 
perforated.  In  one  case  in  which  I  operated  the  abscess  developed  after 
cholecystitis. 

Symptoms. — A  patient  with  subphrenic  abscess  usually  complains  of  pain 
in  the  lower  part  of  the  chest  on  the  right  side.  The  area  of  liver-dulness  is 
distinctly  enlarged,  and  there  is  tenderness  in  the  lower  part  of  the  right  chest 
when  pressure  is  made  through  one  or  through  several  intercostal  spaces. 
Frequently  friction-sounds  may  be  heard  about  the  region  of  the  dome  of  the 
liver.  Sometimes  the  symptoms  are  obscure  or  indefinite,  and  not  accom- 
panied with  particular  pain.  If  the  abscess  happens  to  contain  a  considerable 
amount  of  gas,  and  about  one-half  of  such  abscesses  do  contain  gas,  not 
only  will  there  be  no  increase  in  the  area  of  liver-dulness,  but  the  normal 
area  of  dulness  may  be  diminished  or  obliterated.  The  presence  of  gas  is 
due  to  some  connection  with  an  organ  which  contains  gas.  It  is  very  common 
for  a  pleural  elTusion  to  be  associated  with  a  subphrenic  abscess.  A  pleural 
effusion  will  be  preceded  by  or  accompanied  with  symptoms  pointing  to 
the  lung  or  pleura;  and  it  is  to  be  remembered  that  the  area  of  percussion- 
dulness  found  in  the  pleural  effusion  shifts  its  position  whenever  the  posi- 
tion of  the  patient  is  changed,  which  is  not  true  of  the  area  of  dulness  found 
in  subphrenic  abscess.  When  the  abscess  breaks  through  the  diaphragm,  the 
patient  develops  collapse,  cough  and  other  thoracic  symptoms;  and  if  the 
abscess  breaks  into  a  bronchus,  the  patient  will  expectorate  pus.  In  sub- 
phrenic abscess,  the  diaphragm  of  the  diseased  side  is  paralyzed — a  con- 
dition rarely  met  with  in  hver-abscess.  There  are  general  symptoms  of 
suppuration  and  a  swelling  in  the  subdiaphragmatic  region  following  some 
recognized  causative  condition.  The  history  of  chills  with  recurrent  fever  and 
sweats  is  rather  indicative  of  abscess  of  the  liver;  but  in  abscess  of  the  liver  there 
is  usually  pain  in  the  shoulder-blade  of  the  right  side,  and  this  is  rarely  en- 

*  Annals  of  Surgery,  Dec,  1901. 


Rupture   and   Wounds   of   the    Liver  747 

countered  in  subphrenic  abscess.  The  proof  of  the  diagnosis  is  not,  however, 
obtained  until  an  exploratory  incision  has  been  made  and  the  purulent  matter 
has  been  examined.  In  many  cases  the  abscess-cavity  contains  gas  as  well  as 
fluid.  Empyema  and  subphrenic  abscess  resemble  each  other.  In  empyema 
the  upper  limit  of  the  fluid  is  concave;  in  subphrenic  abscess  it  is  convex.  In 
empyema  the  flow  of  pus  through  an  aspirating-needle  will  be  most  marked 
during  expiration ;  in  abscess,  during  inspiration.  The  same  is  true  of  the  rush 
of  gas.  In  empyema  the  needle  does  not  oscillate;  in  abscess  it  does.*  If 
an  abscess  contains  gas  percussion  elicits  a  tympanitic  note  over  a  part  of 
the  cavity  and  there  is  an  alteration  in  the  area  of  tympany  with  an  alteration 
in  the  position  of  the  patient.  An  abscess  of  the  liver  does  not  contain  gas 
and  decidedly  changes  the  outlines  of  the  organ. 

Treatment." — Incision  and  drainage.  The  incision  in  some  cases  may  be 
made  in  the  lumbar  region,  in  some  cases  through  the  abdominal  wall  (epi- 
gastric region,  iliac  region,  hypochondrium).  In  other  cases  the  chest- wall 
is  incised,  the  ninth  or  tenth  rib  is  resected,  and  the  abscess  is  opened  below  the 
pleura  or  the  pleura  is  opened,  and  the  diaphragm  is  incised.  If  appendicitis 
is  the  cause,  be  sure  the  appendicitis  is  well;  and  if  not,  open  and  drain  freely 
(Elsberg).  If  it  is  necessary  to  open  the  pleural  sac,  try  to  stitch  the  parietal 
to  the  visceral  layer  of  the  pleura,  or,  if  this  is  impossible,  protect  the  cavity 
with  iodoform  gauze  to  prevent  infection. 

The  Liver,   Gall-bladder,  and  Bile-ducts. 

Rupture  and  Wounds  of  the  Liver.— Rupture  of  the  liver  is  due  to 
very  great  force,  and  is  usually  accompanied  by  injury  of  other  viscera.  It 
may  be  produced  by  a  blow,  by  a  fall,  or  by  the  end  of  a  broken  rib.  The 
superior  surface  or  margin  most  often  suffers.  It  is  a  very  fatal  accident.  Out 
of  543  reported  cases,  over  one-half  died  of  hemorrhage  within  twenty-four 
hours  of  the  accident. f  Wilms  t  collected  19  cases,  and  only  3  recovered 
after  operation.  An  attempt  should  be  made  to  save  the  patient  by  opening 
the  abdomen  and  arresting  hemorrhage,  and  in  a  suspected  case  an  explora- 
tory operation  should  be  performed.  A  wound  of  the  liver  causes  violent 
hemorrhage  which  is  usually  rapidly  fatal.  Such  a  wound  is  apt  to  divide 
bile-ducts  and  allow  bile  to  escape  into  the  peritoneal  cavity.  Bile  if  sterile 
will  do  little  harm,  but  if  it  contains  bacteria  it  will  produce  diffuse  peri- 
tonitis. The  symptoms  of  a  rupture  or  wound  of  the  liver  are  those  of  severe 
intra-abdominal  hemorrhage,  with  collapse  and  hepatic  tenderness.  Soon 
after  the  injury  the  abdomen  is  soft  and  flat,  but  it  quickly  becomes  rigid 
and  ultimately  distended.  The  diagnosis  becomes  more  probable  when 
it  is  known  that  violence  was  applied  in  the  hepatic  region.  Usually  there 
is  abdominal  pain  and  often  pain  in  the  back.  Sugar  may  appear  in  the 
urine.  Jaundice  seldom  arises.  The  area  of  liver-dulness  is  usually  in- 
creased. Patients  do  not  always  die  from  a  serious  traumatism  of  the  liver. 
Some  recover  because  operation  has  been  performed.  Some  few  recover  with- 
out operation.  This  last  fact  is  proved  by  reports  of  autopsies  in  which  scars 
were  found  in  the  liver-parenchyma  (Nussbaum).     The  fatality  which  usually 

*  Wharton  and  Curtis,  "  Practice  of  Surgery." 
t  Mercade,  in  Rev.  de  Chir. ,  Jan.   10,  1902. 
j  Deut.  med.  Woch.,  Nos.  34  and  35,  1901. 


748  Diseases  and   Injuries  of   the   Abdomen 

ensues  on  a  liver  injury  may  be  due  to  hemorrhage  or  peritonitis.  If  a  surgeon 
is  called  to  a  patient  suffering  from  wound  of  the  liver,  he  must  open  the  abdo- 
men to  arrest  hemorrhage.  If  a  penetrating  wound  is  suspected,  it  may  be 
desirable  to  enlarge  the  wound  in  the  abdominal  wall  layer  by  layer,  in  order 
to  determine  that  the  liver  is  wounded.  If  the  left  lobe  of  the  liver  is  wounded, 
or  if  it  is  uncertain  which  lobe  is  wounded,  the  incision  should  be  median. 
If  the  right  lobe  is  wounded,  a  curved  incision  is  made  along  the  line  of  the 
costal  cartilages.  In  some  cases  these  two  incisions  are  joined.*  The 
convex  surface  of  the  liver  can  be  reached  by  Lannelongue's  plan.  Lan- 
nelongue  resects  the  eighth,  ninth,  tenth,  and  eleventh  costal  cartilages 
and  draws  the  ends  of  the  ribs  well  out.  When  the  wound  in  the  liver  is 
discovered  and  well  exposed  deep  sutures  of  catgut  should  be  inserted  in 
the  liver  and  the  capsule  should  be  stitched  with  fine  silk  (Schlatter).  If 
sutures  fail  to  arrest  hemorrhage,  the  liver  should  be  sutured  to  the  belly- 
wall  and  the  wound  in  the  liver  packed  with  iodoform  gauze.  It  is  useless 
to  try  packing  without  first  attaching  the  liver  to  the  abdominal  wall,  be- 
cause pressure  will  simply  push  the  liver  away  and  will  not  arrest  the  bleeding. 
The  cautery  is  a  very  useful  means  of  arresting  bleeding.  It  should  be  avoided 
if  possible  in  a  large  wound,  because,  even  if  it  arrests  primary  hemorrhage, 
secondary  hemorrhage  may  occur.  After  arresting  hemorrhage  wash  out  the 
abdomen  with  hot  saline  fluid,  insert  drainage,  and  close  the  abdominal 
wound.  In  a  case  of  the  author's  in  the  Philadelphia  Hospital  the  liver  was 
wounded  by  the  sharp  ends  of  fractured  ribs.  The  abdomen  was  opened,  a 
wound  was  found,  and  bleeding  was  arrested  by  suturing  the  liver  to  the  belly- 
wall  and  packing  the  wound.  The  patient  died,  and  necropsy  showed  an- 
other wound  on  the  posterior  portion  of  the  organ.  The  possibility  of  such 
an  occurrence  should  not  be  lost  sight  of. 

Tumors  and  Cysts  of  the  Liver. — The  hver  may  be  the  seat  of 
primary  carcinoma,  sarcoma,  or  endothelioma,  of  angioma,  lymphangioma, 
adenoma,  fibroma,  myxoma,  or  lipoma.  Secondary  malignant  growths 
are  far  more  common  than  primary  neoplasms.  The  frequency  of  cancer 
of  the  liver  secondary  to  cancer  of  the  stomach  has  already  been  alluded 
to;  in  fact,  nineteen-twentieths  of  cases  of  cancer  of  the  liver  are  secondary. 
The  commonest  primary  tumor  of  the  liver  is  cavernous  hemangioma.  It  is 
especially  apt  to  take  origin  in  the  atrophying  hver  of  an  elderly  individual. 

Among  the  cysts  occurring  in  the  liver  are  blood  cysts,  congenital  cysts, 
bile  cysts,  and  hydatid  cysts. 

Angiomata  have  been  removed  successfully  by  hepatectomy,  a  cautery 
being  used  to  cut  through  the  normal  liver  tissue  around  the  base  of  the 
tumor.  Enucleation  is  not  feasible  because  of  excessive  hemorrhage.  In 
a  pedunculated  case  the  base  may  be  encircled  by  an  elastic  ligature  held 
in  place  by  a  steel  needle,  and  five  or  six  days  later  the  tumor  may  be  cut 
across  with  the  cautery. f 

Carcinoma  of  the  liver  has  been  extirpated,  but  it  is  seldom  that  a  growth 
is  recognized  early  enough  and  is  found  sufficiently  limited  to  justify  such 
a  procedure. 

*  See  Schlatter,  Beilrage  zur  klinischen  Chirurgie,  Bd.  xv,  Ileft  ii,  1896. 
f  Russell   S.    Fowler  on  "Tumors  of  the    Liver,"    Brooklyn    Medical   Journal,    Dec, 
1 90  J. 


Abscess  of  the   Liver  749 

Hydatid  cysts  of  the  liver  may  be  of  small  size  and  productive  of  no 
signs  or  symptoms ;  or  may  be  of  large  size  and  productive  of  the  signs  of  tumor. 
In  the  epigastrium  the  mass  may  be  prominent  and  may  fluctuate.  In  cyst  of 
the  right  lobe  the  dulness  is  found  in  the  axillary  line  and  the  growth  en- 
croaches on  the  pleura.  In  a  large  cyst  fluctuation  and  hydatid  fremitus  may 
exist.  Hydatid  fremitus  is  a  vibration  imparted  to  the  palpating  fingers  of  one 
hand  when  the  fingers  of  the  other  hand  knock  upon  the  cyst.  There  may  be 
no  discomfort  produced  by  even  a  large  cyst,  but,  as  a  rule,  the  patient  suft'ers 
from  a  dragging  sensation  in  the  epigastrium  and  pressure-symptoms.  Sup- 
puration in  the  cyst  produces  the  symptoms  of  abscess  of  the  liver  and  septice- 
mia. Rupture  of  the  cyst  produces  shock,  and  even  death.  Rupture  may 
take  place  into  the  pleural  sac,  the  lung,  or  the  peritoneal  cavity.  If  the  shock 
is  recovered  from,  inflammation  arises,  the  area  of  which  depends  upon  the 
structures  damaged.  The  escape  of  even  a  small  quantity  of  hydatid  fluid 
into  the  peritoneal  cavity  produces  urticaria  (hydatid  toxemia).  Aspiration 
for  diagnostic  purposes  is  not  advisable. 

Treatment. — Exploratory  incision  may  be  necessary  to  confirm  the  diag- 
nosis, and  the  operation  is  completed  at  this  time.  After  exposing  the  cyst 
it  is  packed  around  with  gauze  and  a  trocar  is  introduced.  When  the  fluid 
is  evacuated  the  sac  is  incised  and  is  drawn  partly  through  the  wound  in  the 
abdominal  wall,  and  is  attached  to  the  wound-margins  (marsupialization). 
The  endocyst  can  be  removed  by  the  hand  or  by  irrigation.  A  large  drainage- 
tube  is  introduced.  If  there  is  a  considerable  thickness  of  liver-tissue  over  the 
cyst,  incise  the  liver  with  the  cautery  knife. 

Abscess  of  the  Liver. — An  abscess  of  the  liver  may  be  produced  by 
bacteria,  especially  staphylococci  and  streptococci.  These  organisms  reach 
the  liver  by  the  general  circulation,  or,  what  is  more  frequent,  are  taken  up 
from  the  intestinal  tract  and  reach  the  liver  by  the  portal  circulation.  The 
fact  that  abscess  of  the  liver  is  in  hot  countries  frequently  preceded  by  amebic 
dysentery  has  led  to  the  presumption  that  amoeba  coli  produces  the  abscess. 
Habitual  intemperance  and  constant  overeating  predispose  to  abscess  of  the 
liver.  The  disease  may  follow  traumatism,  dysentery,  diarrhea,  cholangitis, 
suppuration  of  a  hydatid  cyst,  gall-stones,  typhoid  fever,  appendicitis,  and  a 
chill  to  the  surface  of  the  body.*  Abscess  of  the  fiver  may  be  metastatic,  and 
such  abscesses  are  multiple.  It  may  be  caused  by  foreign  bodies  and  para- 
sites. A  tropical  abscess  is  an  abscess  of  the  liver  in  an  inhabitant  of  a  hot 
country. 

There  are  three  forms  of  abscess  of  the  liver:  traumatic,  pyemic,  and 
tropical. 

Traumatic  abscess  may  result  from  a  wound  of  the  liver  or  mav  follow 
a  contusion  without  a  break  of  the  .skin.  In  the  latter  case  bacteria  from  the 
blood  are  arrested  in  the  injured  liver  tissue.  Such  an  abscess  is  usually 
solitary.     Streptococci,  staphylococci,  or  colon  bacilli  may  be  found. 

Pyemic  Abscess. — Multiple  abscesses  exist.  It  is  frequently  due  to  sup- 
purative inflammation  of  radicles  of  the  portal  vein,  infected  emboli  forming 
and  reaching  the  liver;  may  follow  ulceration  of  the  intestine,  hemorrhoids, 
or  appendicitis.  Occasionally  abscess  may  arise  from  the  extension  of  an  in- 
fective process,  such  as  pylephlebitis,  or  in  cholelithiasis  with  obstruction.     In 

*  G.  B.  Johnston,  Annals  of  Suigeiy,  October,  1897. 


750  Diseases  and   Injuries  of  the   Abdomen 

these  latter  cases  both  the  bacillus  typhosis  and  the  pneumobacillus  of  Fried- 
lander  have  been  found  as  the  direct  bacterial  agent.  Colon  bacilh  are  a  com- 
mon cause.  Echinococcus  cyst  of  the  liver  may  suppurate  and  form  abscess. 
The  round-worm,  the  liver  fluke,  and  the  balantidium  coli  sometimes  cause 
abscess,  and,  finally,  it  has  been  observed  in  measles,  epidemic  influenza,  and 
perforating  ulcer  of  the  stomach.* 

Tropical  Abscess  of  the  Liver. — Tropical  abscess  of  the  liver  is  rare 
in  temperate  climates,  but  is  extremely  common  in  the  tropics.  Its  usual 
antecedent  in  either  climate  is  dysentery.  The  reason  for  the  great  frequency 
of  the  disease  in  tropical  regions  is  that  the  chief  causative  agent,  the  amoeba 
coli,  is  found  widely  distributed  in  hot  countries;  and  that  passive  congestion 
of  the  liver  is  a  common  condition  among  the  white  inhabitants  of  tropical 
regions.  It  has  been  pointed  out  that  tropical  abscess  is  particularly  common 
among  white  persons  that  abuse  alcohol,  the  condition  of  passive  congestion 
of  the  liver  making  that  organ  a  nutritious  soil  for  a  fruitful  infection.  Pre- 
disposing factors  are  also  malaria  and  chilling  of  the  surface  of  the  body. 

Captain  Charles  F.  Kieffer,  U.  S.  A.,*  in  a  lecture  on  tropical  abscess 
of  the  liver,  states  that  in  his  own  experience  he  found,  in  a  series  of  33  ab- 
scess cases  in  soldiers,  that  dysentery  was  present  in  every  case;  and  that 
in  a  second  series  of  25  cases  in  natives  and  civilians,  he  ehcited  a  history 
of  dysentery  in  22  cases.  Some  observers — notably  McLeod — state  that 
dysentery  is  the  antecedent  factor  in  97.5  per  cent,  of  cases.  Kieffer  points 
out  that  in  all  the  figures  allowance  must  be  made  for  a  number  of  latent 
dysenteries,  as  well  as  for  cases  in  which  no  effort  was  made  to  ehcit  a  history 
of  dysentery  one  or  two  years  previously.  It  is  also  to  be  remembered  that 
a  case  of  amebic  infection  of  the  colon  may  have  been  so  mild  in  the  beginning 
as  to  have  caused  but  a  transient  diarrhea,  which  the  patient  may  have 
forgotten.  Again,  as  Kieffer  observes,  amebae  occasionally  exist  in  the  colon 
without  producing  any  dysenteric  evidences.  His  conclusions  are  that  from 
20  to  25  per  cent,  of  severe  amebic  dysenteries  lead  to  the  formation  of  abscess 
of  the  liver,  and  that  at  least  85  per  cent,  of  all  tropical  abscesses  are  due  to 
infection  with  the  amoeba  coli.  Occasionally,  an  abscess  begins  very  soon 
after  the  dysentery;  but,  as  a  rule,  it  does  not  take  place  for  some  time 
afterward — weeks,  months,  a  year,  or  even  two  years. 

When  an  abscess  of  this  sort  forms  in  the  liver,  that  organ  becomes  en- 
larged and  congested,  and  an  area  or  areas  of  necrosis  exist  in  it.  But  one 
abscess  may  be  present;  there  may  be  an  abscess  with  satellite  abscesses 
about  it;  several  abscesses  may  coalesce,  making  a  very  large  cavity;  or 
genuine  multiple  abscesses  may  exist.  In  about  70  per  cent,  of  cases,  how- 
ever, the  tropical  abscess  is  solitary  (Kieffer). 

The  right  lobe  of  the  liver  is  the  region  most  frequently  involved.  The 
abscess  is  founrl  in  the  right  lobe  in  from  70  to  80  per  cent,  of  cases;  and 
it  is  more  often  toward  the  convexity  of  the  liver  than  toward  the  base. 

An  abscess  of  the  liver  contains  characteristic  and  peculiar  material; 
it  is  different  from  the  pus  found  in  other  abscesses,  and,  in  fact,  is  not  pus, 
but  is  necrotic  liver-substance.  Liver  abscesses  due  to  pyogenic  organisms 
contain  true  pus;  a  tropical  abscess,  free  from  pyogenic  infection,  does  not. 

*Capt.  Chas.  F.  Kieffer,  U.  S.  A.,  in  Phila.  Med.  Jour.,  Feb.  21,  1903. 
t  Phila.  Med.  Jour.,  Feb.  21,  1903. 


Tropical   Abscess   of   the    Liver  751 

Ordinary  pus  contains  hordes  of  leukocytes;  but  the  pus  of  a  tropical  abscess 
contains  very  few.  Riesman  is  of  the  opinion  that  the  reason  there  are  so 
few  leukocytes  is  that  the  abscess  contains  a  substance  that,  by  chemiotaxis, 
repels  leukocytes.  The  pus  is  of  a  reddish-brown  color,  is  thick,  and  fre- 
quently contains  some  blood  or  a  little  yellowish  pus.  Occasionally  it  is 
offensive  in  odor.  Microscopic  examination  shows  it  to  contain  portions  of 
necrotic  liver-tissue,  some  liver-cells  that  are  not  destroyed,  elastic  tissue, 
blood,  pus-cells,  and  amebae  (Kieffer).  On  bacterial  examination  it  may  be 
found  that  the  pus  is  infected,  containing  staphylococci,  streptococci,  or 
pyogenic  bacteria.  In  about  20  per  cent,  of  the  cases  the  pus  contains 
neither  bacteria  nor  the  amoeba  coh.  In  nearly  60  per  cent,  of  the  cases 
the  pus  is  free  from  bacteria.  In  cases  in  which  the  fluid  is  sterile  it  is  probable 
that  bacteria  were  originally  present,  but  have  died.  The  reason  for  the  death 
of  micro-organisms  in  this  pus  is  in  great  doubt;  because,  as  Riesman  points 
out,  bile  cannot  kill  them,  and  organisms  may  be  grown  in  the  pus.  Kieffer 
says  that  in  the  large  majority  of  cases  amebas  are  readily  demonstrable  in 
the  pus;  but  that  in  some  few  cases  it  is  necessary  to  rub  a  piece  of  gauze 
on  an  abscess-wall  in  order  to  obtain  amebae,  and  that  in  others  they  can 
be  demonstrated  only  after  the  abscess  has  been  discharging  for  some  days. 
The  causative  role  of  the  amoeba  has  been  doubted  by  some  observers,  but 
most  surgeons  who  have  had  experience  in  the  tropics  believe  it  to  be  a  fact. 

Symptoms. — The  symptoms  may  be  very  definite  and  positive;  they  are 
frequently  misleading  and  obscure;  and  in  some  cases  nothing  whatever 
directs  the  surgeon's  attention  to  the  liver  until  the  patient  passes  a  huge 
quantity  of  pus  at  stool  or  coughs  up  an  enormous  amount  of  the  charac- 
teristic material.  If  rupture  takes  place  death  usually  ensues.  As  a  rule, 
the  symptoms  of  a  tropical  abscess  are  positive  and  marked. 

Kieffer  sums  up  the  chief  symptoms  under  four  heads:  fever,  sepsis,  en- 
largement of  the  liver,  and  pain.  In  about  three-fourths  of  the  patients 
fever  and  sweats  are  definitely  present;  in  about  one-fourth  they  are  absent  or 
are  very  trivial.  The  type  of  fever  met  with  is  what  has  been  previously 
spoken  of  as  hectic.  Usually  there  is  an  evening  rise,  preceded  by  a  chilly 
sensation  or  by  a  chill;  and  as  the  temperature  begins  to  fall,  toward  morning, 
there  is  a  profuse  sweat.  It  is  seldom  that  there  is  any  violent  chill,  though 
there  is  frequently  a  slight  one.  The  sweats  are  extremely  exhausting.  They 
may  occur  either  during  the  night  or  in  the  daytime,  according  to  the  time 
in  which  the  patient  sleeps.  Kieffer  says  that  they  should  not  be  called 
night-sweats,  but  rather  sleeping-sweats.  In  very  chronic  cases  there  may 
be  no  pyrexia.  As  a  rule,  the  temperature  resembles  that  of  malaria,  but 
it  is  not  controlled  by  quinin  and  the  blood  is  free  from  malarial  parasites. 
Sometimes  the  temperature  suggests  typhoid,  with  the  exception  that  from 
time  to  time  there  are  episodes  of  subnormal  temperature.  The  patient 
loses  flesh  and  strength,  the  appetite  fails  completely,  and  the  skin  becomes 
pasty  or  dirty  yellow. 

The  entire  liver  is  usually  enlarged,  and  the  enlargement  may  be  detected 
by  percussion,  and  in  some  cases  a  hard,  smooth  area  can  be  palpated.  Some- 
times the  liver  reaches  as  high  as  the  third  rib  anteriorly,  or  to  the  spine 
of  the  scapula  behind,  and  it  may  extend  downward  to  the  anterior  superior 
spine  of  the  ilium   (Kieffer).     It   is  rarely,   however,   that   the  enlargement 


752  Diseases  and   Injuries  of  the  Abdomen 

takes  place  in  a  downward  direction;  it  is  usually  upward.  In  many  cases 
the  right  side  of  the  chest  appears  to  be  rather  full,  and  sometimes  there 
is  actual  obliteration  of  the  intercostal  spaces.  If  an  abscess  becomes  ad- 
herent to  the  surface,  there  may  be  skin-edema  and  dusky  discoloration. 
In  very  rare  instances,  if  a  very  large  abscess  comes  near  the  surface,  fluctua- 
tion may  be  obtained.  By  auscultation  it  is  frequently  possible  to  obtain 
friction-sounds  in  the  region  of  the  diaphragm  and  the  superior  surface  of 
the  liver. 

The  hver  becomes  tender.  This  tenderness  may  be  developed  par- 
ticularly by  pressure  upon  the  lower  edge  of  the  organ,  and  sometimes 
by  pressure  through  the  intercostal  spaces.  There  is  not  always  pain, 
but,  as  a  rule,  there  is.  The  pain  may  be  dull  and  heavy;  but  as  the 
abscess  nears  the  surface  of  the  organ,  the  pain  becomes  sharp  and 
lancinating.  The  pain  is  persistent  and  is  not  strictly  localized,  but  radiates 
to  the  back,  the  right  shoulder-blade,  and  the  point  of  the  shoulder.  It 
is  increased  by  pressure,  coughing,  sudden  or  violent  movement,  and  is 
sometimes  felt  in  the  esophagus  when  food  is  swallowed.  When  the  upper 
.surface  of  the  liver  is  involved,  the  patient  breathes  as  if  he  had  pleurisy; 
and  pleurisy  frequently  does  develop,  with  marked  effusion. 

Paralysis  of  the  diaphragm  rarely  occurs  in  abscess  of  the  liver;  and  the 
respiration  is  not  much  affected,  unless  the  diaphragm  of  that  side  and  the 
pleura  become  involved,  though  the  patient  frequently  has  a  dry  cough. 
A  severe  cough  suggests  that  the  abscess  is  on  the  convex  surface  of  the 
organ.  Such  a  cough  is  aggravated  by  recumbency.  Kieffer  points  out  that 
the  patient  lies  on  his  right  side,  and  almost  on  the  right  front  aspect;  the 
shoulder  being  drawn  down  and  the  right  knee  drawn  up,  to  relieve  the 
tension  of  the  abdominal  muscles.  In  about  one-fourth  of  the  cases  of 
tropical  abscess  of  the  liver  jaundice  occurs;  usually,  however,  it  occurs  only 
when  the  abscess  is  on  the  inferior  surface.  Jaundice  does  not  occur  unless 
the  common  or  hepatic  ducts  are  compressed  or  cholangitis  exists.  The 
leukocyte-count  is  of  no  particular  help  in  the  diagnosis,  as  there  may  or  may 
not  be  a  leukocytosis.  The  urine  is  usually  scanty.  Diarrhea  is  a  common 
accompaniment,  but  constipation  may  exist,  and  nausea  and  vomiting  are 
by  no  means  unusual. 

Diagnosis. — With  an  antecedent  history  of  dysentery  the  diagnosis  is 
easy.  Without  .such  a  history,  it  is  always  difficult  and  may  be  impossible. 
In  the  tropics  exploratory  aspiration  is  freely  used,  but  exploratory  incision, 
with  subsequent  exploratory  aspiration,  if  neces.sary,  must  be  safer  and  more 
certain. 

Symptoms  oj  Traumatic  Abscess. — Are  similar  to  those  of  tropical  abscess. 

Symptoms  oj  Pyemic  Abscess. — The  liver  is  enlarged  and  tender,  there 
is  slight  jaundice,  and  the  general  .symptoms  of  pyemia  are  present. 

Treatment  oj  Tropical  Abscess. — Make  an  exploratory  incision.  If  the 
abscess  is  adherent  to  the  parietal  peritoneum,  and  is  not  covered  by  liver- 
sub.stance,  at  once  proceed  to  operation.  If  it  is  not  adherent,  or  is  covered 
by  a  considerable  layer  of  liver-substance,  stitch  the  visceral  peritoneum 
to  the  parietal  peritoneum  and  postpone  further  interference  for  forty-eight 
hours.  The  operation  consists  in  evacuating  the  pus  with  a  trocar  and 
cannula,  incising  the  ab.scess,  stitching  its  edges  to  the  edges  of  the  abdominal 


Hepatoptosis,    Floating   or   Movable    Li\er  753 

wound,  irrigating,  and  inserting  a  drainage-tube.  If  the  abscess  is  covered 
by  a  layer  of  liver-tissue,  after  locating  it  with  a  cannula  open  into  it  with 
a  cautery  knife  and  arrest  hemorrhage  by  packing.  When  the  parietal  and 
visceral  layers  of  peritoneum  are  adherent,  packing  will  arrest  bleeding; 
if  they  are  not  adherent,  packing  will  only  push  away  the  movable  liver 
(John  O'Connor).  If  pyothorax  exists,  resect  a  rib,  open  the  pleural  sac, 
and  reach  the  abscess  in  the  liver  by  an  incision  through  the  diaphragmatic 
pleura  and  the  diaphragm  (transthoracic  hepatotomy). 

Treatment  of  Traumatic  Abscess. — Is  the  same  as  for  tropical  abscess. 

Treatment  of  Pyemic  Abscess. — Surgery  is  usually  futile,  because  multiple 
abscesses  exist.     If  pointing  takes  place,  an  operation  should  be  performed. 

Hepatoptosis,  Floating  or  Movable  Liver.— Hepatoptosis  may  be 
congenital,  but  is  usually  acquired.  In  a  congenital  case  certain  ligamen- 
tous supports  of  the  liver  are  absent.  In  the  following  discussion  the 
acquired  form  is  the  variety  referred  to.  This  condition  is  rare.  Ninety- 
eight  cases  have  been  reported.*  It  is  a  form  of  splanchnoptosis  and  is 
due  to  relaxation  of  the  abdominal  wall  and  stretching  of  the  supports  of 
the  liver.  It  may  occur  alone,  but  it  is  more  often  a  part  of  a  general  ab- 
dominal relaxation  or  of  Glenard's  disease,  and  often  a  kidney  is  movable, 
or  uterine  displacement  or  hernia  may  exist.  The  liver  mav  descend  into 
the  lower  abdomen,  may  be  upside  down  (Demarquay),  mav  rotate  on  its 
transverse  axis  (Griflfiths),  the  anterior  surface  may  become  posterior,  or 
the  organ  may  lie  with  the  superior  surface  in  the  right  flank  and  the  inferior 
surface  looking  to  the  left,t  may  be  movable,  or  may  be  anchored  by  adhe- 
sions. It  is  most  common  in  women.  The  liver  is  supported  bv  ligaments 
and  also  by  the  inferior  vena  cava,  which  vessel  is  firmly  adherent  to  the 
central  tendon  of  the  diaphragm  (Faure),  by  the  abdominal  wall,  and  by  the  in- 
testines (Glenard).  The  cause  of  the  condition  is  in  dispute.  It  can  result 
from  relaxation  of  the  belly-wall,  relaxation  of  the  ligaments,  enteroptosis, 
great  enlargement  of  the  gall-bladder,  increase  in  weight  of  the  organ,  atrophy 
of  the  connective  tissue  between  the  liver  and  diaphragm,  pregnancy,  the 
growth  of  a  liver  tumor,  and  tight  lacing.  Either  a  strain,  cough,  or  the 
dragging  of  an  adherent  tumor  may  be  the  exciting  cause. 

Signs  and  Symptoms. — An  abdominal  mass  may  appear  suddenlv  after 
a  blow  or  a  strain,  and  if  it  does  appear  suddenly  there  is  always  pain  in 
the  hepatic  region,  nausea,  and  weakness.  When  the  condition  comes  on 
gradually,  there  may  be  no  symptoms  for  a  long  time,  but  as  a  rule  there 
is  some  pain  in  the  loin  which  becomes  worse  after  exercise  or  effort.  In 
rare  cases  jaundice  appears,  and  occasionally  there  is  ascites.  The  abdominal 
walls  are  relaxed  and  the  signs  of  splanchnoptosis  are  manifest.  When 
the  patient  stands,  a  transverse  furrow  of  skin  covers  the  lower  part  of  the 
umbilicus  (Glenard's  sign).  In  most  cases  the  shape,  the  movability,  and 
the  absence  of  the  liver  from  its  proper  position  are  diagnostic.  Even  when 
the  organ  is  dislocated  and  attached  in  its  new  situation  it  is  missed  from 
its  proper  abode  and  palpation  outlines  the  characteristic  shape.  When  the 
patient  lies  down  the  liver  usually  returns  to  place,  and  in  most  cases  it  can 
be  restored  by  manipulation.     In   some  cases,   however,   it   will  not   return 

*  J.  H.  ("aistens,  Jour.  Am.  Med.  Assoc,  Mav  17,  1902. 
t  Terrier  atid  Auvray,  Rev.  de  Chir. ,  Aug.  and  Sept.,  1897. 


754  Diseases  and   Injuries  of   the  Abdomen 

to  place  and  cannot  be  restored  by  manipulation.  The  floating  liver  causes 
a  recognizable  enlargement  in  the  right  loin,  and  the  mass  moves  on  respiration. 
Treatment. — In  many  cases  the  patient  can  be  kept  comfortable  by 
wearing  an  abdominal  support,  and  can  be  distinctly  improved  by  the  use 
of  massage  and  electricity  to  the  abdominal  wall,  the  administration  of  tonics, 
and  a  course  of  forced  feeding.  If  these  means  fail,  and  the  patient  suffers, 
an  operation  should  be  performed.  The  operation  of  hepatopexy  was  de- 
vised by  Marchant.  He  opens  the  abdomen  and  tries  to  restore  the  liver 
to  its  proper  position.  This  can  usually  be  accomplished.  In  some  cases 
it  can  be  done  after  adhesions  have  been  separated.  In  other  cases  it  can 
be  only  partially  accomplished.  After  the  liver  has  been  restored,  he  sutures 
it  by  rneans  of  catgut  or  silk  to  the  abdominal  wall  or  costal  cartilages,  the 
stitches  passing  through  the  hepatic  parenchyma  and  being  carried  through 
the  liver  by  means  of  a  round  and  blunt  needle.  The  sutures  attaching  the 
liver  to  the  belly-wall  are  tied  beneath  the  skin.  Marchant  scarifies  the 
dome  of  the  liver  in  order  to  favor  adhesions.  Ramsay  rubs  the  upper 
surface  of  the  liver  with  gauze  to  promote  adhesion  and  transfixes  the  round 
ligament  with  a  suture  which  is  carried  around  the  cartilage  of  the  seventh 
rib.  In  a  severe  case  follow  Depage's  advice  and  associate  hepatopexy  with 
an  excision  of  a  portion  of  the  abdominal  wall  to  amend  relaxation  (laporec- 
tomy).  If  in  operating  on  a  floating  liver  it  is  found  impossible  to  get  the 
hver  back  into  its  normal  position,  fix  it  with  sutures  as  near  its  proper  abode 
as  is  possible.  Terrier  and  Auvray  report  ii  cases  of  hepatopexy.  One 
case  died  and  eight  completely  recovered. 

Floating  Hepatic   Lobe  (Partial  Hepatoptosis).— This  condition 

is  not  uncommon  in  cases  of  chronic  disease  of  the  gall-bladder  and  is 
most  often  met  in  cholelithiasis.  It  is  believed  that  it  can  be  caused  by 
tight  lacing.  A  tongue-like  projection  forms  upon  the  right  lobe  of  the 
liver  (linguiform  lobe).  It  can  be  palpated  below  the  costal  margin  and 
the  dulness  of  the  mass  on  percussion  is  continuous  with  liver-dulness.  A 
linguiform  lobe  can  usually  be  moved  laterally  and  forward  and  backward; 
it  is  always  tender  and  is  sometimes  the  seat  of  pain. 

Treatment. — When  this  condition  is  associated  with  gall-bladder  trouble, 
it  may  disappear,  or  at  least  cease  to  cause  pain,  when  the  gall-bladder  is 
drained  by  cholecystotomy.  Langenbuch  has  successfully  removed  a  lin- 
guiform lobe. 

Cholecystitis  (Inflammation  of  the  Qall=bladder).— Inflamma- 
tion of  the  gall-bladder  is  produced  by  infection.  Healthy  bile  is  sterile; 
and  when  bacteria  are  found  in  the  bile,  the  condition  is  one  of  dis- 
ease. Micro-organisms  may  find  entrance  into  the  gall-bladder  by  way 
of  the  Vjlood,  the  bile  becoming  infected  secondarily  to  the  infection  of  the 
gall-bladder;  or  they  may  enter  by  way  of  the  ducts,  from  the  intestine. 
The  conditions  that  follow  infection  depend  upon  the  characteristic  ten- 
dency and  the  virulence  of  the  infecting  germs.  A  trivial  infection  produces 
mucous  catarrh;  a  more  active  infection  causes  suppuration,  and  possibly 
ulceration;  a  very  violent  infection  leads  to  gangrene. 

In  most  cases  of  cholecystitis  an  inflammatory  swelling  blocks  the  cystic 
fjuct,  and  obstructs  it  so  that  the  bile  stagnates  in  the  gall-bladder.  In 
many  cases  this  condition  lasts  but  a  short  time;  and  when  the  obstruction 


Catarrhal    Cholecystitis  755 

is  relieved,  bile  flows  down  the  duct.  Occasionally,  as  a  secondary  conse- 
quence, cholangitis,  or  infection  of  the  hepatic  ducts,  follows.*  Occasionally, 
also,  the  obstruction  of  the  duct  is  not  relieved;  and  a  quantity  of  clear, 
thin  mucus  gathers  in  the  gall-bladder  and  overdistends  it — the  condition 
known  as  hydrops.  The  gall-bladder  may  likewise  become  distended  with 
pus,  constituting  an  empyema  of  the  gall-bladder;  and  any  overdistended 
gall-bladder  may  rupture.  In  cases  of  very  chronic  inflammation  of  the 
gall-bladder,  this  structure  becomes  fibrous  and  contracts,  until  it  mav  become 
no  larger  than  the  thumb,  in  which  condition  it  may  contain  a  very  small 
amount  of  thickened  bile.  In  some  inflammatory  conditions  due  to  infection 
the  bile  mixes  with  thickened  mucus,  and  micro-organisms  form  the  nucleus 
upon  which  bile-salts  are  deposited.  Thus  are  gall-stones  formed  (McFar- 
land).  As  the  same  author  points  out,  cholelithiasis  mav  result  from  chole- 
cystitis, and  may  cause  chronic  cholecystitis;  because  the  stones  e.xisting  in 
a  gall-bladder  are  sources  of  irritation. 

Bacteriology  of  Cholecystitis.— It  has  been  proved  by  abundant  ob- 
servation that  the  fact  that  bile  contains  micro-organisms  is  no  evidence 
that  the  gall-bladder  is  inflamed;  but  that  when  the  gall-bladder  is  inflamed, 
micro-organisms  are  demonstrable  in  the  bile.  We  know  that  the  bile  is 
infected  during  the  course  of  typhoid  fever,  and  that  it  is  frequentlv  so  in 
pneumonia.  The  colon  bacillus  is  not  unusually  demonstrable  in  chole- 
cystitis; and  pus-germs,  either  in  pure  culture  or  mixed  with  other  germs, 
con.stitute  the  most  common  cause  of  the  inflammation.  It  is  probable  that 
bacteria  entering  the  gall-bladder  and  not  being  particularly  virulent  produce 
no  immediate  harm  when  the  flow  of  bile  is  unobstructed,  though  even  then 
they  may  become  the  nuclei  of  gall-stones;  but  if  the  bacteria  are  very  viru- 
lent, they  may  actually  lead  to  obstruction.  Stagnation  of  the  bile  favors 
infection,  and  infection  may  be  the  cause  of  stagnation.  Each  influence 
reacts  upon  the  other  and  aggravates  the  other,  and  it  seems  more  than 
possible  that  infection  of  the  gall-bladder  is  to  be  regarded  as  serious  onlv 
when  there  is  obstruction  to  the  outflow  of  bile.  The  same  variety  of  germ 
may,  under  some  circumstances,  cause  catarrhal,  and  under  others  suppu- 
rative, inflammation;  that  is,  when  bacteria  are  virulent  and  tissue  resist- 
ance is  slight,  suppurative  cholecystitis  results;  but  when  the  bacteria  are  not 
virulent  and  the  tissue-resistance  is  powerful,  the  gall-bladder  is  not  infected 
at  all,  or  only  catarrhal  inflammation  is  produced. 

Catarrhal  Inflammation  of  the  Qall=bladder  and  Bile=ducts. — 

This  condition  is  known  as  catarrhal  jaundice,  acute  or  chronic,  and  is 
usually  treated  by  the  physician;  but,  as  A.  W.  Mayo  Robson  points  out, 
chronic  catarrhal  jaundice  sometimes  resembles  the  jaundice  of  organic 
disease,  and  is  occasionally  associated  with  gall-stones,  malignant  disease, 
or  hydatid  cyst.  Therefore,  in  a  case  of  chronic  catarrhal  jaundice  in  which 
medical  treatment  fails,  surgical  treatment  must  be  considered. 

Catarrhal  Cholecystitis.— This  is  a  catarrhal  inflammation  of  the 
gall-bladder  without  jaundice.  The  gall-bladder  becomes  thick  and  its 
mucous  membrane  is  frequently  plicated.  \'ery  thick  mucus  is  secreted, 
which  gathers  in  masses,  and  the  descent  of  these  plugs  causes  pain  that 
is  sometimes  indistinguishable  from  that  produced  by  the  passage  of  a  gall- 
*  Joseph  McFarland,  Proceedings  of  the  Phila.  Co.  Med.  I^oc,  Sept.,  1902. 


756  Diseases   and   Injuries   of   the   Abdomen 

stone.  Such  a  plug  may  temporarily  block  the  cystic  duct.  In  catarrhal 
cholecystitis  the  gall-bladder  is  frequently  distended,  but  rarely  admits  of 
palpation;  and  there  are  no  adhesions  to  surrounding  structures,  unless 
gall-stones  have  been  present  (Robson).  Catarrhal  cholecystitis  may  lead 
to  the  formation  of  gall-stones;  may  result  from  the  presence  of  gall-stones; 
or  may  be  found  in  cases  in  which  gall-stones  have  been  present,  but 
have  passed.  In  one  case  upon  which  I  operated,  the  gall-bladder  was 
enlarged,  thick,  and  without  adhesions;  the  mucous  membrane  was  con- 
voluted; and  the  viscus  was  filled  with  thick,  tenacious  mucus,  and  the 
mucous  membrane  of  the  gall-bladder  contained  many  minute  concretions. 
In  this  case  stone-formation  was  probably  beginning  to  follow  upon  catarrhal 
cholecystitis.  In  another  case  a  woman  had  presented  violent  symptoms 
of  gall-stone  cohc,  and  stones  had  been  recovered  from  the  feces;  but  on 
opening  the  gall-bladder  no  stones  were  found — only  a  condition  of  catarrhal 
cholecystitis.  Jaundice  is  rare  in  catarrhal  cholecystitis,  unless  gall-stones  are 
present;  it  is,  however,  occasionally  noted.  Even  if  jaundice  does  occur,  it 
is  slight  and  lasts  but  a  short  time.  The  painful  attacks  that  occur  during 
catarrhal  cholecystitis  are  similar  to  gall-stone  attacks;  but  the  pain  is  less 
violent  and  of  briefer  duration,  and  jaundice  is  not  apt  to  follow  the  passage 
of  a  plug  of  mucus  and  is  apt  to  follow  the  passage  of  a  gall-stone.  Further, 
as  Robson  has  shown,  in  cholecystitis  with  gall-stones  there  is  usually  ten- 
derness on  pressure  over  the  gall-bladder;  and  there  is  rarely  tenderness  in 
uncomplicated  catarrhal  cholecystitis. 

Treatment. — The  majority  of  the  cases  recover  under  medical  treatment. 
If  a  case  fails  to  recover  under  medical  treatment,  one  cannot  be  sure  whether 
there  are  gall-stones  or  not;  but  an  operation  is  indicated  in  either  case. 
Cholecystotomy  should  be  performed,  and  the  gall-bladder  should  be  drained 
for  a  week  or  two.     This  treatment  will  almost  always  produce  cure. 

Croupous    Inflammation   of   the    Qall=bladder  and  the    Bile= 

ducts. — This  is  an  extremely  rare  condition  due  to  the  formation  of  a 
thick  membrane  in  the  bile-passages,  which  causes  obstruction  to  the  flow 
of  bile  and  spasmodic  contraction  of  the  gall-bladder.  The  symptoms  are 
identical  with  those  of  gall-stones.  Robson  points  out  that  a  study  of  the 
evacuations  may  discover  membranous  intestinal  casts;  and  that,  as  mem- 
branous enteritis  is  usually  associated  with  croupous  inflammation  of  the 
gall-bladder  and  bile-ducts,  a  diagnosis  may  thus  be  reached.  The  same 
author  says  that  one  may,  in  some  ca.ses,  even  find  a  cast  of  the  gall-bladder 
in  the  evacuations. 

Treatment. — If  medical  treatment  fails,  cholecystotomy  should  be  ])er- 
formed  and  drainage  should  be  employed  for  a  considerable  time. 

Suppurative    Inflammation    of    the    Qall=bladder    and    Bile= 

ducts. — Adopting  the  classification  of  Mr.  Robson,  we  divide  these 
suppurative  inflammations  into  simple  suppurative  cholecystitis,  suppurative 
and  infective  cholangitis,  ])hlegmon()us  cholecystitis  and  gangrene  of  the 
gall-bladder,  ulceration  of  the  gall-bladder  and  bile-ducts,  pericy.stic  abscess 
with  adhesions,  and  certain  con.sequences  of  these  conditions,  such  as  stric- 
ture of  the  gall-bladder  and  bile-ducts,  perforation  of  the  gall-bladder  and 
bile-flucts,  and  fistula  of  the  gall-bladder  and  bile-ducts.  Suppurative  in- 
flammations of  the  gall-bladder  and   the  bile-pa.s.sages  are  due  to  infection 


Simple  Suppurative    Cholecwstitis  757 

with  virulent  organisms  or  to  infection  when  the  tissue-resistance  is  at  a 
low  ebb. 

One  fact  must  strike  the  physician  in  regard  to  these  cases;  that  is,  that 
there  is  a  strong  similarity  between  the  possible  changes  of  acute  cholecystitis 
and  the  possible  changes  of  acute  appendicitis.  In  the  gall-bladder,  as  in 
the  appendix,  there  may  be  a  catarrhal  inflammation,  which  may  not  advance 
beyond  this  stage,  or  which  may  advance  into  a  more  dangerous  form;  in 
each  structure,  blocking  and  stagnation  favor  infection  and  aggravate  ex- 
isting infection;  in  each,  there  may  be  suppuration,  ulceration,  gangrene,  and 
perforation;  in  each,  there  may  be  grave  comphcations  and  disastrous  and 
fatal  consequences;  and  in  each,  prompt  surgical  operation  is  often  life- 
saving.* 

Simple  Suppurative  Cholecystitis. — This  condition  is  also  spoken 

of  as  suppurative  catarrh  of  the  gall-bladder,  or  simple  empyema  of  the 
gall-bladder.  It  is  a  rare  condition,  unless  gall-stones  exist,  or  unless 
some  infectious  disease — especially  typhoid  fever — has  antedated  the  con- 
dition. It  is  not  only  typhoid  fever  that  may  be  causative,  but  also  other 
continued  fevers.  No  matter,  however,  what  organism  is  primarily  responsi- 
ble,— be  it  colon  bacillus,  typhoid  bacillus,  or  what  not, — a  mixed  infection 
with  pyogenic  organisms  takes  place.  In  simple  suppurative  catarrh  of  the 
gall-bladder  when  the  duct  becomes  blocked,  the  condition  known  as  simple 
empyema  exists;  and  when  hydrops  of  the  gall-bladder  undergoes  suppura- 
tion, simple  empyema  is  produced. 

In  an  ordinary  case  of  suppurative  catarrh  following  gall-stones,  one 
usually  obtains  the  history  of  a  number  of  attacks  of  bihary  colic,  the  pain 
finally  having  become  persistent,  instead  of  intermittent;  and  a  definite  swell- 
ing being  palpable  in  the  gall-bladder  region.  This  swelling  is  tender  on 
pressure.  There  are  usually  constitutional  symptoms;  sometimes  trivial, 
often  severe.  The  trivial  symptoms  are  a  somewhat  rapid  pulse,  sweating 
at  night,  and  some  elevation  of  temperature.  The  more  severe  symptoms 
are  chills,  a  remittent  fever,  and  profuse  sweats.  The  development  of  severe 
symptoms  indicates  that  a  dangerous  change  is  taking  place;  usually  ulcera- 
tion of  the  gall-bladder,  occasionally  phlegmonous  cholecystitis.  Distinct 
jaundice  is  rare  in  simple  empyema,  though  the  patient  usually  shows  loss 
of  flesh,  has  a  very  poor  appetite,  and  suffers  considerably  from  thirst. 

To  distinguish  an  enlarged  gall-bladder  from  any  other  intra-abdominal 
mass  is  sometimes  difficult.  An  enlarged  gall-bladder  moves  on  respiration, 
unless  the  mass  becomes  adherent  to  the  abdominal  walls,  when  it  will  cease 
to  do  so.  An  enlarged  gall-bladder  is  sometimes  mistaken  for  a  movable 
kidnev,  and  the  diagnosis  between  these  conditions  is  discussed  in  the  section 
on  Mo\able  Kidney  (page 934). 

Treatment. — The  gall-bladder  should  be  opened  and  drained  by  the 
operation  of  cholecystotomy.  After  it  has  been  exposed,  it  is  packed  about 
with  gauze  pads,  a  considerable  amount  of  the  contents  is  removed  through 
an  aspirator,  the  gall-bladder  is  opened  and  irrigated  with  salt  solution, 
and  a  search  is  made  for  an}-  cause  of  obstruction  in  the  cystic  duct.  This 
cause  should  be  removed;  and  any  gall-stones  that  are  present  should,  of 
course,   be  taken  away.     The  walls  of  the  gall-bladder  will  frequently  be 

*  The  Author:   Proceedings  of  the  Phila.  Co.  Med.  Soc. ,  Sept.,  1902. 


758  Diseases  and   Injuries  of  the   Abdomen 

found  diseased  and  softened,  so  that  it  is  impossible  to  apply  stitches.  In 
some  cases,  if  the  gall-bladder  is  badly  diseased,  it  should  be  removed;  but 
in  others,  cholecystotomy  with  drainage  is  sufficient. 

Recurrent  Simple  Empyema  of  the  Qall=bladder.— In  this  con- 
dition a  person  develops,  at  intervals,  pain,  fever,  tenderness,  and  enlarge- 
ment of  the  gall-bladder.  Then  the  symptoms  clear  up,  he  is  well  for  a 
time,  but  they  finally  recur;  and  at  last  they  may  become  persistent  or  vio- 
lent, because  of  the  development  of  some  complication.  In  these  cases  it 
becomes  impossible,  after  a  number  of  attacks,  to  palpate  any  enlargement 
of  the  gall-bladder;  and  when  an  operation  is  performed,  the  gall-bladder  is 
found  shrunken,  thickened,  and  deeply  placed,  containing  some  purulent 
matter,  and  strongly  fixed  to  the  surrounding  structures  by  adhesions. 

Treatment. — Cholecystectomy  is  usually  the  proper  operation. 

Acute  Phlegmonous  Cholecystitis. — Some  call  this  condition  acute 
empyema.  It  is  extremely  dangerous,  and  is  apt  to  cause  gangrene  of  the 
gall-bladder.  It  is  due  to  infection  with  extremely  virulent  organisms. 
It  may  produce  rapid  peritonitis  and  death  without  perforation,  but  oftener 
perforation  takes  place.  It  is  usually  associated  with  the  presence  of  calculi, 
but  sometimes  none  are  found;  and  the  condition  sometimes  develops  during 
typhoid  fever  or  septicemia. 

This  disease  begins  with  sudden  and  violent  pain  in  the  gall-bladder 
region.  This  pain  usually  radiates  toward  the  right  shoulder-blade,  and 
soon  becomes  general  throughout  the  abdomen.  There  is  tenderness  in  and 
great  rigidity  over  the  gall-bladder  region,  thoracic  respiration,  exhausting 
vomiting,  septic  fever,  and  in  some  cases  jaundice.  If  an  operation  is  not 
promptly  performed,  general  peritonitis  quickly  takes  the  patient's  life.  In 
one  case  upon  which  I  operated  there  were  intense  jaundice,  tenderness, 
violent  pain,  abdominal  rigidity  and  distention,  chills,  and  seotic  fever;  and 
when  the  abdomen  was  opened,  it  was  found  that  a  portion  of  the  gall- 
bladder was  gangrenous  and  that  a  calculus  projected  through  the  gangrenous 
opening. 

It  is  this  form  of  cholecystitis  that  is  especially  likely  to  be  mistaken 
for  appendicitis.  In  making  a  diagnosis,  the  situation  of  the  primary  pain 
is  of  importance,  and  likewise  the  situation  of  the  tenderness;  but  a  dis- 
placed gall-bladder  or  an  abnormally  situated  appendix  will  lead  to  error. 
Acute  phlegmonous  cholecystitis  is  usually  accompanied  by  absolute  con- 
stipation, and  the  sudden  onset  and  the  abdominal  distention  may  lead  to 
the  disease  being  mistaken  for  intestinal  obstruction.  It  may  also  be  con- 
fused with  perforating  ulcer  of  the  stomach  or  of  the  duodenum. 

Treatment. — In  any  case  of  doubt,  an  exploratory  incision  should  be 
made.  If  phlegmonous  cholecystitis  is  found  to  exist,  the  gall-bladder 
should,  whenever  possible,  be  extirpated;  but  if  the  desperate  condition  of 
the  patient  forbids  this  operation,  it  should  be  surrounded  with  iodoform 
gauze  and  a  drainage-tube  should  be  carried  well  up  toward  the  cystic  duct. 

Pericystic  Abscess. — Pericystic  abscess  is  a  condition  that  may  fol- 
low infection  of  the  gall-bladder.  It  is  especially  common  in  the  condition 
known  as  recurrent  simple  em[)yema.  When  a  pericystic  ab.scess  exists  the 
localized  abdominal  tenderness  is  great  and  the  temperature  is  usually  in- 
dicative of  suiif)uration.     The  causative  micro-organisms  may  have  passed 


Suppurative   Cholangitis  ,■  759 

through  a  diseased  gall-bladder  wall,  rupture  not  existing;  or  the  abscess 
mav  follow  ulceration  or  perforation  of  the  gall-bladder  wall.    • 

Treatment. — Operation  should  invariably  be  performed,  though  it  is 
frequently  difficult.  After  a  pericystic  abscess  has  been  drained,  it  will 
be  found  necessary  in  some  cases  to  extirpate  the  gall-bladder;  whereas  in 
others,  cholecystotomy  and  drainage  will  prove  sufficient. 

Suppurative    and    Infective    Cholangitis.— The   usual    cause   of 

infective  cholangitis  is  gall-stones  lodged  in  the  common  duct,  particularly 
tho.se  cases  in  which  a  gall-stone  acts  as  a  ball-valve.  A.  \V.  Mayo  Robson, 
though  he  believes  that  infective  cholangitis  does  occur  when  the  gall-stones 
are  freely  movable  in  the  common  duct,  sets  it  forth  as  his  experience  that 
it  is  much  more  common  in  such  cases  to  find  gall-stones  impacted  in  the 
common  duct. 

In  such  cases  the  patient  gives  a  history  of  attacks  of  gall-stone  colic 
without  jaundice  for  several  years,  and  then  of  attacks  followed  'by  tem- 
porary jaundice.  Finally  comes  an  attack  that  is  followed  by  a  chill  and 
fever;  and  jaundice,  varying  in  intensity,  ensues  upon  this,  but  ^it  now 
almost  never  completely  disappears  between  the  attacks  of  pain.  Robson 
points  out  that  the  interval  between  the  attacks  may  be  short  or  long,  and 
that  the  rigors  may  be  repeated  daily  or  at  uncertain  intervals;  that  the 
gall-bladder  is  usually,  but  not  always,  contracted;  and  that  after  the  con- 
dition has  persisted  for  some  time,  the  liver  becomes  distinctly  enlarged. 
There  is  tenderness  over  th%  gall-bladder  or  in  the  epigastric  region,  loss 
of  flesh,  and  persistent  jaundice. 

Infective  cholangitis,  even  after  it  has  lasted  for  a  considerable  length 
of  time,  may  be  recovered  from;  but  it  may  pass  on  into  an  acute  condition 
in  which  poisoning  takes  place  from  the  biliary  elements,  suppurative  cho- 
langitis may  arise,  an  empyema  of  the  gall-bladder  may  develop,  and  there 
may  be  an  abscess  of  the  liver  or  some  other  dangerous  or  fatal  complication. 
The  ague-like  attacks  of  infective  cholangitis  have  been  called  by  Charcot 
intermittent  hepatic  jever. 

Treatment. — After  an  incision  has  been  made,  the  duct  is  opened  and 
the  cause  removed;  but,  as  Mayo  Robson  points  out,  the  complication  should 
be  anticipated.  When  one  finds  that  carefully  applied  medical  treatment 
has  failed  to  free  the  patient  of  gall-stones,  they  should  be  removed  surgically. 

Suppurative  Cholangitis. — ^Suppurative  cholangitis  is  usually  a  de- 
velopment of  ordinary  infective  cholangitis,  which  has  just  been  discussed. 
Among  the  other  causes  that  Robson  sums  up  are  acute  infectious  diseases, 
particularly  typhoid  fever  and  influenza:  cancer  of  the  bile-ducts;  and  hyda- 
tid disease. 

In  this  condition  the  liver  enlarges  notably  and  becomes  tender.  In 
some  cases  there  is  an  empyema  of  the  gall-bladder,  but  this  is  rare;  in 
fact,  the  gall-bladder  is  usually  very  much  shrunken.  \Mien,  in  a  chronic 
case,  there  is  enlargement  of  the  liver,  blocking  of  the  common  duct,  and 
enlargement  of  the  gall-bladder,  the  inference  is  in  favor  of  cancerous 
obstruction  of  the  common  duct.  If  the  obstruction  is  due  to  cancer,  there 
will  usually  be  little  pain;  but  when  it  is  due  to  gall-stones,  there  will  be 
violent  attacks  of  pain,  accompanied  by  rigors  and  fever,  with  deepening 
of  the  jaundice.     In  this  disease  there  is  always  jaundice,  usually  unfading; 


760  Diseases  and   Injuries  of   the  Abdomen 

but  in  cases  of  ball-valve  gall-stone  in  the  duct,  it  may  be  mitigated  from 
time  to  time.  The  patient  suffers  with  septic  fever  and  very  rapid  loss  of 
flesh. 

The  condition  is  generally  fatal,  unless  operation  is  performed  early. 
There  is  a  strong  tendency  for  abscess  of  the  liver  to  form,  and  in  one  case 
upon  which  I  operated,  a  subphrenic  abscess  had  developed. 

Treatment. — Cholecystotomy  with  free  and  prolonged  drainage.  If  an 
abscess  of  the  hver  exists,  it  should  also  be  drained.  If  gall-stones  are 
gathered  in  the  common  duct,  they  should,  of  course,  be  removed. 

Qall=Stones. — Gall-stones  are  formed  during  life  in  the  gall-bladder 
or  bile-ducts  by  the  agglutination  of  materials  which  have  precipitated  from 
bile.  The  nucleus  of  a  gall-stone  may  be  a  mass  of  bacteria,  a  blood-clot, 
epithelium,  crystals  of  cholesterin  or  carbonate  of  lime,  or  a  cast  of  a  small 
duct.*  The  condition  of  the  body  which  leads  to  the  formation  of  gall- 
stones is  designated  by  the  term  cholelithiasis  (Brockbank).  But  one  stone 
mav  be  present  or  great  numbers  may  e.xist.  Solitary  stones  may  be  nearly 
round  or  cvlindrical.  When  several  stones  or  many  stones  e.xist  the  mutual 
pressure  often  leads  to  the  formation  of  facets  (Naunyn).  In  color  calculi 
may  be  pale  yellow,  green,  black,  or  brown.  Some  are  heavier  than  bile 
and  some  are  hghter.  Brockbank  gives  the  following  varieties  of  gall-stones; 
pure  cholesterin  stones,  stratified  cholesterin  stones,  common  or  gall-bladder 
calculi,  mi.xed  bilirubin  calcium  calculi,  pure  bilirubin  calcium  calculi,  and 
certain  rare  forms. t  Gall-stones  usually  take. origin  in  the  gall-bladder,  but 
may  arise  in  the  common  duct,  the  cystic  duct,  the  hepatic  duct,  or  the  smaller 
ducts  of  the  liver.  As  a  rule,  however,  calculi  in  the  common  or  cystic  duct 
were  not  formed  there,  but  were  transported  from  the  gall-bladder  or  hepatic 
ducts. 

Causes. — Gall-stones  are  very  commonly  found  post-mortem.  In 
Germany  it  is  estimated  that  they  are  found  in  12  per  cent,  of  all  cases.  In 
1655  autopsies  in  the  Johns  Hopkins  Hospital  gall-stones  were  present  in 
6.94  per  cent,  of  all  cases.t  The  cause  is  a  catarrhal  condition  of  the  bile- 
ducts,  due  particularly  to  the  entrance  of  bacteria  from  the  intestine  (colon 
bacilli,  typhoid  bacilli,  pus  organisms,  pneumococci).  This  catarrhal  con- 
dition causes  stagnation  of  bile.  Experimental  infection  of  the  gall-bladder 
producing  mild  cholecystitis  is  almost  always  followed  by  gall-stone  forma- 
tion.^ Welch  pointed  out  that  recent  gall-stones  have  bacteria  in  their  center. 
Gushing  tells  us  that  30  per  cent,  of  gall-stone  ca.ses  operated  upon  in  the 
Johns  Hopkins  Hospital  had  previously  suffered  from  typhoid  fever,  but 
Mayo's  experience  is  not  in  accord  with  this  view.  Thirty  per  cent,  of  Ochs- 
ner's  cases  had  had  appendicitis. 

The  chief  predisposing  causes  are  advancing  years,  insufficient  exercise, 
the  consumption  of  an  excess  of  nitrogenous  food,  gouty  tendencies,  conditions 
which  interfere  with  the  emptying  of  the  gall-bladder,  cardiac  disease,  and 
cancer  of  the  liver.  Gall-stones  rarely  form  before  the  age  of  thirty-five. 
The  disease  is  more  common  in  the  insane  than  in  the  mentally  sound,  in  the 

*  Bevan,  in  Chicago  Med.   Kecf)nier,  Ajiril,   iHqS. 

f  Brockbank' s  treatise  on  "  (iall -stones." 

t  C.  D.   Mosher,  in  Johns  Hopkins  Hosp.,  Bull.,  Aug.,  1901. 

§  Gilhert,  in  Archives  gen6rales  de  med.,  .Aug.  and  Se|)t.,   1898. 


Gall-stones  761 

white  race  than  in  the  black,  and  in  women  than  in  men.  In  25  per  cent,  of 
all  females  beyond  sixty  years  of  age  gall-stones  are  present  (Naunyn). 
The  special  liability  of  women  may  be  brought  about  by  tight  lacing,  preg- 
nancy, inactivity,  or  movable  right  kidney.  There  are  two  forms  of  the 
condition  to  be  considered.  The  acute  type,  due  to  efforts  made  by  the  gall- 
bladder or  duct  to  expel  the  concretion;  and  the  chronic  condition,  in  which 
a  calculus  is  lodged  for  a  long  time,  or  in  which,  as  soon  as  one  calculus  is 
passed  into  the  intestine,  "  another  begins  its  journey"  (Brockbank).  The 
fact  that  bacteria  cause  the  condition  must  not  lead  us  to  infer  that  pus  is 
formed.  The  bacteria  are  present  in  small  numbers  or  else  their  virulence 
is  greatly  mitigated,  they  produce  only  catarrhal  inflammation,  quantities  of 
cholesterin  are  secreted,  the  bile  stagnates,  and  a  stone  forms.  In  many 
cases  the  stone  or  stones  never  cause  trouble.  A  gall-stone  may  begin  to 
descend  because  of  violent  muscular  exertion,  external  pressure,  or  at  the 
onset  of  a  fresh  inflammation  which  leads  to  loosening  of  the  stone.  A  very 
small  stone  usuall}'  passes  freely.  A  larger  stone  in  passing  causes  colic.  A 
still  larger  stone  remains  in  the  gall-bladder,  or  becomes  fixed  in  the  cystic 
duct  or  the  intestinal  outlet  of  the  common  duct. 

Symptoms. — The  formation  of  a  stone  requires  several  months,  and  during 
the  antecedent  period  of  gastro-intestinal  catarrh,  "the  prodromal  state"  of 
Kraus,  certain  symptoms  may  exist,  viz.:  constipation,  flatulence,  loss  of 
appetite,  migraine,  uneasy  sensations  in  the  epigastrium  or  right  hypochon- 
drium,  sallowness  of  the  skin,  slight  yellowness  of  the  conjunctiva",  scantiness  of 
urine,  which  excretion  is  saturated  with  uric  acid,  and  may  after  a  time  contain 
a  little  bile.  If  this  condition  is  not  arrested  by  treatment,  it  grows  worse. 
The  abdomen  becomes  decidedly  distended;  pressure  over  the  stomach  or  liver 
may  cause  distinct  uneasiness,  or  even  pain;  acid  indigestion  is  very  trouble- 
some, violent  attacks  of  migraine  occur,  constipation  becomes  more  decided, 
the  feces  become  clay-colored,  gastralgia  may  occur,  the  skin  is  apt  to  be 
slightly  jaundiced,  itching  is  complained  of,  the  patient  is  irritable  and  sleeps 
poorly.  The  liver  is  found  to  be  enlarged,  and  the  urine  contains  distinct 
amounts  of  bile.  When  the  patient  reaches  this  stage  gall-stones  are  very 
liable  to  form.  These  symptoms  may  pass  away  even  if  a  concretion  forms. 
It  is  quite  true  that  in  some  cases  a  stone  exists  for  years  without  causing 
trouble;  but  it  may  greatly  aggravate  the  condition.  When  a  stone  forms 
pain  is  apt  to  become  a  marked  -feature  of  the  case.  A  sense  of  pressure  or  of 
soreness  in  the  hepatic  region  has  added  to  it  sudden  and  transient  paroxysms 
of  pain,  due  to  the  passage  of  thick  bile  from  the  gall-bladder  and  small  ducts, 
or  of  gravel  from  the  small  ducts  urged  on  by  bile-pressure.  When  a  stone 
begins  to  pass  from  the  gall-bladder  violent  colic  is  experienced.  Such  a  colic 
usually  comes  on  very  suddenly,  and  often  about  three  hours  after  a  meal. 
It  may,  however,  come  on  gradually,  the  patient  complaining  greatly  of  flatu- 
lence. The  pains  are  violent,  spasmodic,  and  paroxysmal,  and  over  the 
hepatic  and  epigastric  regions,  "  radiating  upward  over  the  right  half  of  the 
thorax"  (Kraus),  and  passing  particularly  from  the  epigastrium  to  the  right 
shoulder-blade.  The  patient  is  profoundly  nauseated,  and  usually  vomits, 
the  abdomen  is  distended,  and  a  condition  almost  of  collapse  is  soon  reached. 
The  attack  lasts  a  variable  time,  and  terminates  by  the  stone  passing  into  the 
intestine  or  fallins;  back  into  the  Ijladder.     After  its  conclusion,  if  the  feces  are 


762  Diseases   and   Injuries   of  the   Abdomen 

examined  carefully  during  several  days,  the  stone  may  be  discovered.  The 
fact  that  no  stone  is  discovered  does  not  prove  that  no  stone  was  passed,  be- 
cause a  cholesterin  stone  will  be  destroyed  in  the  intestinal  canal.  Jaundice 
almost  invariably  follows  the  attack  in  about  twenty-four  hours  and  lasts 
several  days.  If  the  stone  is  impacted,  after  a  time  the  pains  become  less 
violent,  but  again  and  again  the  patient  suffers  from  aggravation  of  them.  An 
individual  may  get  about  with  impacted  stone,  but  again  and  again  tierce 
attacks  of  colic  occur,  and  if  the  stone  is  in  the  common  duct  the  patient  be- 
comes and  remains  deeply  jaundiced.  In  certain  cases  attacks  of  gall-stones 
are  accompanied  bv  febrile  seizures  resembling  malaria  and  called  hepatic 
fever.  The  fever  may  be  intermittent,  a  chill  or  chills  often  occur,  there  is 
jaundice  and  tenderness  of  the  liver.  The  fever  is  due  to  intoxication  with 
ptomaines  from  infected  bile  retained  in  the  ducts  by  obstruction.  The  con- 
dition is  ominous  because  it  is  due  to  infection. 

If  a  stone  lodges  in  the  cystic  duct,  it  does  not  cause  jaundice.  It  grows  in 
size  from  incrustation,  prevents  the  entrance  of  bile  into  the  gall-bladder, 
and  the  bladder  becomes  filled  with  mucus  (hydrops  of  the  gall-bladder). 
If  a  bladder  so  blocked  becomes  infected,  pus  forms,  and  the  condition  known 
as  empyema  of  the  gall-bladder  exists.  An  empyema  of  the  gall-bladder  may 
rupture  into  the  bowel,  the  peritoneal  cavity,  or  even  through  the  skin. 

The  common  duct  is  involved  in  i  out  of  5  or  6  cases.*  If  a  stone  blocks 
the  common  duct,  jaundice  always  exists.  Blocking  may  be  complete,  and 
the  stone  may  ulcerate  into  the  bowel  or  the  peritoneal  cavity.  Blocking  may 
be  incomplete,  the  stone  acting  as  a  ball-valve  and  producing  intermittent 
colic  and  jaundice  (Christian  Fenger).  Fenger  points  out  that  if  a  stone 
remains  fixed  in  the  common  duct  the  liver  becomes  tender  and  enlarged; 
but  if  a  stone  floats  about  in  the  common  duct,  the  gall-bladder  undergoes 
atrophy.  In  complete  obstruction  the  stools  become  clay-colored  and  bili- 
rubin is  found  in  the  urine. 

Gall-stones  may  lead  to  suppurative  inflammation  of  the  gall-bladder 
or  bile-passages,  ulceration,  occlusion  of  the  neck  of  the  gall-bladder,  dilata- 
tion of  the  stomach  from  the  formation  of  adhesions  which  kink  the  pylorus, 
abscess,  peritonitis,  empyema  of  the  gall-bladder,  and  cancer  of  the  gall- 
bladder. If  the  patient  develops  distinct  infection  of  the  gall-bladder  or 
bile-ducts,  he  will  suffer  from  chills,  fever,  and  sweats. 

Gall-stones  may  lead  to  cirrhosis  of  the  liver.  A  stone  may  ulcerate 
into  the  bowel  and  cause  intestinal  obstruction.  It  may  be  difficult  to  make 
a  diagnosis  between  gall-stones  with  icterus  and  cirrhosis  of  the  liver  with 
icterus.  In  the  former  case  the  urine  contains  bilirubin  and  in  the  latter 
case  urobilin. 

Treatment. — In  the  prodromal  stage  and  after  recovery  from  an  attack 
insist  on  the  patient  taking  considerable  outdoor  exercise.  Direct  him  to 
take  a  cold  sponge-bath  every  morning,  to  move  the  bowels  freely  every 
day,  and  to  employ  a  simple  diet.  He  .should  avoid  all  highly  seasoned 
foods,  pastry,  rich  .soups,  fatty  food,  cheese,  alcohol,  and  sweets.  Alkalies 
internally  are  of  value. 

During  the  attack  give  an  enema,  apply  hot  turpentine  stupes  over  the 
hepatic  region,  and  administer  a  hyjjodermatic  injection  of   morphin  and 

*  Robson,  in  Lancet,  April  12,  1902. 


Gall-stones  763 

atropin.     If  vomiting  does  not  occur,  let  the  patient  drink  a  large  amount 
of  warm  water  to  favor  it.     After  the  attack  administer  a  purgative. 

When  the  attack  has  terminated  examine  carefully  for  an}-  evidence  of 
inflammatory  trouble  in  the  hepatic  region. 

In  certain  cases  operation  becomes  necessary.  Mr.  A.  W.  Mayo  Robson 
advises  operation  in  the  following  cases:*  in  frequently  recurring  biliary  colic 
without  jaundice,  whether  the  gall-bladder  is  enlarged  or  not;  in  cases  of 
enlargement  of  the  gall-bladder  without  jaundice,  even  if  there  is  no  pain; 
in  persistent  jaundice  which  was  ushered  in  by  pain,  painful  seizures  occur- 
ring, whether  or  not  febrile  attacks  occur;  in  empyema  of  the  gall-bladder; 
in  peritonitis  beginning  in  the  gall-bladder  region;  in  intrahepatic  abscess  and 
in  abscess  about  the  liver,  gall-bladder,  or  bile-ducts;  in  some  cases  where 
the  stones  have  been  passed,  but  adhesions  remain  and  ])roduce  pain;  in 
fistula  cases;  in  some  cases  of  persistent  jaundice  due  to  obstruction  of  the 
common  duct,  although  there  may  be  a  possibility  of  cancer  existing;  in 
phlegmonous  cholecystitis  and  gangrene  of  the  gall-bladder.  Besides  these 
conditions  which  may  be  produced  by  gall-stones,  Robson  operates  for  wounds 
of  the  gall-bladder,  infective  and  suppurative  cholangitis,  and  for  some  con- 
ditions of  chronic  catarrh  of  the  bile-ducts  and  gall-bladder.f  The  tendenc}^ 
to  operate  early  for  gall-stones  is  growing.  It  is  true  that  stones  may  cause 
no  trouble,  but  sooner  or  later  they  are  apt  to,  there  is  no  tendency  whatever 
to  spontaneous  cure,  and  medicine  cannot  dissolve  them  in  the  bladder. 
Early  operations  are  easy  and  comparatively  safe;  late  operations  are  difficult 
and  dangerous,  and  by  early  operation  dangerous  complications  (infection, 
adhesions,  obstructive  jaundice)  are  avoided.  As  Maurice  H.  Richardson  | 
says:  An  early  operation  is  less  dangerous  than  the  passage  of  a  stone;  com- 
plications are  avoided  or  lessened;  even  if  the  diagnosis  is  wrong  the  real 
condition  may  be  found  and  removed.  If  obstructive  jaundice  exists,  opera- 
tion is  dangerous  because  of  the  probability  of  fatal  oozing  of  blood. 

The  common  operation  is  cholecystotomy,  which  consists  in  opening  the 
gall-bladder,  removing  the  stones,  and  making  a  temporary  fistula  in  the  gall- 
bladder (page  819).  The  fistula  is  permitted  to  heal,  hence  we  say  cholec}'s- 
totomy  rather  than  cholecystostomy.  After  drainage  gall-stones  rarely  re-form. 
The  operation  of  incision,  removal  of  the  stone,  and  suture  of  the  gall-bladder 
is  known  as  cholecystendysis.  If  calculi  exist  in  the  common  duct,  it  may 
be  possible,  after  celiotomy,  to  manipulate  them  back  into  the  bladder  and 
extract  them  from  that  viscus  with  a  scoop,  but  this  maneuver  is  impossible 
unless  the  cystic  duct  is  dilated.  In  some  cases  cholecystotomy  is  performed, 
a  fistula  is  made,  and  the  duct  and  bladder  are  frequently  irrigated.  In 
other  cases  the  stone  may  be  crushed  by  the  fingers  manipulating  the  duct 
and  the  concretion  within  it  (choledocholithotrity).  Robson  points  out 
that  crushing  of  the  stone  is  apt  to  leave  fragments  which  may  cause  trouble, 
and  it  should  be  done  only  when  the  stones  are  soft.  It  is  wrong  to  endeavor 
to  force  a  stone  from  the  common  duct  into  the  duodenum.  The  attempt 
will  fail,  and  in  some  cases  the  patient  will  be  placed  in  a  worse  condition 

*  Mayo  Robson  on  tlie  "  Gall-bladder  and  Bile-ducts." 

f  Robson's  treatise,  from  which  the  above  is  taken,  is  a  valuable  exposition  of  the  sur- 
gery of  the  gall-bladder  and  bile-ducts. 

j  Boston  Med.  and  Surg.  Jour.,  Sept.  5,  1901. 


764  Diseases  and    Injuries   of   the   Abdomen 

bv  the  stone  lodging  in  X'ater's  diverticuhmi.*  The  duct  may  be  opened, 
and  after  the  removal  of  the  stone  closed  by  sutures  or  drained  for  a  time, 
strands  of  gauze  being  carried  down  to  the  opening  and  in  some  cases  a 
tube  being  carried  up  a  dilated  duct  toward  the  liver  (choledochotomy). 
If  the  stone  is  impacted  near  the  outlet  of  the  duct,  it  may  be  necessary  to 
incise  the  duodenum  in  order  to  remove  the  stone  (choledochoduodenostomy). 
A  dilated  bile-duct  maybe  anastomosed  to  the  bowel  (choledocho-enterostomy) 
or  to  the  surface  (choledochostomy).  The  obstruction  may  be  side-tracked 
bv  anastomosing  the  gall-bladder  to  the  bowel  (cholecystenterostom)-)  (p. 
820),  or  a  dilated  duct  to  the  bowel  (choledocho-enterostomy).  Cholecysten- 
terostomy  affords  drainage  but  does  not  remove  the  cause  of  trouble,  and 
infection  is  apt  to  be  received  from  the  bowel.  In  some  rare  cases  of  com- 
mon duct  obstruction,  in  which  the  gall-bladder  is  distended  and  the  condition 
of  the  patient  is  desperate,  anastomose  the  gall-bladder  to  the  colon  (Robson). 
In  some  cases  the  gall-bladder  is  removed  (cholecystectomy).  Cysticotomy 
is  incision  of  the  cystic  duct. 

Diseases  and  Injuries  of  the  Pancreas. 

Wounds  and  Injuries. — The  pancreas  is  very  rarely  ruptured  alone, 
although  this  sometimes  occurs  as  the  result  of  blows  or  crushes.  In  the 
majority  of  cases  in  which  the  pancreas  is  damaged,  other  organs  are  in- 
volved; for  instance,  the  stomach,  the  spleen,  and  the  liver.  A  gunshot 
w'ound  of  the  pancreas  is  almost  certain  to  injure  the  left  kidney,  the  stomach, 
or  the  vertebral  column.  It  will  be  remembered  that  in  the  case  of  President 
McKinlev  the  bullet  passed  through  the  stomach,  damaged  the  left  kidney, 
and  injured  the  pancreas. 

Symptoms. — When  the  pancreas  is  injured  alone,  hemorrhage  is  not 
usually  severe;  but  if  adjacent  organs  are  also  damaged,  it  is  sure  to  be 
profuse.  Hence,  when  adjacent  organs  are  damaged  there  are  apt  to  be 
immediate  symptoms  of  severe  intra-abdominal  hemorrhage;  but  profound 
collapse  is  not  often  present  when  the  pancreas  alone  is  injured.  In  fact, 
symptoms  may  not  arise  for  a  considerable  length  of  time  after  injury  of 
the  pancreas.  A  diagnosis  at  this  stage  is  impossible  without  e.xploratory 
operation.  Injury  of  the  pancreas  is  usually,  but  not  invariably,  fatal.  After 
slight  damage  of  the  gland,  the  patient  may  completely  recover;  but,  as  a 
rule,  he  partly  recovers  and,  after  a  number  of  weeks,  a  smooth  tumor,  pal- 
pable in  the  epigastric  region,  is  formed.  When  operation  is  performed,  this 
tumor  is  found  to  be  back  of  the  stomach.  It  contains  a  quantity  of  blood, 
clot,  and  pancreatic  fluid.  Such  a  fluid  collection  is  in  the  lesser  peritoneal 
cavity  and  is  called  a  cyst,  though  it  is  not  a  true  cyst  of  the  pancreas.  Rob- 
son  and  Moynihan,  in  their  valuable  treatise  on  "  Diseases  of  the  Pancreas, " 
explain  the  formation  of  this  collection  of  fluid  as  follows: 

The  injury  lacerates  the  posterior  layer  of  the  lesser  sac  of  the  peritoneum 
and  the  pancreas,  to  which  it  is  adherent.  Blood  and  pancreatic  fluid  enter 
the  lesser  peritoneal  .sac.  Peritonitis  follows.  The  foramen  of  Winslow  is 
blocked  by  adhesions;  and  the  lesser  peritoneal  cavity,  being  now  a  closed 
sac,  is  distended  with  a  serous  exudation  mixed  with  blood  and  i>ancreatic 

*  See  A.  \V.  Mayo  Kobson,  in  Lancet,  April   12,  1902. 


Pancreatitis  765 

fluid.  Collections  of  this  character  form  \er\-  rapidly,  and  several  pints 
may  gather  in  a  few  days.  Other  results  of  injur\-  to  the  pancreas  are  abscess, 
pancreatitis,  and  true  cyst-formation. 

Treatment. — In  a  gunshot  wound  of  the  abdomen,  when  exploration 
leads  to  the  view  that  the  pancreas  has  been  injured,  this  organ  should  be 
approached  by  dividing  either  the  gastrocolic  omentum  or  the  transverse 
mesocolon.  The  pancreas  may  also  be  exposed  by  dividing  the  gastrohepatic 
omentum.  Accessory  injuries  must  be  carefully  noted;  and  if  a  bullet  has 
penetrated  the  posterior  wall  of  the  stomach,  the  pancreas  is  almost  certain 
to  be  damaged.  One  should  remember  that,  as  Park  says,  even  after  opening 
the  abdomen,  it  is  difficult  to  explore  the  pancreas,  especially  in  a  stout 
person.  If  there  is  no  evidence  of  posterior  perforation  of  the  stomach  by 
a  foreign  body,  one  may  assume  that  the  pancreas  has  escaped.  When 
the  pancreas  is  exposed,  if  it  is  found  to  be  bleeding,  the  vessels  should  be 
ligated  and  the  tear  in  the  gland  should  be  sutured,  care  being  taken  not 
to  puncture  the  main  duct  of  the  gland.  If  this  duct  has  been  cut,  it  must 
be  carefully  sutured.  In  some  cases  of  gunshot  wound  it  is  necessary  to 
resect  a  portion  of  the  gland.  At  the  termination  of  the  operation,  posterior 
drainage  should  always  be  used. 

In  cases  of  crush  with  pancreatic  injur}-,  the  associated  injury  to  other 
structures  usually  proves  rapidly  fatal;  but  in  a  less  severe  case  the  abdomen 
may  be  opened  for  exploration,  and  if  this  is  done  the  surgeon  should  pro- 
ceed as  previously  directed. 

The  question  of  excising  a  lacerated  portion  of  the  pancreas  is  one  of 
great  interest.  It  is  known  that  dogs  have  lived  after  complete  excision 
of  the  pancreas,  but  the  operation  is  not  justifiable  in  man.*  In  man,  how- 
ever, quite  large-sized  pieces  of  the  gland  have  been  removed  and  recovery 
has  followed.  Hence,  it  is  justifiable  to  excise  a  hopelessly  damaged  por- 
tion, bearing  in  mind  Park's  caution  that  the  chief  danger  in  excising  a 
portion  of  the  pancreas  is  injury  to  the  splenic  artery. 

Movable  Pancreas. — In  cases  of  splanchnoptosis  the  pancreas  may 
become  considerably  displaced;  though  this  condition  cannot  be  recognized 
without  opening  the  abdomen.  So  far,  I  know  of  no  case  in  which  fixation 
has  been  attempted;  though,  of  course,  theoretically  it  could  be  done. 

Pancreatitis. — Pancreatitis  often  leads  to  the  production  of  jaundice; 
always  to  verv  rapid  loss  of  weight;  occasionally  to  the  presence  of  fat  and 
sugar  in  the  urine;  sometimes  to  the  presence  of  fat  in  the  stools;  and  fre- 
quently to  the  condition  known  as  fat-necrosis.  Robson  and  Moynihan  point 
out  that  when  there  is  no  diarrhea  and  the  stools  contain  undigested  muscle- 
fiber,  one  may  assume  that  there  is  a  deficiency  in  pancreatic  juice;  and,  further, 
that  when  there  is  a  blockage  to  the  secretion  from  the  pancreas,  if  60  grains  of 
salol  are  given  by  mouth  during  one  day,  carbolic  and  .salicyluric  acids  do  not 
appear  in  the  urine.  The  general  cause  of  pancreatitis  is  infection.  Often 
obstruction  of  the  common  bile-duct  is  followed  by  infection  and  suppuration 
of  the  pancreatic  ducts  and  pancreatitis.  Besides  the  general  cause,  which 
is  infection,  various  exciting  causes  may  be  named;  among  which  are  gall- 
stones in  the  common  duct  and  calculi  in  the  pancreatic  ducts,  traumatism, 
cancer  of  the  stomach  or  duodenum,  catarrh  of  the  stomach  or  duodenum, 

*  Park  :  Annals  of  Surgery,  Dec.   15,  1901. 


766  Diseases  and   Injuries  of   the   Abdomen 

and  many  infectious  diseases.  It  tlius  becomes  evident  that  the  infection 
mav  be  by  way  of  the  blood ;  but  undoubtedly,  in  the  vast  majority  of  cases, 
the  infection  comes  by  way  of  the  duct.  One  manner  in  which  the  disease 
mav  be  produced  was  suggested  by  Halsted  and  Opie,  of  Baltimore:  A  stone 
becomes  impacted  in  the  outlet  of  the  common  duct;  the  pancreatic  duct, 
where  it  emerges  above  the  common  duct,  not  being  blocked.  The  bile 
and  pancreatic  juice  are  thus  prevented  from  entering  the  duodenum,  and 
the  bile  flows  back  into  the  pancreatic  ducts. 

That  strange  condition  known  as  fat-necrosis  is  often  present  in  pan- 
creatitis. In  fat-necrosis  the  fat  is  decomposed  into  fatty  acids  and  glycerin. 
The  glycerin  is  absorbed;  but  the  fatty  acids  unite  with  calcium  salts  and 
remain  in  the  tissues,  forming  patches  of  yellowish-white  color  and  varying 
size.  These  patches  are  found  in  the  fat  beneath  the  peritoneum,  in  the 
omentum,  and  in  the  mesentery;  and  even  in  distant  parts  (for  instance, 
the  pericardium).*  It  is  an  undoubted  fact  that  fat-necrosis  is  not  uncom- 
monly found  after  diseases  and  injuries  of  the  pancreas;  and  many  assume 
that  it  is  produced  by  the  entering  of  the  ferment  of  the  pancreas  into  the 
fatty  tissue.  How  the  ferment  gets  there  is  a  matter  of  some  doubt.  In 
the  case  of  a  wound  of  the  pancreas,  one  can  understand  the  flow  of  the 
secretion  and  its  imbibition  by  adjacent  parts;  but  in  other  cases  one  must 
assume  that  it  has  been  absorbed  by  the  lymphatics  and  distributed  to  more 
distant  parts.  When  one  reflects  that  in  some  conditions  of  the  pancreas 
there  is  no  fat-necrosis,  while  in  others  this  condition  arises,  it  is  pre- 
sumable that  the  pancreatic  conditions  associated  with  it  are  such  as  to 
permit  the  fat-splitting  ferment  to  diffuse  into  neighboring  tissues. 

In  pancreatic  disease  hemorrhage  into  that  organ  is  common.  The 
hemorrhage  is  not,  of  necessity,  fatal;  but  frequently  is  so.  Occasionally 
death  takes  place  as  the  result  of  sudden  pancreatic  hemorrhage  in  a  person 
apparently  in  excellent  health.  It  is  thought  by  Robson  and  Moynihan  that 
during  the  existence  of  cancer  of  the  pancreas  there  is  a  strong  tendency 
to  excessive  hemorrhage  after  operation.  In  one  case  of  my  own  the  patient 
bled  to  death  after  the  performance  of  cholecystotomy  for  obstructive  jaundice. 
The  oozing  of  blood  in  this  case  was  from  the  margins  of  the  gall-bladder 
and  the  adjacent  peritoneal  surfaces.  We  therefore  conclude  that  in  certain 
conditions  of  the  pancreas  there  is  a  tendency  to  local  hemorrhage  in  that 
organ;  and  that  there  may  also  be  a  tendency  to  the  development  of  a  general 
hemorrhagic  diathesis,  the  general  hemorrhagic  tendency  being  much  in- 
creased if  jaundice  exists.  During  acute  inflammation  of  the  pancreas 
hemorrhage  is  almost  certain  to  occur  into  that  gland;  in  other  varieties  of 
inflammation  hemorrhage  may  occur  or  may  be  ab.sent. 

Forms  of  Pancreatitis. — This  disease  is  divided  by  Robson  and  Moyni- 
han into  the  acute,  the  subacute,  and  the  chronic  form;  and  they  say  that 
recorded  cases  demonstrate  the  fact  that  three  distinct  classes  of  inflammation 
may  arise;  (i)  Cases  that  die  within  forty-eight  hours  of  the  beginning  of 
the  trouble.  In  this  group  hemorrhage  is  u.sually  found;  and  if  fat-necrosis 
is  present,  it  is  limited  in  area.  (2)  Those  that  live  for  some  weeks  after 
the  beginning  of  the  trouble.  In  these  ca.ses  the  pancreas  may  become 
necrotic  or  suppuration  may  occur.     Fat-necrosis  is  usually  widespread.     (3) 

*  Robsoi)  and  Moynihan,  on  "  Diseases  of  the  Pancreas." 


Subacute    Pancreatitis  "j^y 

In  the  third  class  of  cases  long-continued  inflammation  or  repeated  attacks 
produce  sclerosis  of  the  pancreas. 

Acute  Pancreatitis. — The  symptoms  of  this  condition  come  on  suddenly 
and  consist  of  violent  pain  in  the  epigastric  region,  vomiting,  constipation, 
rapidity  and  w^eakness  of  the  circulation,  cold  extremities,  and  collapse.  The 
pain  is  extremely  violent  and  is  intensified  in  paroxysms,  and  there  is  distinct 
tenderness  and  rigidity  in  the  epigastrium.  The  patient  vomits  the  contents 
of  the  stomach  and  then  bilious  matter.  Distention  soon  becomes  distinct 
in  the  upper  portion  of  the  abdomen.  The  patient  presents  the  appearance 
of  one  suffering  with  peritonitis.  This  condition  is  not  unusually  mistaken  for 
intestinal  obstruction,  but  in  acute  pancreatitis  the  constipation  is  not  abso- 
lute; the  patient  passes  wind,  and  may  even  have  a  bowel  movement  as 
the  result  of  the  administration  of  an  enema.  The  condition  is  usually  fatal 
within  a  few  days;  but  in  very  rare  instances  recovery  takes  place. 

The  diagnosis  cannot  be  made  with  certainty  and  is  merely  an  inference. 
Reginald  Fitz  tells  us  that  the  existence  of  this  disease  should  be  suspected 
when  a  person  previously  in  good  health,  or  who  has  complained  only  of 
occasional  attacks  of  digestive  disorder,  is  suddenly  seized  with  severe  pain 
in  the  epigastric  region,  followed  by  vomiting  and  collapse;  and  when,  within 
twenty-four  hours  or  more,  there  appears  a  circumscribed  swelling  in  the 
epigastrium,  which  is  resistant  or  tympanitic.  When  an  exploratory  incision 
is  made  in  the  abdomen,  if  fat-necrosis  is  detected,  the  diagnosis  becomes 
certain. 

Treatment. — The  exploratory  operation  is  carried  out  in  front.  When 
exploratory  incision  suggests  the  condition,  the  infected  area  should  be  ex- 
posed either  above  or  below  the  stomach,  hemorrhage  should  be  arrested 
by  ligation  or  packing,  and  posterior  drainage  should  be  inserted.  One 
should  follow  the  rule  laid  down  by  Roswell  Park,  and  explore  in  every  case 
in  which  the  disease  is  suspected  to  exist. 

Subacute  Pancreatitis. — Subacute  pancreatitis  comes  on  suddenly,  with 
violent  pain,  vomiting,  and  constipation;  but  there  is  far  less  exhaustion  and 
weakness  than  in  the  acute  form.  The  vomiting  is  less  marked  and  the 
swelling  in  the  epigastric  region  is  not  so  rapid.  The  symptoms  are  similar 
to  those  of  the  acute  form,  but  not  so  violent  nor  so  rapidly  progressive. 
The  temperature  frequently  rises  higher  than  in  the  acute  form;  and  it  may 
become  irregular,  or  chills  may  occur.  In  many  cases  the  patient  seems  to 
grow  better  after  a  time,  the  violent  pain  abating,  though  some  pain  and 
tenderness  remain;  but  he  does  not  gather  strength  and  continues  to  lose 
flesh,  and  there  is  usually  albumin,  and  occasionally  sugar,  in  the  urine. 
In  rare  instances  fat  is  found  in  the  urine.  In  subacute  pancreatitis  abscess 
is  prone  to  form.  This  abscess  may  make  a  distinct  swelling  in  front,  and 
may  lead  to  the  development  of  a  subphrenic  or  of  a  perirenal  abscess.  In 
rare  cases  an  abscess  of  the  pancreas  tracks  its  way  for  a  long  distance  in 
the  subperitoneal  tissue;  occasionally  it  opens  into  the  stomach  or  bowel. 
Cases  of  subacute  pancreatitis  occasionally  recover  after  a  long  illness,  but 
usually  they  die. 

Treatment. — Exploratory  incision.  Expose  the  pancreas,  either  above  or 
below  the  stomach;  determine  the  condition;  remove  purulent  matter  and 
necrotic  areas;  arrest  hemorrhage  with  packing;  and  insert  posterior  drainage 


768  Diseases  and   Injuries  of   the   Abdomen 

at  the  costovertebral  angle.     In  some  cases  close  the  anterior  wound,  and 
in  others  leave  it  open.* 

Wm.  J.  Mayo  f  reports  a  successful  operation  for  subacute  pancreatitis. 
The  patient  was  a  man  of  fifty-two  years,  who,  seven  days  before  Mayo  saw 
him,  had  developed  violent  pain  in  the  epigastrium,  collapse,  distention,  and 
other  signs  of  intestinal  obstruction;  but  some  slight  movements  had  taken 
place  from  the  bowels,  as  the  result  of  medication.  On  admission,  the  abdomen 
w'as  tympanitic.  An  ill-defined  mass  the  size  of  a  fist  could  be  palpated 
to  the  right  of  and  above  the  umbilicus.  The  pulse  was  120  and  very  weak; 
the  temperature,  between  loi  and  102;  and  there  was  slight  jaundice,  rest- 
lessness, and  hiccough.  A  diagnosis  of  gangrenous  cholecystitis  was  made. 
The  abdomen  was  opened,  and  the  omentum  was  found  to  be  studded  with 
thick,  adherent,  infihrated  round  spots,  the  size  of  a  pea  or  larger.  There 
were  some  similar  spots  in  the  mesentery,  and  the  peritoneal  cavity  con- 
tained bloody  fluid.  On  palpation,  the  pancreas  felt  like  a  pudding  in  a 
tight  sac;  and  on  aspiration,  a  little  blood  was  obtained.  The  gall-bladder 
was  opened,  a  stone  was  removed,  and  some  pus  was  evacuated.  Drainage 
was  inserted  into  the  gall-bladder;  and  eighteen  days  later  there  was  an 
enormous  flow  of  bloody  fluid,  containing  bile  and  pancreatic  juice,  from 
the  drainage-tube.  The  patient  recovered.  This  plan  of  treatment — free 
drainage  of  the  pancreas  by  the  performing  of  cholecystotomy — is  to  be  taken 
into  consideration. 

Chronic  Pancreatitis. — This  usually  results  from  disease  of  the  bile- 
passages.  It  produces  enlargement  of  the  organ;  and  the  enlarged  area  is 
hard,  and  feels  like  a  malignant  growth.  This  condition  is  more  common 
than  is  the  acute  or  the  subacute  form.  Robson  and  Moynihan  have  operated 
upon  thirty  cases.  The  disease  is  frequently  associated  with  gall-stones  or 
with  stones  in  the  pancreatic  duct,  and  occasionally  with  ulcer  of  the  stomach 
or  of  the  duodenum.  In  some  cases  the  condition  comes  on  acutely  and 
jaundice  develops  rapidly,  as  it  does  after  the  passage  of  a  gall-stone.  It 
is  noted,  however,  that  the  pain  is  not  in  the  region  of  the  gall-bladder,  but 
is  in  the  middle  of  the  epigastrium;  and  it  passes  to  the  left,  rather  than 
to  the  right.  The  tenderness,  too,  is  in  the  middle  of  the  epigastrium,  and 
not  in  the  gall-bladder  region.  A  series  of  these  attacks  may  occur,  the 
jaundice  growing  worse  after  each  attack.  In  some  cases,  however,  the 
condition  comes  on  gradually  and  insidiously,  the  pain  slowly  developing, 
but  no  violent  seizures  taking  place.  There  is  rigidity  of  the  rectus  muscles, 
rapid  loss  of  flesh,  usually  vomiting,  and  considerable  flatulence.  The  gall- 
bladder is  enlarged  and  commonly  palpable. 

Treatment. — Exploratory  incision,  and  opening  or  draining  the  gall- 
bladder; or  the  performing  of  cholecystenterostomy. 

Pancreatic  Calculi.— When  the  pancreatic  secretion  is  blocked,  .stones 
tend  to  form;  and  the  blocking  may  be  due  to  inflammation  of  the  duct 
of  Wirsung,  or  may  result  from  chronic  pancreatitis.  The  stones  may  be 
single  or  multiple. 

Symptoms. — There  is  jjain  in  the  epigastric  region,  which  usually  comes 
on  in  i^aro.xysms  that  resemble  those  due  to  gall-stones,  though  they  are  not 

*Ro.swel!  Park  :  Annals  of  Surgery,  December  15,  1901. 
IJour.  Am.  Med.  Assoc,  Jan.  Ii,  1902. 


Pancreatic   Cysts  769 

so  violent.  Pain  is  accompanied  with  vomiting,  exhaustion,  and  sometimes 
actual  collapse;  and  may  be  followed  by  rigors.  Portions  of  stone  are  some- 
times recovered  from  the  feces,  and  sugar  is  occasionally  found  in  the  urine. 
Fat  has  also  been  noted  in  the  stools  in  some  cases.  Sometimes  jaundice 
develops,  because  the  calculus  presses  upon  the  common  duct. 

Treatment. — Pancreatic  calculi  have,  in  rare  in.stances,  been  removed 
bv  operation;  and  this  is  the  proper  procedure  when  the  diagnosis  can  be 
made.  The  diagnosis  is,  however,  possible  only  after  exploratory  incision. 
As  a  rule,  no  operation  is  performed  until  a  cyst  results  or  an  abscess  forms; 
and  when  the  cyst  or  abscess  is  opened,  fragments  of  stone  may  be  found 
in  the  fluid,  and  stones  may  subsequently  come  away  in  the  resulting  fistula. 

Pancreatic  Cysts. — Many  forms  of  cyst  may  develop  in  the  pancreas; 
the  following  are  set  forth  by  Robson  and  Moynihan:  (i)  Retention  cysts; 
(2)  proliferation  cysts,  including  cystic  adenoma  and  cystic  epithelioma;  (3) 
hydatid  cysts;  (4)  congenital  cysts;  (5)  hemorrhagic  cysts;  and  (6)  pseudo- 
cysts. What  we  speak  of  as  pseudocysts  have  already  been  considered  in 
discussing  effusions  into  the  lesser  peritoneal  cavity.  They  result  from 
lacerations  of  the  pancreas.  Retention  cysts  are  due  to  blocking  of  the 
pancreatic  duct.  Congenital  cystic  disease  is  extremely  rare.  Hemorrhagic 
cvsts  result  from  hemorrhage  into  the  substance  of  the  pancreas  itself. 

Symptoms. — Cysts  are  somewhat  more  common  in  men  than  in  women. 
A  cyst  of  the  pancreas  proper  is  more  often  met  with  in  the  head  of  the 
organ  than  in  its  body  or  tail.  The  cyst  may  be  single  or  multiple.  In  its 
growth  it  either  destroys  the  substance  of  the  pancreas;  or  it  grows  away 
from  the  pancreas  and  damages  it  but  little.  In  some  cases  the  cysts  grow 
to  a  verv  large  size;  and  Robson  and  Moynihan  refer  to  a  case  in  which  the 
cyst  attained  the  size  of  a  man's  head,  and  to  another  in  which  it  was  the 
size  of  a  full-term  pregnancy.  A  pancreatic  cyst  is  smooth,  round,  elastic, 
and  rather  tense  (Robson  and  Moynihan).  The  contained  fluid  varies 
greatly.  As  a  rule,  it  is  brownish-red  in  color;  in  one  case  upon  which  I 
operated  it  was  clear  yellow;  in  some  cases  it  is  milky,  and  in  others  it  is 
nearly  black.  The  fluid  is  always  albuminous.  Urea  may  be  present,  and 
in  many  cases  pancreatic  ferments  are  found.  In  most  cases  the  cyst  adheres 
so  closely  to  'the  surrounding  structures  as  to  render  extirpation  practically 
impossible.  A  pancreatic  cyst  of  considerable  size  causes  epigastric  dis- 
comfort, pain  during  digestion,  and  frequently  vomiting.  In  some  cases 
the  pain  is  trivial;  in  others,  it  is  very  violent.  As  a  general  rule,  the  patient 
is  constipated;  but  sometimes  diarrhea  occurs,  and  the  movements  may  even 
contain  blood.  If  the  tumor  presses  upon  the  common  bile-duct,  jaundice 
will  develop.  The  patient  loses  flesh  markedly  and  with  considerable  rapidity, 
and  he  becomes  very  weak.  In  rare  instances  fat  is  present  in  the  stools, 
and  in  other  unusual  cases  sugar  is  found  in  the  urine.  A  test  should  always 
be  made  with  salol,  to  see  whether  pancreatic  ferment  is  present  in  the  intes- 
tine (page  765).  In  the  beginning  the  pancreatic  cyst  is  behind  the  stomach; 
but  it  enlarges  and,  as  a  rule,  pushes  the  stomach  upward  and  to  the  right 
side,  and  the  transverse  colon  downward.  The  cyst  approaches  the  surface 
of  the  abdomen  below  the  greater  curvature  of  the  stomach  (Robson  and 
Moynihan).  The  same  authors  tell  us  that  in  rare  cases  the  cyst  appears 
at  the  upper  border  of  the  stomacli,  and  that  in  others  it  inserts  itself  between 
49 


jjO  Diseases   and   Injuries   of   the   Abdomen 

the  lavers  of  the  transverse  mesocolon.  In  the  case  upon  which  I  operated 
it  had  worked  its  way  through  the  subperitoneal  tissue  into  the  right  loin, 
and  had  been  looked  upon  by  Professor  Montgomery  and  myself  as  a  hydro- 
nephrosis. As  a  rule,  the  pancreatic  cyst  is  immovable;  but  in  rare  instances 
it  is  movable.  When  a  hand  is  placed  in  the  loin  and  another  on  the 
abdomen,  ballottement  may  be  appreciated.  If  the  distended  stomach  or 
colon  overlies  the  tumor,  there  will  be  a  tympanitic  percussion-note  ;  but 
when  the  tumor  reaches  the  abdominal  wall,  there  will  be  a  dull  percussion- 
note.  On  inquiring  into  the  history  of  these  cases,  it  will  frequently  be  found 
that  there  has  been  a  severe  injury  to  the  upper  abdomen. 

Treatment. — Exploratory  incision  makes  the  condition  clear.  In  the 
majority  of  cases  the  cyst  is  incised,  emptied,  and  stitched  to  the  wall  of 
the  abdomen.  This  operation  may  be  done  in  two  stages,  first  exposing 
the  cvst  and  fixing  it  to  the  abdominal  wall;  and,  when  adhesions  have 
formed,  opening  it.  As  a  rule,  however,  it  is  performed  in  one  stage,  the 
abdominal  cavity  being  carefully  protected  with  gauze.  Some  authors  advo- 
cate exposing  the  cyst,  opening  and  evacuating  it  through  the  abdominal 
wound,  and  draining  through  the  loin.  Complete  extirpation  is  usually 
impossible  because  of  the  adherence  of  the  cyst.  If  the  cyst  is  movable, 
extirpation  may  be  carried  out;  but  incision  and  drainage  is  the  safest 
operation. 

Tumors  and  Other  Growths   of   the  Pancreas. — The   pancreas 

may  be  affected  with  sarcoma,  carcinoma,  adenoma,  tuberculous  disease,  or 
syphilis. 

Treatment. — Attempts  have  been  made  to  remove  tumors  of  the  pan- 
creas. After  an  exploratory  incision  has  determined  the  condition,  the 
pancreas  is  exposed  at  the  point  at  which  the  tumor  projects.  This  is  usually 
done  by  an  opening  in  the  gastrocolic  omentum.  If  the  tumor  is  in  the  tail 
of  the  pancreas,  however,  the  exposure  may  be  effected  in  the  flank.  When 
the  tumor  has  been  exposed,  an  attempt  may  be  made  to  enucleate  it.  At 
the  present  time,  however,  these  operations  are  in  the  experimental  stage; 
though  tumors  of  the  splenic  portion  of  the  pancreas  have  been  removed. 

Injuries  and  Diseases  of  the  Spleen. 

Wounds  and  Rupture. — A  wound  of  the  spleen  causes  great  hemor- 
rhage, and  if  no  .•^urgical  aid  is  offered  will  rapidly  produce  death. 

Rupture  of  the  spleen  produces  the  signs  and  symptoms  of  intra-ab- 
dominal hemorrhage.  The  blood  clots  so  rapidly  that  it  gathers  in  the  left 
loin,  and  is  not  commonly  diffu.sed  throughout  the  abdomen.  Exploratory  in- 
cision will  be  required  to  positively  recognize  the  condition.  In  Elder's  table 
there  are  52  uncomplicated  cases.  Not  a  case  was  operated  upon  (operation 
was  not  the  rule  until  1890)  and  84.6  percent,  died.  Eisendrath  has  collected 
50  cases  operated  upon :  56  per  cent,  recovered  and  44  per  cent,  died.*  Fe\riert 
has  collected  56  ruptures  of  the  s])leen.  In  46  cases  operation  was  performed 
and  the  mortality  was  50  per  cent. 

Treatment. — The  treatment  is  evident  from  the  previous  remarks.     It 

*  Daniel  N.  Ei.sendrath :  Jour.  Am.  Med.  A.ssoc,  Oct.  25,  1902, 
t  Rev.  de  Chir.,  Nov.,  1901. 


splenoptosis,   or  Wandering  Spleen  771 

is  as  follows:  Open  the  abdomen,  the  patient  being  surrounded  with  hot 
bottles  and  hot  salt  solution  flowing  into  a  vein.  Explore,  and  if  the  spleen 
is  damaged  perform  splenectomy  (page  823). 

Abscess  of  the  spleen  is  a  rare  condition  which  is  metastatic  in 
origin.  It  may  follow  typhoid,  may  develop  during  pyemia,  or  may  result  from 
injury.  Chronic  suppuration  may  be  due  to  tuberculosis  or  actinomycosis. 
Pain  is  felt,  and  enlargement  is  noted  in  the  splenic  region,  and  the  symptoms 
of  pyemia  exist.  It  may  become  adherent  to  the  belly-wall,  may  become 
encapsuled,  or  may  rupture  into  a  viscus  or  the  peritoneal  cavity.  The 
treatment  consists  in  incising  at  the  outer  edge  of  the  left  rectus  muscle, 
suturing  the  spleen  to  the  abdominal  wall,  opening  the  abscess  and  providing 
for  drainage  (Tedenat  *).  If  the  abscess  is  adherent  to  the  abdominal 
wall,  incise  it  directly. 

Tumors  of  the  Spleen. — The  spleen  undergoes  hypertrophy  in  the 
course  of  infectious  diseases,  from  amyloid  disease,  from  leukemia,  and  from 
Hodgkin's  disease.  Genuine  primary  tumors  are  extremely  rare.  Fibrom.a, 
angeioma,  and  sarcoma  occasionally  develop.  Secondary  carcinoma  and 
secondary  sarcoma  are  more  common.     Hydatid  cysts  occasionally  develop. 

Treatment. — The  condition  may  only  become  clear  after  exploratory 
incision.  For  some  tumors  splenectomy  is  indicated.  A  hydatid  cyst  is 
treated  as  is  a  cyst  of  the  liver  (page  749). 

Splenoptosis,  or  Wandering  Spleen.— The  spleen  may  wander  into 
any  part  of  the  general  peritoneal  cavity.  This  condition  is  seldom  met  with 
except  in  women.  It  is  most  common  in  women  who  have  borne  children 
(J.  Bland  Sutton).  A  wandering  spleen  may  undergo  atrophy,  engorgement, 
or  axial  rotation  (J.  Bland  Sutton).  The  organ  when  displaced  drags  upon 
the  stomach,  producing  dilated  stomach;  it  may  interfere  with  the  bile-duct, 
causing  jaundice;  it  may  cause  intestinal  obstruction  by  forming  adhesions, 
or  may  cause  uterine  retroflexion  or  prolapse  by  passing  into  the  pelvis. 

J.  Bland  Sutton  says  this  condition  may  endanger  life,  as  it  may  lead 
to  rupture  of  the  stomach,  intestinal  obstruction,  splenic  abscess,  or  splenic 
rupture. t  A  wandering  spleen  can  be  identified  by  the  fact  that  it  has  a 
notch  upon  its  edge,  and  can  be  pushed  about  the  abdomen.  When  this 
condition  exists  the  spleen  may  be  missed  from  its  normal  situation.  Always 
examine  the  blood  in  order  to  determine  if  leukemia  or  malaria  exists. 

Treatment. — Greiffenhagen  advocates  suturing  the  organ  in  place  (spleno- 
pexy). Most  surgeons  prefer  to  perform  splenectomy.  In  a  case  without 
leukemia  the  operation  is  very  successful.  Splenectomy  for  wandering  spleen 
is  rarely  followed  by  serious  blood-changes  or  other  trouble.  The  reason 
is  that  a  wandering  spleen  is  usually  a  diseased  organ,  having  undergone 
hypertrophy  or  fibroid  change,  and  other  structures  have  taken  on  splenic 
function.  Splenectomy  should  not  be  undertaken  if  leukemia  exists.  In 
such  a  case  apply  a  support  and  employ  medical  treatment  for  the  existing 
disease  or  endeavor  to  suture  the  organ  in  place. 

*  Rev.  de  Gynec.  et  de  Chir.  Abd.,  July,  August,  1901. 
t  Brit.  Med.  Jour.,  Jan.  16,  1897. 


772  Diseases  and   Injuries  of   the   Abdomen 

Operations  upon  the  Abdomen. 

Abdominal  Section  {Celiotomy :  Laparotomy). — There  are  many  dif- 
ferent methods  of  opening  the  abdomen.  The  plan  selected  depends  upon 
the  nature  and  the  situation  of  the  disease,  and  upon  the  inclinations  and 
the  custom  of  the  operator.  The  abdomen  may  be  opened  to  attack  a  recog- 
nized seat  of  disease  or  to  determine  what  the  disease  is  and  where  it  is  situated. 
Abdominal  section  performed  for  the  latter  purpose  is  spoken  of  as  exploratory 
section  or  exploratory  incision. 

Of  recent  years,  exploratory  operations  have  become  extremely  common; 
and  many  abdominal  conditions  would  be  unrecognized  without  such  ex- 
ploration, or  would  be  recognized  at  so  late  a  period  as  to  be  beyond  the 
reach  of  surgery,  by  the  time  the  diagnosis  had  been  made.  This  is  notably 
true  of  the  surgical  diseases  of  the  stomach.  The  surgeon  should,  however, 
not  be  too  radical  in  employing  exploratory  operations.  The  fact  that  he 
can  explore  with  such  comparative  impunity  does  not  release  him  from  the 
obligation  to  endeavor  by  every  proper  method  to  make  a  diagnosis  before  re- 
sorting to  operation.  I  fancy  that  of  recent  years  the  belief  that  it  is  almost 
waste  of  time  to  make  prolonged  efforts  to  diagnosticate  many  intra-abdom- 
inal troubles,  because  -the  solution  is  so  much  easier  by  section,  has  be- 
come so  common  as  to  have  led  young  and  unskilled  operators  to  perform 
section  in  cases  in  which  the  diagnosis  might  have  been  made  without  this 
procedure. 

Before  opening  the  abdominal  cavity  for  exploratory  purposes  or  to  gain 
access  to  some  area  of  abdominal  or  pelvic  disease,  the  patient  is  carefully 
prepared  as  for  any  other  operation.  In  an  appendicitis  case  the  patient 
is  moved  with  the  utmost  care  and  is  prepared  for  operation  most  gently, 
because  of  the  possible  danger  of  rupturing  an  abscess.  In  an  emergency 
case  no  prolonged  or  complicated  method  of  cleansing  can  be  employed. 
The  abdomen  and  loins  are  scrubbed  carefully  with  soap  and  water,  special 
attention  being  given  to  the  umbilicus;  the  pubic  region  is  shaved,  the  soapsuds 
are  washed  away  with  sterile  water,  the  surface  is  gently  scrubbed  with 
alcohol  and  then  with  a  hot  solution  of  corrosive  sublimate  (i  :  looo),  and 
is  covered  with  gauze  wet  with  the  sublimate  solution.  Whenever  there  is 
time  it  is  eminently  desirable  to  prepare  the  patient  the  day  before.  The 
instruments  required  depend  upon  the  nature  of  the  case.  As  a  rule,  there 
are  required  scalpels,  scissors,  a  dry  dis.sector,  two  pairs  of  di.s.secting  forceps, 
hemostatic  forceps,  pedicle  forceps,  Hagedorn  needles,  calyx-eyed  intestinal 
needles,  a  needle-holder,  drainage-tubes,  gauze  pads,  gauze  for  sponging, 
silk,  catgut,  silkworm-gut,  the  Paquelin  cautery,  an  electric  light,  also 
an  instrument  and  a  .saline  .solution  for  hypodermoclysis  or  intravenous 
infusion.  Always  count  the  instruments,  sponges,  and  pads,  and  write 
down  the  number,  and  count  them  again  after  operation.  This  rule  is  adopted 
so  that  no  instrument,  sponge,  or  pad  will  be  left  in  the  abdomen.  The 
abdominal  pads  and  sponges  are  not  u.sed  when  rhy.  Dry  sponges  injure 
the  peritoneum  and  favor  the  subsequent  devclo[)mein  of  adhesions  (Sanger). 
The  pads  and  sponges  should  be  wrung  out  in  hot  normal  salt  solution  before 
being  used. 

Operation. — An  anesthetic  is  given.     In  .some  cases  the  jjatient  is  placed 


Abdominal   Section  773 

recumbent;  in  others,  is  put  in  the  position  of  Trendelenburg  (Fig.  367). 
The  patient  is  to  be  carefully  protected  from  cold,  the  extremities  and  the 
chest  are  covered  with  blankets,  and  sterilized  sheets  are  placed  well  around 
the  field  of  operation.  The  parts  are  .sterilized  anew  immediately  before 
operating.  The  surgeon  steadies  the  skin  of  the  belly  with  the  fingers  of  his 
left  hand,  and,  holding  the  knife  free  in  the  right  hand,  makes  an  incision. 
For  purposes  of  exploration  the  incision  is  made  about  two  inches  in 
length,  and  it  is  lengthened  if  it  is  found  necessary.  The  abdomen  may 
be  opened  in  the  median  line  above  or  below  the  umbilicus.  This  incision 
is  advantageous  for  operations  on  the  pelvis,  for  general  exploration,  and 
for  certain  procedures  upon  the  stomach,  the  intestines,  and  the  left  lobe 
of  the  liver.  The  closure  of  such  an  incision,  however,  lacks  strength,  as 
compared  with  the  closure  of  an  incision  where  strong  muscles  wn'll  overlie 
the  scar  through  the  peritoneum  and  the  transversalis  fascia.  Incision  through 
the  semilunar  line  is  practised  by  a  number  of  operators.  A  favorite  incision 
is  through  the  rectus  mu,scle.  The  fibers  of  this  muscle  are  separated,  the 
structures  beneath  it  are  divided,  and,  after  the  completion  of  the  operation, 
the  deeper  structures  are  sutured  and  the  parts  of  the  separated  muscle  are 
allowed  to  fall  together.  The  scar  resulting  from  .such  an  incision  is  well  sup- 
ported and  solid,  hence  the  likelihood  of  hernia  developing  is  diminished.  A 
good  method  in  some  cases  is  to  open  the  sheath 
of  the  rectus  muscle,  retract  the  entire  muscle 
aside,  incise  the  posterior  portion  of  the  sheath 
and  the  structures  back  of  it,  and,  when  the 
operation  has  been  completed,  allow  the  entire 
muscle    to    come    back    into    place,    and    thus 

strengthen    the    deep-seated    scar.     When    the      tj  ^^ "      yt  ririi^ 

abdominal  trouble  is  in  a  region  that  admits         Fig.  367.— The  Trendelenburg 
of  it,  I  almost  invariably  go  through  the  rectus  position, 

muscle  or  retract  the  entire  muscle.     Besides 

these  methods,  there  are  special  incisions,  suitable  for  particular  cases:  An 
incision  along  the  costal  margin,  for  reaching  the  gall-bladder;  an  incision 
shaped  like  the  italic  letter  ''f, "  for  the  same  purpose;  special  incisions  for 
certain  operations  upon  the  stomach,  for  abdominal  nephrectomy,  etc.  Some 
operators  have  even  used  a  transverse  incision  in  certain  pelvic  operations. 

In  an  operation  through  the  median  line  the  first  cut  goes  to  the  aponeu- 
rosis of  the  external  oblique  muscle.  Clamp  the  vessels.  Do  not  hunt  for 
the  linea  alba  below  the  umbilicus,  but  go  right  through  or  between  the 
recti  muscles.  Above  the  umbilicus  the  linea  alba  is  very  distinct  and  the 
surgeon  often  cuts  through  it.  Divide  the  transversalis  fascia,  beneath  which 
is  a  little  fat,  and  expose  the  peritoneum.  The  latter  structure  is  recognized 
by  its  glistening  appearance,  by  the  ea.se  with  which  it  can  be  pinched  up 
between  the  finger  and  thumb,  and  by  the  readiness  with  which  its  opposed 
surfaces  may  be  made  to  glide  over  each  other.  On  identifying  the  perito- 
neum, catch  it  at  each  side  of  the  incision  with  forceps,  raise  a  fold,  nick 
it  with  a  knife,  and  open  it  with  scissors  to  the  length  of  the  external  wound. 
To  prevent  stripping  of  the  peritoneum  a  good  plan  is  to  anchor  it  to  the 
Ijellv-wall  with  a  stitch  on  each  .side  of  the  incision.  Through  the  wound 
thus  made  the  abdomen  and  its  contents  are  explored,  the  imublc  located, 


774  Diseases  and   Injuries  of   the   Abdomen 

and  determination  made  as  to  whether  or  not  further  operation  is  advisable, 
and,  if  it  is  advisable,  what  form  it  shall  take.  It  may  be  necessary  to  enlarge 
the  wound.  This  is  done  by  placing  the  index  and  middle  fingers  of  the 
left  hand  in  the  belly,  with  their  pulps  against  the  peritoneum,  in  the  line 
where  the  surgeon  will  cut,  to  serve  as  supports  to  the  scissors  and  as  guards 
to  intraperitoneal  structures.  The  scissors  are  introduced  and  the  wound 
is  enlarged  upward,  around  the  umbilicus  if  necessary.  As  soon  as  the 
incision  is  complete  it  is  a  good  plan  to  push  a  large  pad  into  Douglas's 
pouch  and  leave  it  there  until  the  operation  is  finished,  when  it  must  be 
removed.  Slender  adhesions  are  broken  off'  with  the  finger  or  are  pushed 
off  with  gauze;  iirm  adhesions  are  tied  in  two  places  and  cut  between  the 
ligatures. 

The  toilet  of  the  peritoneum  is  important  after  the  operation  is  com- 
pleted. Following  a  clean  laparotomy,  when  but  little  blood  has  flowed  into 
the  cavity,  flushing  is  not  required;  if  much  blood  has  flowed  or  if  septic 
matter  has  passed  into  the  peritoneal  cavity,  after  removing  the  sponge  from 
Douglas's  pouch  flush  the  belly  thoroughl}'  with  hot  normal  salt  solution, 
emptv  out  most  of  the  fluid,  but  let  a  pint  or  more  remain  in  the  abdomen. 
The  retention  of  the  saline  fluid  in  the  belly  minimizes  shock.  It  is  absorbed 
with  great  rapidity  after  the  operation  if  the  patient  is  placed  with  his  head 
lower  than  his  feet,  because  in  this  position  the  saline  fluid  gravitates  to 
the  diaphragmatic  region,  where  absorption  is  very  active.  If  there  is  wide- 
spread infection,  eviscerate,  wipe  out  the  peritoneum  with  pads  soaked  in 
hot  normal  salt  solution,  and  wipe  the  intestines  carefully,  slowly  returning 
them  as  they  are  wiped.  Extravasated  septic  matter  is  apt  to  collect  in 
the  peritoneal  fossae  and  between  the  liver  and  diaphragm,  and  these  regions 
must  be  carefully  wiped  or  irrigated.  In  some  cases  it  is  desirable  to  drain 
through  a  lumbar  incision.  Rutherford  Morison  has  pointed  out  that  a 
lumbar  opening  into  the  right  kidney  pouch  will  drain  a  fossa  which  holds 
over  a  pint  of  fluid,  and  which,  when  the  patient  is  recumbent,  is  the  most 
dependent  portion  of  the  peritoneal  cavity.  In  some  cases  a  drainage-open- 
ing is  made  on  each  side  of  the  belly  or  above  the  pubis,  or  through  the 
vagina.  In  septic  cases  it  may  be  advisable  to  drain  with  several  pieces  of 
iodoform  gauze  instead  of  inserting  tubes.  In  most  instances  drainage  is  not 
needed,  but  it  must  be  used  in  septic  cases  and  when  hemorrhage  has  been 
severe.  We  may  drain  by  a  rubber  tube,  strands  of  gauze,  or  a  glass  tube. 
If  a  gla.ss  tube  is  used,  it  is  introduced  at  the  lower  angle  of  the  wound 
and  reaches  the  bottom  of  the  pouch  of  Douglas.  This  tube  is  repeatedly 
emptied  during  the  progress  of  the  case  by  means  of  a  syringe.  Before  clos- 
ing the  wound  arrest  hemorrhage  and  count  the  instruments  and  sponges. 

It  is  highly  important  that  an  abdominal  incision  .shall  be  accurately 
closed,  for  any  failure  of  neat  approximation  will,  in  all  probability,  result 
in  the  formation  of  a  hernia  through  the  cicatrix.  Various  methods  have 
been  employed.  Probably  the  majority  of  operators  u.se  layer  sutures, 
.sewing  up  the  peritoneum  with  a  continuous  suture  of  catgut,  and  the  apon- 
eurotic layers  with  the  same  material  or  with  chromic  catgut,  and  closing 
the  skin  with  either  interrupted  sutures  of  silkworm-gut  or  a  subcuticular 
stitch  of  catgut,  silkworm-gut,  or  silver  wire.  Other  oi^erators  close  the 
peritoneum    with    a    continuous   suture   of   catgut,    then   pass   silkworm-gut 


Abdominal   Section  775 

sutures  through  all  the  other  structures,  leaving  them  for  the  time  untied; 
put  in  layer-sutures  of  catgut  or  of  chromicized  catgut,  and  then  tie  the 
silkworm-gut  sutures.  A  layer  suture  makes  a  beautifully  neat  approxima- 
tion, and  is  frequently  quite  satisfactory;  but  I  have  become  persuaded  that 
the  dead  space,  so  often  left  unobliterated  when  this  method  of  suturing 
is  employed, — a  space  in  which  blood  and  inflammatory  exudate  may  gather, — 
is  a  danger  to  the  future  integrity  of  the  wound.  The  combination  of  a 
dead  space  with  catgut,  a  material  that  is  always  somewhat  uncertain,  is 
an  unfortunate  one  from  the  surgical  point  of  view.  Recently  I  have  re- 
.  turned  to  the  use  of  the  through-and-through  suture,  applied  according  to 
the  method  of  Dr.  Joseph  Price.  This  suture  is  inserted  with  the  straight 
needle,  is  composed  of  silk  or  of  silkworm-gut,  is  put  in  close  to  the  margin 
of  the  skin,  gathers  up  a  great  deal  more  muscle  than  skin,  and  then  passes 
close  to  the  margin  of  the  cut  peritoneum  and  transversalis  fascia.  When 
these  sutures  are  adjusted,  the  peritoneal  edges  are  brought  into  accurate  and 
firm  apposition,  the  peritoneal  surface  is  overlaid  with  abundant  muscle,  the 
skin-edges  are  brought  into  neat  approximation,  and  the  formation  of  a  dead 
space  is  rendered  impossible.  When  passing  the  sutures  have  a  gauze  pad 
under  the  wound  and  be  very  careful  not  to  include  bowel  or  omentum. 
It  is  necessary  to  tighten  and  tie  most  carefully  to  prevent  omentum  being 
caught  in  the  loop  of  the  stitch.  After  closing  a  laparotomy  wound,  dress 
with  aseptic  gauze  and  wood-wool,  and  apply  a  flannel  binder.  In  badly 
infected  cases  the  wound  is  often  kept  open. 

If  a  two-inch  incision  was  closed  without  drainage  and  primary  union 
takes  place,  the  patient  can  usually  sit  up  in  from  ten  days  to  two  weeks. 
A  larger  incision  offers  greater  danger  of  subsequent  hernia,  and  the  patient 
should  be  kept  in  bed  for  three  weeks.  If  the  wound  was  kept  open  for 
drainage,  a  prolonged  retention  in  bed  may  be  necessary.  In  a  case  in  which 
an  incision  of  considerable  length  was  made,  an  abdominal  support  should 
be  worn  for  a  variable  time.  It  limits  the  movements  of  cough,  laughter, 
etc.,  and  reminds  the  patient  of  the  necessity  of  caution  in  lifting,  hurr\-ing, 
etc. 

After-treatment. — The  after-treatment  depends  somewhat  on  the  case, 
but  certain  general  rules  can  be  laid  down.  The  late  J.  Greig  Smith  said 
many  wise  things,  and  among  them  this:  "A  golden  rule  in  the  treatment 
of  cases  of  celiotomy  is  to  let  the  patient  alone.  Everything  approaching 
to  meddlesomeness  is  to  be  condemned.  The  patient  must  not  be  upset 
by  fussy  applications  of  tentative  therapeutics;  when  an  emergencv  arises, 
it  is  to  be  met,  promptly  and  decisively,  by  a  method  which  has  been  approved 
trustworthy"  ("Abdominal  Surgery").  In  many  cases,  immediately  after 
the  operation  the  patient  must  be  treated  for  shock  by  methods  previously 
set  forth.  The  treatment  of  vomiting  resulting  from  the  administration  of 
an  anesthetic  is  discussed  on  page  877.  If  vomiting  persists  during  the 
third  or  fourth  day,  it  is  probably  due  to  the  development  of  inflamma- 
tion which  has  caused  intestinal  paresis;  and  if  it  is  so  produced,  medicine 
is  practically  useless.  In  this  condition  there  is  usually  marked  tympan- 
itic distention,  and  vomiting  is,  in  a  sense,  a  relief.  Nothing  should  be 
given  by  the  mouth,  and  the  patient  should  be  fed  entirely  by  enemata. 
The  insertion  of  a  rectal  tube  and  its  retention  for  a  consideralile  time  may 


7^6  Diseases  and   Injuries  of   the   Abdomen 

afford  relief.  Lving  on  the  side  is  more  comfortable  than  recumbency. 
Washing  out  the  stomach  from  time  to  time  gives  great  comfort  and  is  often 
of  real  service. 

In  the  average  case  of  cehotomy,  in  which  persistent  vomiting  does  not 
occur,  the  cjuestion  of  feeding  is  of  much  importance.  Usually,  for  the 
first  twelve  or  twenty-four  hours,  nothing  is  given  by  the  mouth  but  small 
quantities  of  hot  water.  The  day  after  the  operation,  if  everything  is  satis- 
factory, food  is  given  to  the  patient.  In  many  cases,  however,  food  is  not 
given  by  the  stomach  for  forty-eight  hours  and  the  patient  is  fed  by  the 
rectum  during  the  wait.  He  should  not  be  given  milk,  because  it  will  not 
be  easily  digested,  may  lead  to  nausea,  and  causes  flatulence.  Peptonized 
milk,  if  the  patient  will  take  it,  does  not  possess  these  hurtful  qualities. 
At  first  albumin-water  or  liquid  beef  peptonoids  should  be  given  and  later 
Valentine's  meat-juice,  beef-jelly,  broth,  etc.  Food  is  given  every  third  or 
fourth  hour,  and  stimulants  are  administered  if  required.  After  the  first 
twenty-four  or  forty-eight  hours  considerable  quantities  of  plain  water  or 
Poland  water  should  be  taken,  when  possible,  to  favor  elimination  by  the 
kidnevs.  Hot  coffee  is  not  only  a  stimulant,  but  is  an  excellent  diuretic. 
The  urine  is  always  scanty  after  an  abdominal  operation,  and  a  normal 
daily  amount  is  not  voided  for  ten  days  or  more.  Solid  food  is  not  given 
for  seven  or  eight  days.  The  patient  is  apt  to  suffer  greatly  from  thirst, 
in  spite  of  the  hot  water  given  during  the  first  twelve  to  twenty-four  hours. 
It  does  not  do  to  give  any  considerable  amount  of  hot  water,  and  cold 
water  and  ice  are  inadmissible  and  tend  to  induce  nausea  and  vomiting. 
Thirst  can  be  much  mitigated  by  enemata  of  water.  J.  Greig  Smith  recom- 
mended an  enema  composed  of  from  4  to  20  ounces  of  tepid  water  and 
some  brandy.  Usually,  after  the  first  twenty-four  hours,  a  sufficient  amount 
of  liquid  can  be  given  to  keep  the  patient  free  from  actual  distress. 

The  bladder  must  be  watched  to  see  that  retention  does  not  occur.  If 
retention  occurs,  a  clean  catheter  must  be  used  at  regular  intervals.  If 
tympanitic  distention  occurs  after  forty-eight  hours  a  saline  purgative 
should  be  given  and  it  should  be  followed  by  an  enema  of  turpentine. 
The  rectal  tube  is  frequently  of  signal  service  in  such  cases.  If  obstruction 
develops  it  is  treated  as  directed  on  page  719. 

In  any  ordinary  case  after  operation  the  bowels  should  be  moved  after 
forty-eight  hours  as  a  prophylactic  measure  against  distention,  peritonitis, 
and  obstruction.  From  four  to  eight  .5j  doses  of  Epsom  salts  are  given, 
in  hot  water,  the  solution  having  been  filtered  through  gauze.  The  saline 
is  followed  by  the  administration  of  an  enema  consisting  of  soap,  water, 
and  half  an  ounce  of  castor  oil.  Should  opium  be  given?  Never  as  a 
routine,  and  not  to  secure  sleep;  but  if  the  patient  is  in  pa'in  which  not  only 
hara.sses  him  but  cau.ses  him  to  turn  and  shift  in  torturing  restlessness,  one 
or  possibly  two  hypodermatic  injections  eacli  containing  gr.  ^  of  morphia 
can  he  given  with  confidence  that  the  good  will  overbalance  the  harm. 

Operation  for  Acute  Appendicitis. — Before  operating  try  to  locate  the 
situation  of  the  appendix,  and  the  relation  the  area  of  infection  bears  to 
the  ascending  colon.  The  incision  should  be  over  the  seat  of  disease.  In 
the  rare  left-sided  cases  and  in  median  cases  the  incision  is  on  the  left  side 
or  median.     In  some  cases  where   the  appendix   is  posterior  the   cut   may 


Abdominal   Section 


777 


be  in  the  loin.  In  one  case,  I  opened  a  purulent  collection  through  the 
rectum.  In  the  vast  majority  of  cases  the  incision  is  made  in  the  right 
iliac  region. 

In  acute  appendicitis  when  there  is  not  thought  to  be  a  distinct  abscess 
the  incision  usually  made  is  two  inches  internal  to  the  anterior  superior 
iliac  spine  and  perpendicular  to  a  line  drawn  from  the  spine  to  the  umbilicus 
(Fig.  368).  The  skin  incision  is  usually  three  inches  in  length,  the  upper 
third  of  the  incision  being  above  the  omphalospinous  line;  the  incision  in 
the  peritoneum  is  from  two  to 
three  inches  in  length,  but  if 
there  are  many  adhesions  it 
may  be  necessary  to  make  it 
much  longer.  The  oblique  in- 
cision may  be  carried  out  as 
advised  by  McBurney,  the 
muscles  being  separated  by 
blunt  dissection.  By  this 
method  very  few  nerve-fibers 
are  divided,  and  hence  the 
operation  is  not  followed  by 
marked  muscular  wasting,  a 
condition  which  strongly  pre- 
disposes to  hernia.  Further, 
as  Van  Hook  points  out,*  the 
oblique  incision  enables  the 
surgeon  to  reach  freely  all 
the  ordinary  areas  of  appen- 
dix trouble,  the  wound  is 
parallel  with  the  lines  of  trac- 
tion of  the  abdominal  muscles 
and  does  not  tend  to  gap 
widely.  In  an  acute  case  I 
make  an  oblique  incision ,  but 
cut  the  muscles.  In  an  in- 
terval case  I  separate  the 
muscular  fibers.  After  open- 
ing the  peritoneum  examine 
very  gently  to  detect  the  situ- 
ation of  the  appendix,  and  if 
there  are  or  are  not  adhesions. 

In  a  very  recent  case  and  in  a  very  acute  case  there  will  probably  be  no  adhe- 
sions unless  there  have  been  previous  attacks.  Surround  the  region  of  infec- 
tion with  strips  of  iodoform  gauze,  each  strip  being  two  and  one-half  inches 
wide,  fifteen  inches  long,  and  four  layers  in  thickness.  The  edges  of  the 
wound  should  be  lifted  up  by  retractors  and  the  strips  inserted  around  the 
cut,  between  the  parietal  peritoneum  and  intestines  and  to  a  distance  of  three 
inches  from  the  wound.  Strips  of  gauze  are  passed,  when  possible,  below 
the  appendix  to  prevent  entrance  of  infected  material  into  the  pelvis,  and  a 

*  Tour.  Amer.  Med.  Assoc,  Feb.  20,  1897. 


Fig.  368. — Resection  of  the  vermiform  appendix,  in- 
cision through  the  abdominal  wall  :  a,  External  oblique 
muscle;  <?,  internal  oblique  muscle;  c,  aponeurosis  of  ex- 
ternal oblique  ;  d,  aponeurosis  of  internal  oblique  ;  e,  peri- 
toneum ;  /,  outer  border  of  rectus  abdominis  muscle  (un- 
der it  the  deep  epigastric  vessels)  (ICocher). 


778 


Diseases  and   Injuries   of   the   Abdomen 


piece  is  pushed  upward  toward  the  Hver  (Van  Hook).  Over  the  iodoform 
gauze  which  it  may  be  necessary  to  leave  in  place  after  the  operation,  gauze 
pads  are  packed.     The  appendix  is  sought  for  by  finding  the  colon.     The 

colon  is  found  by  following  the 
parietal  peritoneum  with  the  fin- 
ger. The  course  of  the  finger  is 
first  outward,  next  backward, 
and  finally  inward;  the  first  ob- 
struction it  encounters  is  the 
colon.  The  fact  that  it  is  the 
colon  can  be  confirmed  by  find- 
ing the  longitudinal  bands.  The 
anterior  longitudinal  band  leads 
directly  to  the  appendix.  Pass 
the  finger  down  to  the  head  of 
the  colon,  find  the  appendix,  usu- 
ally posterior  and  internal,  and 
lift  it  and  the  head  of  the  colon 
into  the  wound.  In  some  cases 
it  will  be  advisable  to  deliver  the 
head  of  the  colon  from  the  belly 
(Fig.  369) ;  in  other  cases  this  will 
not  be  necessary.  If  adhesions 
exist,  they  must  be  gently  and 
carefully  broken  up.  Many  sur- 
geons tie  the  meso-appendix  and 
neck  of  the  appendix  with  two  strong  silk  ligatures  (Fig.  370),  cut  off  the 
appendix  and  the  meso-appendix  below  the  ligatures,  cauterize  the  cut  surface 
and  interior  of  the  stump  with  pure  carbolic  acid,  and  invert  the  stump 


Fig.  369.— Radical  operation  for  appendicitis  (Kocher). 


?*#^ 


Fig.  370. — Ligation  of  appendix  and  meso-appendix. 


Fig.  371. — Barker's  technic  of 
operation    for   removal  of   the  ap- 

plMldi.X. 


into  the  coats  of  the  colon  by  Lembert  sutures.  An  excellent  method 
is  to  turn  up  a  cuff  of  peritoneum,  pull  down  the  other  coats,  ligate  at  the 
base,  cut  through  the  tube,  let  the  musculomucous  stump  retract,  and  tie  or 


Abdominal   Section  "jj^ 

suture  the  peritoneal  cuff  over  the  stump.  This  plan  was  devised  by  Barker 
(Fig.  371).  Another  method  is  to  encircle  the  appendix  with  a  ligature,  as  is 
shown  in  Fig.  370,  pass  the  second  ligature  through  the  meso-appendix  at  :x:, 
tie  both  ligatures,  cut  oft"  the  appendix  and  meso-appendix  below  the  threads, 
suture  the  fringe  of  the  meso-appendix,  and  cauterize  and  invert  the  stump  of 
the  appendix.  Some  remove  the  appendix  by  an  elliptical  incision  around  its 
base,  and  close  the  colon-wound  by  Lembert  sutures.  I  always  remove  the 
appendix  completely  by  this  method.  To  leave  a  septic  stump  produces 
post-operative  pain  and  may  lead  to  infection,  adhesions,  or  continued 
ill-health.  Dawbarn  surrounds  the  appendix  with  a  continuous  Lembert 
purse-string  suture  of  silk.  This  is  inserted  in  the  superficial  layers  of  the 
cecum,  half  an  inch  from  the  appendix.  The  appendix  is  divided  so  as  to 
leave  a  stump  never  shorter  than  half  an  inch.  The  lumen  of  the  stump  is 
gentlv  stretched  by  inserting  a  pair  of  mouse-tooth  forceps  and  opening 
the  blades.  The  stump  is  then  invaginated  into  the  cecum — that  is,  it  is 
turned  "outside  in."  The  sutures  are  tightened,  and  while  this  is  being 
done  the  mouse-tooth  forceps  used  in  effecting  inversion  are  withdrawn. 
Finally,  the  sutures  are  tied  (Robt.  H.  M.  Dawbarn,  in  "  Internat.  Jour, 
of  Surg.,"  May,  1895).  The  retained  bit  of  appendix  drains  into  the 
colon.  If  there  is  no  pus  or  no  extra vasated  feces,  if  the  peritoneum  is  not 
seriously  affected,  if  the  appendix  is  not  gangrenous  or  perforated,  and  if 
there  is  no  pus  within  the  appendix,  remove  the  pads,  irrigate  with  hot 
salt  solution,  remove  the  strips  of  gauze,  and  close  the  wound.  If  any  of 
the  above  conditions  were  found,  remove  the  infected  pads,  but  leave  the 
iodoform  strips  in  place  to  limit  infection  and  secure  drainage.  Pass  su- 
tures through  the  wound-edges,  tie  some  of  the  sutures  and  leave  some 
untied  until  the  gauze  is  removed  at  a  later  period  (Van  Hook). 

If  an  operation  is  performed  in  a  distinct  interval,  pus  is  absent  and  the 
surgeon  can  proceed  without  apprehension.  If  there  is  any  question  of  the 
presence  of  pus,  surround  the  region  w^ith  gauze,  as  suggested  above,  before 
breaking  down  adhesions  and  liberating  the  appendix.  An  interval  opera- 
tion should  not  be  performed  until  three  weeks  after  an  attack.  In  an  interval 
case  McBurney  proceeds  as  follows:  He  makes  the  skin  incision  in  the  direc- 
tion of  the  libers  of  the  external  oblique  muscle,  separates  the  fibers  of  this 
muscle  by  blunt  dissection,  retracts  them,  separates  the  fibers  of  the  internal 
oblique  and  the  transversalis  muscles  in  the  same  way  and  retracts  them,  and 
opens  the  transversalis  fascia  and  peritoneum.  No  muscle-fibers  are  cut,  and 
hernia  is  not  apt  to  follow.  Such  a  wound  is  closed  as  follows:  a  continuous 
catgut  suture  for  the  peritoneum,  sutures  of  kangaroo-tendon  for  the  transver- 
salis fascia,  the  muscles  are  restored  to  place,  the  aponeurosis  of  the  ex- 
ternal oblique  is  sutured  with  kangaroo-tendon,  and  the  skin  is  closed  by 
a  subcuticular  stitch. 

If  an  abscess  is  believed  to  exist,  make  an  incision  parallel  with  Poupart's 
ligament  and  over  the  area  of  dulness  on  percussion  (Willard  Parker's  oblique 
incision).  If  the  abscess  is  adherent  to  the  anterior  abdominal  wall,  such  an 
incision  will  not  enter  the  free  peritoneal  cavity.  If,  after  opening  the  abdo- 
men, an  abscess  is  thought  to  exist,  although  it  is  not  adherent  to  the  anterior 
abdominal  wall,  surround  the  abscess  with  gauze  before  opening  it,  as  directed 
under  acute  appendicitis.     The  gauze  is  placed    under  the  margins  of   the 


780  Diseases  and   Injuries  of  the   Abdomen 

incision  in  the  peritoneum  all  around  the  appendix  area;  a  piece  is  carried 
toward  the  pelvis  and  another  piece  toward  the  liver.  Overlay  this  gauze 
with  gauze  pads  (Van  Hook).  Adhesions  are  broken  through  with  the  finger, 
and  when  pus  appears  it  is  at  once  wiped  away.  Remove  the  appendix  in 
most  cases,  but  not  in  all.  If  the  appendix  hes  loose  in  the  abscess-cavity, 
if  it  is  sloughed  off  or  but  loosely  attached  to  the  abscess-wall,  remove  it.  If 
the  appendix  is  firmly  fixed  in  the  abscess-wall  and  must  be  dug  out  of  a  mass 
of  inflammatory  material,  do  not  remove  it.  To  remove  it  under  these  cir- 
cumstances may  rupture  the  wall  and  disseminate  the  pus  into  regions  not 
protected  by  pads  and  gauze.  Deaver,  Murphy,  and  others  tell  us  to  always 
remove  the  appendix.  I  do  not  believe  this  to  be  a  safe  rule  to  follow.  To 
insist  on  removing  the  appendix  may  cause  death.  When  the  appendix  is 
left,  it  usually  sloughs  away.  It  is  true  a  fecal  fistula  may  result,  but  this 
usually  heals  spontaneously.  Even  if  a  fecal  fistula  forms  and  does  not  heal, 
the  surgeon  acted  properly  in  not  removing  the  appendix,  because  a  fecal 
fistula  may  be  remedied  by  another  operation.  It  is  rarely  that  secondary 
abscess  forms,  and  there  are  not  a  great  many  cases  recorded  in  which  an 
appendix  has  subsequently  given  serious  trouble  when  left  after  operation. 
In  fact,  in  many  cases  the  appendix  is  destroyed  or  obliterated  by  inflam- 
mation. In  some  cases,  however,  a  secondary  operation  will  be  required 
because  of  a  fecal  fistula,  a  persistent  sinus,  or  an  acute  inflammatory 
attack.  When  Deaver  decides  to  remove  such  an  appendix  he  makes  an  inci- 
sion in  the  median  line  of  the  abdomen,  packs  around  the  periphery  of  the 
abscess  with  gauze,  opens  the  abdomen  by  another  incision,  removes  the 
appendix,  disinfects,  inserts  drainage,  and  then  removes  the  surrounding 
gauze  and  closes  the  median  incision.  Irrigation  should  not  be  employed  in 
appendicular  abscess.  The  force  of  the  stream  may  break  down  barriers  of 
lymph  and  spread  infection.  After  the  evacuation  of  the  pus,  whether  the 
appendix  was  removed  or  not,  take  out  the  pads,  but  leave  the  long  strands 
of  iodoform  gauze  in  place  (Van  Hook).  Introduce  iodoform  gauze  into 
the  abscess-cavity  and  insert  a  rubber  tube,  partially  suture  the  wound,  and 
dress  with  dry  gauze.  In  forty-eight  hours  all  the  strands  of  gauze  are 
removed  and  fresh  pieces  are  inserted  for  drainage.  After  this  period  the 
gauze  drain  is  changed  daily.  An  interval  case  should  be  up  and  about  in 
from  ten  days  to  two  weeks  after  operation.  An  abscess  case  may  require 
a  much  longer  time  for  complete  recovery.  A  fecal  fistula  sometimes  results 
in  cases  in  which  the  appendix  was  not  removed,  and  occasionally  forms 
when  it  was  removed.  Morris  maintains  and  proves  that  these  large  pieces 
of  iodoform  gauze  sometimes  cause  intestinal  obstruction  and  sometimes 
iodoform-poisoning,  but  the  risk,  it  seems  to  me,  should  be  taken. 

Morlalily  ajler  Operations  jar  Appendicitis. — The  interval  operation  is 
practically  without  mortality.  In  (jver  jooo  cases  Treves  had  2  deaths.  In 
acute  cases  the  mortality  is  large.  In  100  consecutive  cases  collectefl  by 
Hearn  and  operated  upon  in  the  Jefferson  Hospital  by  Keen,  Hearn,  and 
DaCosta,  there  were  8  deaths.  As  previously  stated,  Maurice  H.  Richardson 
reports  a  death-rate  of  j8  per  cent,  in  750  cases.  Deaver  reports  from  the 
German  Hospital  144  cases  with  a  mortality  of  17.8  percent.  He  eliminates 
one  death  from  diabetes,  one  from  pneumonia,  and  one  from  phthisis,  and 
estimates   his   personal    mortality   at    15.9   per   cent.   (Deaver  and  Ross,  in 


Enterorrhaphy,   or  Suture  of   the   Intestine 


781 


"Jour.  Amer.  Med.  Assoc,"  Oct.  5,  1901).  In  124  cases  (including  all 
chronic  cases  and  those  acute  cases  in  which  the  inflammation  had  not  ex- 
tended beyond  the  peritoneal  coat)  there  was  i  death.  The  usual  causes  of 
death  are  intestinal  obstruction,  septic  peritonitis,  septic  endocarditis,  pylo- 
phlebitis,  hepatic  suppuration,  metastatic  abscesses,  endocarditis  and  gan- 
grene of  the  bowel. 

Enterorrhaphy,  or  Suture  of  the  Intestine.— Surgical  opinion  has 


Fig.  372. — Eye  of  the 
calyx-eyed  needle. 


Fig.   373. — Enterorrhaphy:     a,    Lembert's   suture;    b,    Dupu>tren's 
suture. 


greatly  altered  in  regard  to  this  operation  since  the  day  when  John  Bell  wrote 
his  famous  attack  on  Benjamin  Bell.  John  Bell  said:  "If  in  all  surgery  there 
is  a  work  of  supererogation,  it  is  this  operation  of  sewing  up  a  wounded  gut." 
To-day  we  know  that  if  in  all  surger}-  there  is  a  proceeding  of  imperative 
necessity,  it  is  the  sewing  up  of  a  wound  in  the  intestine.  To  perform  this 
operation,  take  fine  sterile  silk  and  thread  a  thin,  round,  straight  caly.x-eyed 


Fig.  374. — Cushing's  right-angled  suture  (Senn) 


Fig.  375. — Ford's  stitch,  showing  a  Lembert 
insertion  and  the  needle  passed  so  as  to  tie  a 
single  knot  by  drawing  it  on  through. 


needle  with  it  (Fig.  372).     This  needle  is  very  useful,  as  it  can  be  threaded 
rapidly  by  pushing  the  calyx  eye  down  upon  the  silk  thread  while  the  latter  is 


kept  taut.     Lemherfs  suture  (Figs. 


.A,  379,  and  380)  was  introduced  in 


1823.  Lembert  used  it  on  animals,  but  never  on  man.  It  is  inserted  at  right 
angles  to  the  wound.  It  goes  down  to,  but  not  through,  the  mucous  mem- 
brane.    It  is  formed  liy  picking  up  a  fold  of  the  intestine  (one-twelftii  to  one- 


782 


Diseases  and   Injuries  of   the  Abdomen 


eighth  of  an  inch  wide)  one-eighth  of  an  inch,  from  the  edge  on  one  side  of  the 
wound,  passing  the  needle  through,  picking  up  a  fold  on  the  opposite  side  of 
the  wound,  and  passing  the  needle  through.  On  tying  the  threads  the  serous 
membrane  is  inverted  and  peritoneum  is  brought  into  contact  with  peritoneum. 
For  many  years  it  was  taught  that  this  suture  should  include  only  the  serous 
coat,  but  Halsted,  in  1887,  showed  that  it  must  include  the  tough  submucous 
coat.    The  submucous  coat  is  strong,  and  will  hold  a  suture.    The  other  coats 

are  thin,  tear  easily,  and  will  not  hold  a  suture. 
-■^  ^  So  thin  are  the  coats  that  a  surgeon  could  not 

suture  the  serous  coat  alone  were  he  to  try. 
Sutures  which  include  only  the  muscular  and 
serous  coats  tear  out  easily.  Dupnytren's 
suture  (Fig.  373,  b)  is  simply  a  continuous 
Lembert  suture  running  obliquely  across  the 
wound.  Cushings  right-angled  suture  (Fig. 
374)  is  a  continuous  suture  catching  up  the 
submucous  coat  and  serving  to  invert  the 
serous  layer.  Ford,  of  San  Francisco,  em- 
ploys a  continuous  inversion  suture,  which 
is  tied  in  a  single  knot  each  time  it  is  drawn 
through  (Fig.  375).  Downes,  of  Philadelphia, 
uses  a  similar  stitch.  Halsted's  mattress  or 
quilt  suture  is  shown  in  Fig.  376.  Each 
stitch  picks  up  the  submucous  coat.  Mattress  sutures  do  not  tear  out 
easily,  they  appose  evenly  considerable  surfaces,  and  do  not  constrict  the 
tissue  as  much  as  Lembert  stitches.  The  Czerny-Lemhert  suture  is  a  suture 
passed  through  the  serous  membrane  on  one  side  of  the  wound,  made  to  per- 
forate the  mucous  membrane,  and  to  emerge  at  a  corresponding  point  of  the 
serous  membrane.  A  Lembert  suture  is  added  (Fig.  377).  As  at  present 
used,  the  Czerny  suture  is  carried  to,  but  not  through,  the  mucous  membrane. 


] 


Fig.  376. — A.  Halsted  sutures  un- 
tied ;  B,  Halsted  sutures  tied  and 
serous  surface  inverted. 


Fig.  377. — Czerny-Lemhert  suture. 


Fig.  37S. — Czerny-Lembert  suture  as  at 
present  used. 


Gussenbauer's  suture  is  similar  to  the  Czerny-Lembert  suture,  except  that  it 
applies  the  Czerny  and  the  Lembert  with  one  suture,  and  this  suture  does 
not  pass  through  the  mucous  membrane  (Fig.  382).  In  ConnelPs  suture  the 
knots  are  placed  within  the  lumen  of  the  bowel  (Plate  9),  Wo/fler's  su- 
ture unites  broad  layers  of  the  serous  coat,  the  knots  being  tied  internally 
(Fig.  381).  Senn  says  that  after  suturing  a  large  wound  of  the  stomach  or  of 
the  intestine  a  strip  of  omentum  ought  to  be  laid  over  the  wound  and  fast- 
ened by  catgut  sutures    (omental    graft).     These    grafts   adhere   and   are  a 


EXPLANATION  OF  PLATE  9. 

Intestinal  suture,  all  knots  inside  (Connell). 

a,  Suspending  loops  2,  3,  and  4  are  made  with  one  thread  inserted  at  a  point  two  thirds 
of  the  distance  from  mesenteric  to  convex  border.  The  needle  with  suture  is  passed 
through  the  four  walls  of  the  cut  ends,  and  that  portion  of  suture  within  each  lumen  is 
drawn  up  to  a  sufficient  length,  then  cut,  and  the  contiguous  threads  tied  at  the  points 
indicated  by  the  arrows;  thus  having  as  a  result  four  suspending  loops  dividing  the  cir- 
cumference of  each  cut  end  into  thirds.  Instead  of  employing  four  suspending  loops 
which  divide  the  circumference  of  the  bowel  into  thirds,  we  may  use  but  two  loops,  and 
thus  divide  the  circumference  into  halves;  or,  if  available,  the  "holder"  devised  by  Dr. 
E.  H.  Lee  can  be  recommended  highly,  and  will  be  found  a  most  efficient  aid  in  main- 
taining the  cut  edges  in  apposition.  (The  description  of  the  instrument  will  be  found  in 
the  "Annals  of  Surgery,"  January,  1901.) 

b,  Loop  2  has  been  cut  away,  and  loop  i  takes  its  place  in  one  hand  of  the  assistant, 
with  loops  3  and  4  held  in  the  other  hand,  thereby  bringing  into  apposition  that  portion 
of  the  walls  to  be  included  in  the  second  third  of  the  suture.  The  operator  continues 
the  suture  to  the  points  of  insertion  of  loops  3  and  4,  where  again  a  back  stitch  is  taken, 
to  fix  the  suture  and  prevent  a  purse-string  contraction  of  the  same.  The  white  eleva- 
tion in  the  center  of  illustration,  representing  mesentery,  shows  that  that  portion  of  the 
intestinal  wall  not  covered  by  peritoneum,  at  the  mesenteric  border,  has  been  secured 
in  the  suture. 

c,  The  needle,  after  having  entered  the  lumen,  is  passed  out  again  on  the  same  side 
\  inch  distant;  then  over  to  the  opposite  cut  end,  where  it  is  inserted  from  without  in, 
and  again  emerges  from  within  out,  on  the  same  side.  This  step — the  taking  of  a  bite 
— is  repeated  alternately  on  opposing  margins  until  the  necessary  number  of  stitches 
have  been  inserted.  It  will  be  observed  that  when  the  needle  enters  the  lumen  the  last 
time,  it  makes  what  might  be  termed  a  half-stitch,  as  it  does  not  return  again  through 
the  wall;  but  having  reached  the  point  where  the  suture  was  commenced,  the  free  end 
and  the  needle  end  will  complete  the  last  stitch,  when  tied,  on  the  mucosa.  The  needle 
at  this  point  is  then  brought  out  of  the  lumen  at  the  angle  of  wound  alongside  of  the  free 
end  of  the  suture.  The  cross-over  stitches  are  next  carefully  drawn  up,  thus  bringing 
into  contact  the  opposing  serous  surfaces  at  every  point  except  where  the  suture  ends 
still  protrude. 

d,  The  eye-end  of  threaded  needle  is  made  to  emerge  alongside  of  the  suture  ends, 
and  is  then  withdrawn  a  little,  which  causes  its  thread  to  form  a  loop,  through  which  the 
assistant  passes  the  ends  of  the  suture.  The  operator  next  withdraws  the  threaded 
needle,  at  the  same  time  bringing  with  it  the  suture  ends,  and  they  present  externally  at 
the  point  of  withdrawal  of  the  needle.  The  serous  coats  throughout  the  entire  circum- 
ference are  now  in  apposition,  and  the  suture  ends  can  be  tied. 

"  e,  By  slight  traction  on  the  suture  ends  the  opposing  mucous  surfaces  are  brought 
in  close  contact;  the  suture  ends  are  then  tied  firmly,  and  deep  between  the  serous  coats, 
thus  tying  the  knot  upon  the  mucous  coat,  and  the  ends  then  cut  off  short. 


INTESTINAL   SUTURE. 


Plate  9. 


Operations    upon   the   Stomach 


783 


safeguard  against  leakage.     For  other  methods  of  enterorrhaphy,  see  Intes- 
tinal Resection  and  Anastomosis. 

Operations  upon  the  Stomach. — A  patient  must  be  carefully  pre- 
pared for  an  operation  upon  the  stomach.  The  Johns  Hopkins  method, 
founded  on  the  researches  of  Harvey  Gushing  regarding  sterilization  of  the 
stomach,  is  to  be  used.  During  the  two  or  three  days  immediately  preceding 
operation  clean  the  mouth  and  teeth  several  times  during  the  day  with  a  car- 


Serous 

Muse. 


Fig.  379. — Lenibert's  suture. 


Fig.  380. — Lemberl's  suture  closed. 


Fig.  381. — Wolfler's  suture. 


Fig.  3S2. — Gussenbauer's  suture. 


bolic  solution.  Give  only  sterile  water  and  sterile  liquid  food  by  the  mouth, 
and  for  twelve  hours  before  operation  give  no  food  whatever.  During  the 
two  or  three  days  before  operation  wash  the  stomach  with  boiled  water  night 
and  morning.  I  do  not  wash  immediately  before  operation,  as  it  .sometimes 
leads  to  annoying  vomiting  and  thus  may  interfere  with  anesthetization. 
After  operation  give  no  food  whatever  for  thirty-si.x  or  forty-eight  hours.  A 
little  hot  water  is  mven  earlv.     Durinti;  the  first  twentv-four  hours  ejive  an 


784 


Diseases  and   Injuries  of  the   Abdomen 


enema  of  hot  salt  sohition  and  coffee  every  five  hours  and  then  ahernate 
nutritive  enemata  with  sah  enemata.  After  thirty-six  or  forty-eight  hours 
usually  begin  to  give  food;  at  first  small  doses  of  albumin-water,  and,  if  this 
is  tolerated,  broth  and  milk  (Finney,  in  "Johns  Hopkins  Hosp.  Bull.,'"  July, 
1902).     Solid  food  should  not  be  given  for  three  weeks. 

Digital  Dilatation  of  Pylorus  for  Cicatricial  Stenosis  (Lor= 
eta's  Operation). — Place  the  patient  recumbent  and  administer  ether. 
ISIake  a  vertical  incision  in  the  linea  alba  or  through  the  right  rectus  muscle. 
The  median  incision  begins  one  inch  below  the  ensiform  cartilage.  The  cut 
in  either  case  should  be  five  inches  in  length.  When  the  peritoneum  has  been 
opened  the  stomach  is  drawn  out  of  the  wound,  any  adherent  omentum  is 
separated,  and  the  pylorus  is  carefully  examined.  The  stomach,  after  being 
surrounded  with  gauze  pads,  is  opened  near  the  center  of  its  anterior  surface, 
"but  rather  nearer  to  its  pyloric  end  "  (Jacobson). 

Insert  the  index-finger  through  the  stomach  wound  and  into  the  pylorus, 
and  follow  that  with  the  middle  finger.  The  pylorus  can  be  well  dilated  by 
separating  the  fingers.     If  the  stenosis  is  so  tight  as  to  prevent  the  entry  of  a 


Fig.    383.— Heineke-Mikulicz's    pyloroplasty  ; 
•the  incision. 


Fig.  384.— Heineke-Mikulicz's  pyloroplasty. 
The  axis  of  the  incision  is  changed  b\  traction 
from  horizontal  to  vertical  ;  sutures  in  position  ; 
only  one  of  the  two  rows  of  sutures  is  shown. 


finger,  first  introduce  a  pair  of  hemostatic  forceps  and  open  the  blades  a  little 
when  they  are  within  the  lumen  of  the  constricted  area.  The  wound  in  the 
stomach  is  closed  by  a  continuous  silk  suture  of  the  mucous  membrane  and 
two  layers  of  Halsted  sutures,  to  invert  and  approximate  the  peritoneal  sur- 
faces. After  closure  of  the  stomach  wound  the  abdominal  wound  is  sutured. 
Divulsion  by  the  fingers  or  by  an  instrument  is  no  longer  practised,  because 
experience  has  shown  that  the  constriction  is  sure  to  return. 

Pyloroplasty  (Heineke=Mikulicz  Operation).— The  first  opera- 
tion was  performed  by  Heineke  in  1886.  Early  in  1887,  Mikulicz,  not  know- 
ing of  Heineke's  antecedent  operation,  did  the  same  thing.  Open  the  abdo- 
men in  the  middle  line,  or,  better,  through  the  right  rectus  muscle.  Draw 
up  the  pylorus  as  well  as  possible  and  pack  warm  moist  gauze  pads  around  it; 
make  an  incision  through  the  stricture  and  in  a  direction  corresponding  to  the 
long  axis  of  the  stomach  and  bowel  (Fig.  3S3).  Catch  an  aneurysm-needle 
under  the  upper  margin  of  the  incision  and  draw  it  up,  and  an  aneurysm-needle 
under  the  lower  margin  and  draw  it  down.  The  effect  of  traction  is  to  convert 
the  transverse  wound  into  a  vertical  one.   The  sutures  are  applied  so  as  to  main- 


Pyloroplasty 


785 


tain  the  wound  in  a  vertical  line.  The  mucous  membrane  is  sutured  with 
a  continuous  suture  of  silk,  and  interrupted  Lembert  or  Halsted  sutures 
of  -silk  close  the  peritoneal  and  muscular  coats  (Figs.  384,  385).  Drain 
for  twenty-four  hours,  because  there  is  danger  of  leakage.  A.  W.  Mayo 
Robson  inserts  a  bone  bobbin  and  then 
applies  the  sutures.  The  operation 
of  pyloroplasty  shows  a  mortality 
about  the  same  as  or  slightly  less  than 
gastro-enterostomy.  It  is  often  a  very 
satisfactory  procedure,  but  there  are 
objections  to  it.  The  outlet  is  not  at 
the  most  dependent  part  of  the  stom- 
ach, hence  the  stomach  may  not  empty 
itself.  Further,  as  Finney  points  out, 
it  cannot  be  performed  if  there  are 
firm  adhesions,  or  active  ulceration, 
and   the  scar  may  contract  and  give 

rise  to  stenosis.  Again,  it  is  difificult  to  suture  so  as  to  certainly  provide 
against  leakage.  Finney  has  devised  an  operation  to  correct  these  objections. 
Finney's  Method  of  Pyloroplasty. — This  operation  is  described  in  the 
"Johns  Hopkins  Hospital  Bulletin,"  July,  1902.  It  is  performed  as  follows: 
Thoroughly  free  the  first  portion  of  the  duodenum  and  the  pyloric  end  of  the 
stomach.     Insert  three  retractor  sutures  (Fig.  386)  and  draw  upon  them. 


F'g-  385.— Heineke-MikuHcz's  pyloroplasty 
after  tying  the  sutures. 


Fig.  386. — Finney's  pyloroplasty.     The  retractor 
sutures. 


Fig-     387. — Finney's    pyloroplasty.      Suture    of 
greater  curvature  of  stomach  to  duodenum. 


Suture  together,  as  far  posterior  as  possible,  the  peritoneal  surface  of  the 
duodenum  and  the  peritoneal  surface  of  the  stomach,  along  its  greater  curva- 
ture (Fig.  387).  Insert  an  anterior  row  of  mattress  sutures,  but  do  not  tie 
them  as  yet  (Fig.  3S8).  Make  a  horseshoe-shaped  incision  (Fig.  389);  arrest 
bleeding;  excise  as  much  scar-tissue  as  possible  on  either  side  of  the  incision, 
and  trim  oft"  the  redundant  mucous  membrane.  Insert  a  continuous  catgut 
50 


786 


Diseases  and   Injuries   of  the  Abdomen 


suture  on  the  posterior  side  of  the  incision  and  carry  it  through  all  the  coats 
(Fig.  390).     Straighten  out  the  anterior  sutures  and  tie  them  (Fig.  391). 

Pylorectomy  (Excision  of  the  Pylorus). — The  removal  of  a  por 
tion  of  the  stomach  is  a  partial  gastrectomy,  and  pylorectomy  is  a  partial 
gastrectomy  in  which  the  pylorus  and  also  a  portion  of  duodenum  are  re- 
moved. 


Fig.  388. — Finney's  pyloroplasty.  Shows  the 
three  retractor  sutures,  the  posterior  line  of  su- 
tures tied  and  the  anterior  line  of  sutures  untied. 


Fig.  3S9. — Finney's  pyloroplasty.     The  anterior 
sutures  gathered  and  lifted. 


Fig.  390. — Finney's  pyloroplasty.      The  continu- 
ous posterior  catgut  suture. 


Fig.  391. — Finney's   pyloroplasty  completed   by 
tying  the  anterior  sutures. 


This  operation  was  first  performed  by  Pean  in  1879.  ^^  ^'^^  ^""^^^  P^^" 
formed  by  Rydygier  in  1880.  Billroth  did  the  first  successful  pylorectomy  in 
1881.  Pracdcally  its  only  use  is  in  cases  of  cancer  of  the  pylorus.  In  most 
cases  of  pyloric  cancer  the  abdomen  is  opened  after  a  ])alpable  tumor  is  de- 
tected, and  when  a  palpable  tumor  is  detectable  it  is  usually  too  late  to  perform 
pylorectomy.* 

^Keen's  "  Cartwriglit  Lectures"  for  1898. 


Pylorectomy 


787 


Keen  agrees  with  Hemmeter  that  stenotic  symptoms,  even  when  no  tumor 
is  palpable,  call  for  exploratory  laparotomy;  if  the  stomach  is  dilated,  if  there 
is  cachexia,  if  there  is  no  free  hydrochloric  acid  in  the  gastric  juice,  if  there  is 


Fig.  392. — Billroth's    method  of    pylorectomy. 


Fig-  593-— Pylorectomy. 


an  excess  of  lactic  acid  in  the  gastric  juice,  if  the  patient  is  at  or  beyond  fortv 
years  of  age,  when  there  is  vomiting  of  blood,  when  the  Oppler  bacillus  is 
present,  when  blood  examination  shows  a  diminution  in  red  corpuscles  and 
hemoglobin,  and  also  shows 
that  there  is  no  increase  in 
white  corpuscles  after  a  full 
meal.  After  the  abdomen  has 
been  opened  the  stomach  is 
examined,  and  if  a  tumor  ex- 
ists the  surgeon  must  decide 
between  the  performance  of 
pylorectomy  and  gastro-en- 
terostomy.  If  the  tumor  is 
not  ver}'  extensive,  if  there  is 
no  glandular  involvement  or 
only  involvement  which  can 
be  removed,  and  if  adhesions 
are  not  extensive,  pylorectomy 
is  chosen;  otherwise  gastro- 
enterostomy is  selected. 

Until  very  lately  the  mor- 
tality from  pylorectom}-  was 
estimated  to  be  25  per  cent., 
even  in  favorable  cases.  In  9 
complete  pylorectomies,  with 
closure  of  both  the  stomach 
and  duodenal  ends,  communi- 
cation being  re-established  by 
the  performance  of  gastro- 
jejunostomy. Mayo  reports  i 

death,  and  in  14  pylorectomies  and  partial  gastrectomies  he  reports  2  deaths,  or 
14  per  cent.  (Wm.  J.  Mayo,  in  "  Annals  of  Surgerv,"  Aug.,  1902).  Prepare  the 
patient   for  p\i()rectomy  as  for  any  stomach   operation.     The   best   incision 


Fig.  394. — Kocher's  metliod  of  pylorectomy  :  L.  Li\er  ; 
D,  duodenum;  P,  pylorus;  C,  carcinoma;  T.C,  trans- 
verse colon  ;  a.  separation-place  of  the  ligature  gaslrocol- 
icum  ;  h.  separation-place  of  the  lesser  omentum  ;  c,  sepa- 
ration-line of  the  stomach  ;  d,  place  where  the  stomach  is 
kept  closed  by  the  middle  and  index  fingers. 


788 


Diseases  and   Injuries  of   the  Abdomen 


through  the  abdominal  wall  is  transverse  over  the  middle  of  the  tumor.  A  small 
incision  is  made  first  to  permit  of  exploration,  and  if  the  growth  is  found  to  be  re- 
movable the  incision  is  enlarged.  The  center  of  the  incision  is  over  the  most 
prominent  part  of  the  tumor,  and  the  direction  of  the  incision  corresponds 
with  the  long  axis  of  the  pylorus.  Draw  the  tumor  into  the  wound,  and  tuck 
pads  about  the  stomach  and  the  pylorus  to  catch  extravasated  fluids.  Free 
the  pylorus;  incise  between  forceps  the  great  omentum  near  the  greater  curva- 
ture of  the  stomach,  and  ligate  each  end  in  segments;  treat  the  lesser  omentum 
in  the  same  manner.  Each  omentum  is  divided  only  to  an  extent  sufficient 
to  permit  removal  of  the  growth.  Repack  the  gauze  pads  and  tie  a  rubber 
tube   around    the   duodenum   below   the   growth.     In    making   the   excision 

remember  that  the  stomach-wound 
will  be  much  larger  than  the  duo- 
denal wound,  and  a  special  method 
of  suturing  will  be  required  to  ap- 
proximate the  two  wounds  in  size. 
The  lines  of  incision  are  shown  in 
Fig.  393.  The  stomach  is  cut  with 
scissors  until  two-thirds  of  its  depth 
is  divided,  and  the  organ  is  washed 
out.  After  stopping  hemorrhage 
this  cut  is  closed  by  a  continuous 
suture  for  the  mucous  membrane 
and  by  Halsted  sutures  for  the  other 
coats.  The  remaining  portion  of  the 
stomach  is  cut  through.  The  duo- 
denum is  cut  through  its  upper  half 
below  the  growth,  and  is  fastened 
to  the  stomach  by  Halsted  sutures 
at  the  upper  border  and  Wolfler's 
sutures  at  the  posterior  borders. 
Wolfler's  sutures  are  applied  from 
inside,  they  pierce  all  coats,  and 
bring  broad  layers  of  the  serous 
coat  into  apposition.  The  remain- 
der of  the  duodenum  is  cut  through, 
and  its  anterior  and  inferior  parts 
are  united  to  the  stomach  by  a 
double  row  of  Halsted  sutures,  as  set  forth  above  (Fig.  393).  Stitch 
the  edges  of  the  cut  omenta  to  the  stomach,  cleanse  the  parts,  re])iace  the 
stomach,  insert  gauze  for  drainage,  close  the  abdominal  incision,  and  dress 
the  wound.  Drainage  is  necessary  after  any  extensive  operation  upon  the 
stomach  because  there  is  great  danger  of  extravasation,  this  danger  being  due, 
as  Richardson  shows,  to  the  difficulty  of  making  a  tight  approximation  and 
to  the  action  of  the  gastric  juice.*  Another  method  of  performing  pylorec- 
tomy  is  to  excise  the  growth  as  directed  above,  suture  the  o])ening  in  the 
.stomach,  and  implant  the  duodenum  in  the  anterior  or  posterior  wall  of  the 
stomach,  making  an  incision  through  the  stomach-wall  to  permit  of  it.  Kocher 
*  M.  H.  Richardson,  in  Boston  Med.  and  Surg.  Jour.,  Aug-  4,  1898. 


Fig.  395. — Kocher's  method  of  pylorectomy  :  D, 
Duodenum  at  the  posterior  wall ;  a.  continuous 
suture  of  the  peritoneum  ;  b,  posterior  Ime  of  peri- 
toneal continuous  suture  of  the  ring;  />,  assistant's 
thumb  pressing  the  stomach  against  the  duodenum 
so  as  to  close  its  lumen  ;  /,  incision  in  the  posterior 
gastric  wall. 


Gastrostomy  789 

advocates  implantation  of  the  duodenum  in  the  posterior  wall  of  the  stomach. 
Kocher's  method  of  pylorectomy  with  gastro-enterostomy  is  shown  in  Figs. 
394,  395.  The  junction  between  the  duodenum  and  the  posterior  wall  of  the 
stomach  may  be  efTected  by  a  large  Murphy  button.  Give  nothing  by  the 
mouth  for  thirty-six  or  forty-eight  hours  after  the  performance  of  pylo- 
rectomy. Thirst  can  be  relieved  by  enemata  of  water  or  by  the  hypodermatic 
injection  of  boiled  water.  After  thirty-six  or  forty-eight  hours  begin  with 
stomach  feeding,  starting  with  small  doses  of  albumin  water,  and  if  this 
is  tolerated  giving  dessertspoonful  doses  of  peptonized  milk  every  hour. 

Total  Gastrectomy. — The  entire  stomach  was  first  removed  by  Conner, 
of  Cincinnati.  The  first  successful  operation  was  performed  by  Schlatter, 
of  Zurich,  in  189S.  Total  gastrectomy  will  rarely  be  required,  but  in  certain 
unusual  cases  it  will  be  proper  to  perform  it.  In  some  cases  the  duodenal 
end  can  be  sutured  to  the  divided  esophagus;  in  others  it  will  be  necessary 
to  close  the  end  of  the  divided  first  portion  of  the  duodenum,  and  anastomose 
the  esophagus  to  the  third  portion  of  the  duodenum. 

The  cases  suitable  for  total  gastrectomy  are  those  in  which  the  entire 
viscus,  or  almost  the  entire  viscus,  is  cancerous,  the  stomach  being  still  freely 
movable,  and  the  glands  not  so  much  implicated  as  to  forbid  attempts  at 
removal.  It  is  a  remarkable  fact,  first  demonstrated  in  Schlatter's  case, 
that  an  individual  can  digest  food  very  well  without  a  stomach. 

Gastrotomy. — This  term  is  used  to  designate  the  operation  of  opening 
the  stomach  for  the  accomplishment  of  some  purpose,  and  immediately 
closing  the  incision  in  the  gastric  wall  when  that  purpose  is  accomplished. 
Gastrotomy  may  be  performed  to  permit  of  the  removal  of  foreign  bodies, 
of  exploration  of  the  stomach  and  its  extremities,  of  divulsion  of  the  pyloric 
orifice,  of  the  treatment  of  bleeding,  of  an  esophageal  stricture,  or  a  stricture  of 
the  cardiac  orifice  of  the  stomach,  or  of  the  removal  of  a  foreign  body  lodged 
in  the  esophagus. 

The  patient  is  prepared  as  for  pylorectomy.  The  incision  may  be  vertical 
in  the  middle  line  or  identical  with  the  incision  for  pylorectomy.  If  a  large 
foreign  body  can  be  felt,  the  incision  is  made  directly  over  it.  When  the 
peritoneal  cavity  is  opened,  the  surgeon  decides  as  to  the  point  where  the 
stomach  is  to  be  incised,  and  draws  this  portion  out  through  the  wound, 
packing  gauze  pads  under  and  around  it.  The  stomach  is  opened  by  means 
of  scissors,  the  cut  being  at  a  right  angle  to  the  long  axis  of  the  viscus  (Jacob- 
son).  Bleeding  vessels  are  ligated  with  catgut.  The  purpose  for  which  the 
stomach  was  opened  is  now  to  be  carried  out,  the  interior  of  the  stomach 
and  the  surface  of  the  extruded  portion  are  irrigated  with  hot  salt  solution, 
the  mucous  membrane  is  sutured  with  a  continuous  suture  of  silk,  and  two 
rows  of  Halsted  sutures  are  inserted.  The  abdominal  wound  is  closed, 
drainage  being  employed  for  twenty-four  hours. 

Gastrostomy  is  the  making  of  a  permanent  gastric  fistula,  through 
which  opening  the  patient  can  be  fed.  Gastrostomy  was  first  proposed  by 
Egebert  in  1837  (Keen),  and  was  first  performed  by  Sedillot  in  1849.  ^^i 
1875  Sydney  Jones  operated  upon  the  twenty-ninth  case  and  obtained  the 
first  recovery  (Keen).  Up  to  1S84  the  estimated  mortality  was  80  per  cent. 
At  present  the  mortality  in  malignant  cases  is  from  20  to  25  per  cent.,  and 
in  non-malignant  cases  from  8  to  10  per  cent.  Gastrostomy  is  em]51o}-ed 
in  cases  of  esophageal  obstruction  or  obstruction  of  the  cardiac  end  of  the 


790 


Diseases  and   Injuries  of  the  Abdomen 


stomach.  In  many  cases  of  mahgnant  disease  the  operation  is  performed 
too  late,  and  if  performed  when  the  patient  is  greatly  emaciated  and  exhausted 
the  operation  has,  of  course,  a  high  mortality.  An  early  operation  is  far 
safer  and  confers  the  maximum  of  relief.  The  operation  should  be  per- 
formed, as  ^Slikuhcz  advises,  when  the  patient  is  steadily  losing  weight  and 
there  is  beginning  to  be  difficulty  in  swallowing  semi-solids  or  liquids.  The 
surgeon  must  endeavor  to  perform  an  operation  which  will  not  permit  of 
leakage.     Prepare  the  patient  as  for  any  stomach  operation. 

WitzeVs  Method. — This  operation  was  first  practised  in  1S91.  An  incision 
is  made  four  inches  long,  running  to  the  left  from  the  middle  line,  just  below 
the  border  of  the  ribs.     After  opening  the  peritoneal  cavity  seize  the  stomach, 


Fig.  396.— Witzel's  method  of  gastrostomy, 
showing  application  of  sutures  in  wall  of  stom- 
ach, embedding  tube  obliquely  tlierein. 


Fig-   39/ 


-Sutures   tied,   completely  embedding 
tube  obliquely  therein. 


bring  it  out  of  the  wound,  and  pack  gauze  around  it.  Introduce  a  rubber 
tube  into  the  stomach  and  enfold  it  by  a  double  row  of  Lembert  sutures 
(Figs.  396,  397).  This  tube  should  be  five  inches  long  and  of  the  same 
diameter  as  a  No.  25  French  bougie.  The  opening  is  made  in  the  stomach 
toward  the  cardiac  extremity,  the  tube  is  placed  parallel  with  the  belly- 
wound,  and  the  outer  end  of  the  tul^e  emerges  in  the  median  line.  The 
tube  is  retained  in  place  by  a  catgut  stitch  carried  through  the  tube  and 
the  stomach-wall.  The  stomach  is  returned  and  is  stitched  by  three  sutures 
to  the  abdominal  wall.  The  abdominal  incision  is  sutured  and  a  clamp 
is  placed  on  the  tube.  When  the  patient  is  fed,  a  funnel  is  slipped  into 
the  tube,  the  clamp  is  removed,  and  liquid  food  is  poured  into  the  funnel. 


Gastrostomy 


791 


After  the  wound  heals  it  is  not  necessary  to  permanently  retain  the  tube. 
It  is  passed  when  the  patient  desires  food. 

Kadefs  Method. — This  operation  was  devised  in  1S96.     It  is  a  modifica- 


Fig.  398. — Kader's  method  of  gastros- 
tomy. Tube  ill  place  and  first  row  of  su- 
tures inserted. 


Fig-.  399. — Kader's  method  of  gastrostomy. 
First  row  of  sutures  tied  and  second  row  in- 
serted. 


tion  of  Witzel's  method.     A  small  incision  is  made  in  the  stomach  and  a 
tube  is  introduced  and  fastened  to  the  stomach  by  one  catgut  stitch.     Four 
Lembert  sutures  are  passed  so  as  to  form  a  fold  on  each  side  of  the  tube 
and  turn    the  stomach-wall  inward  around 
the  tube  (Fig.  398).     Lembert  sutures  are 
inserted  in  the  furrow  on  each  side  of  the 
tube.     Two    more    folds    are    formed    over 
the  first   two    (Figs.  399   and   400).     The 
stomach-wall   is    stitched    to    the    parietal 
peritoneum  and   sheath  of   the  rectus  mus- 
cle (Willy  :Meyer). 

The  Ssahanejew-Frank  Method. — This 
operation  is  preferred  by  many  surgeons.  I 
usually  employ  it  if  the  stomach  is  not  so 
shrunken  as  to  render  the  pulling  out  of  a 
sufficient  cone  impossible.  It  was  first  per- 
formed by  Ssabanejew  in  1890  and  was  per- 
form.ed  independently  by  Frank  in  1893. 
Fenger's  incision  is  made  (a  curved  incision 
at  the  margin  of  the  costal  cartilages  of  the 
left  side).  A  cone  of  the  stomach  is  pulled 
out  of  the  wound  and  is  passed  under  a 
bridge  of  skin  which  has  been  prepared  for 
it.  The  stomach  is  fi.xed  above  the  margin 
of  the  ribs  and  opened  (Figs.  401,  402). 
fistula  through  the  left  rectus  muscle,  and 
cartilages  (Willy  Meyer). 

The    Younc'er   Senn's    Method. — Emanuel 


Fig.  400. — Kader's  method  of  gas- 
trostomy. Second  row  of  sutures 
tied. 


\'on   Hacker  makes  the  gastric 
Hahn  between   two  of  the  rib 


Senn    devised    the    following 


792 


Diseases  and    Injuries  of   the  Abdomen 


method:  A  cone  of  the  stomach  is  puhed  out  of  the  abdominal  wound,  and 
this  cone  is  puckered  by  the  insertion  of  two  drawing-string  sutures  of  chromic 
catgut  through  the  serous  and  muscular  coats.  A  cuff  of  gastrocolic  omen- 
tum is  sutured  by  silk  around  the  neck  of  the  puckered  cone.  The  stomach 
is  sutured  to  the  belly-wall  with  silk,  the  sutures  including  the  omental  cuff, 
the  serous  and  muscular  coats  of  the  stomach,  and  the  structures  of  the  belly- 
wall,  except  the  skin.  The  skin  is  partly  sutured.  The  stomach  may  be 
opened  at  any  time. 

Gastro=enterostomy  or  gastro=jejunostomy  is  the  establishment  of 

a  permanent  fistula  between  the  stomach  and  the  small  intestine,  in  order 
to  side-track  the  pylorus.  The  operation  is  performed  for  cancer  of  the 
pylorus,  for  non-cancerous  stenosis  of  the  pylorus,  and  in  some  cases  of 
ulcer  of  the  stomach.  Anterior  gastro-enterostomy  was  proposed  by  Nicola- 
doni  in  1881  and  was  first  performed  by  Wolfler  the  same  year.     Posterior 


Fig.  401.  Fig.  402. 

Figs.  401,  402. — The  Ssabanejew-H'raiik  nitnlioil  of  gastrostomy  in  carcinoma  of  the  esophagus. 


ga.stro-enterostomy  was  first  proposed  by  Courvoisier  in  1883.  His  plan 
necessitated  a  transverse  division  of  the  mesocolon,  but  it  was  found  that 
this  impaired  the  blood-supply  of  a  part  of  the  colon  and  might  lead  to 
gangrene.  Von  Hacker,  in  1885,  devised  the  method  we  now  practise.  As 
a  matter  of  fact,  the  transverse  mesocolon  has  a  marginal  artery,  unlike  other 
parts  of  the  colon,  and  the  danger  of  gangrene  from  a  transverse  incision  is 
probably  not  very  great.  In  non-malignant  conditions  the  mortality  is  very 
low  (under  6  per  cent.),  the  hyjjcracidity  of  the  ga.stric  juice  disappears, 
and  the  functions  of  the  stomach  are  restored.  In  malignant  cases  the 
mortality  is  about  20  [)er  cent.,  but  even  in  such  cases,  if  operation  is  done 
early,  life  may  be  prolonged  and  made  comfortable  for  months.  Wm.  J. 
Mayo  reports  107  gastro-enterostomies  with  10  deaths,  an  average  mortality 
of  9  per  cent.  ("Annals  of  .Surgery,"  Aug.,  1902).  The  mortality  in  the 
malignant  ca.ses  was  20  per  cent.;  in  n(Mvma]ignant  cases,  under  6  jjcrccnt. 


Complications   Following   Gastro-enterostomy  793 

The  causes  of  death,  according  lo  Mayo,  are:  exhaustion,  exhaustion  with 
vomiting,  pneumonia,  and  detachment  oi  the  anastomosed  intestine. 

Complications  Following  Gastro-enterostomy. — Among  them  are 
lung  complications.  These  are  not  due  to  the  anesthetic,  for  they  tend 
to  occur  even  when  a  local  anesthetic  was  used.  They  are  not  due  to  the 
epigastric  incision  interfering  with  cough  and  expectoration,  for  they  are 
not  nearly  so  common  after  operations  upon  the  gall-bladder  (\Vm.  J.  Mayo). 
Mayo  says  that  the  latest  theory  is  that  some  of  the  venous  blood  returning 
from  the  stomach  does  not  pass  through  the  liver,  and  infected  emboli  are 
deposited  in  the  lungs.  The  suture  line  may  leak  after  gastro-enterostomy, 
because  of  imperfect  suturing,  or  the  anastomosed  intestine  may  become 
detached.  Twenty  per  cent,  of  the  deaths  among  Mayo's  cases  resulted 
from  this  cause.  Contraction  of  the  anastomosis  opening  may  gradually 
take  place.  This  has  been  held  by  some  to  be  particularly  common  in  cases 
of  dilated  stomach,  shrinking  of  the  stomach  being  the  efficient  cause;  but 
evidence  upon  this  point  is  not  conclusive.  In  cases  in  which  the  pylorus 
is  not  obstructed  shrinking  often  occurs,  but  it  rarely  takes  place  when  the 
pylorus  is  obstructed.  In  some  cases,  after  operation  a  spur  forms  in  the 
jejunum  because  of  angulation;  in  other  cases  adhesions  produce  obstruction; 
and  in  rare  instances  ulceration  takes  place  in  the  duodenum  or  jejunum. 
The  most  common  complication  after  gastro-enterostomy  is  persistent  vomit- 
ing, which  may  or  may  not  be  expressive  of  the  formation  of  a  vicious  circle. 

The  Vicious  Circle  and  Regurgitation. — \'omiting  may  occur  after  the 
performance  of  gastro-enterostomy.  It  may  soon  cease,  may  be  productive 
of  disastrous  consequences,  and  may  be  expressive  of  an  existing  complication 
of  great  gravity.  In  some  cases  of  gastro-enterostomy  A-omiting  arises  because 
the  anastomosis  has  been  made  high  up  on  the  anterior  wall  and  the  stomach 
is  not  drained.  In  other  cases  ether  induces  vomiting,  and  the  mechanical 
efforts  force  the  contents  of  the  duodenum  and  even  of  the  jejunum  into 
the  stomach.  The  true  "vicious  circle"  is  a  condition  in  which  the  contents 
of  the  stomach  pass  through  the  anastomosis  opening  intc^  the  duodenal 
side  of  the  loop  of  intestine,  mix  with  the  duodenal  secretions,  and  return 
to  the  stomach  (Fowler,  in  ''Annals  of  Surgery,"  Nov.,  1902).  The  following 
conditions  are  often  classified  under  the  same  head,  but  each  is  called  by  Fowler 
a  regurgitation  or  reflux:  (i)  When  the  duodenal  secretions  pass  back  into 
the  stomach  through  a  permeable  pylorus  (as  in  cases  of  gastroptosis,  non- 
cancerous pyloric  stenosis,  and  gastric  dilatation) ;  (2)  when  the  duodenal 
secretions  enter  the  stomach  through  the  anastomosis  opening;  (3)  when  the 
contents  of  the  jejunum  pass  into  the  stomach,  because  of  efforts  at  vomiting 
or  as  a  result  of  reversed  peristalsis.  In  some  cases  the  contents  of  the 
jejunum  may  pass  into  the  afferent  loop  of  intestine  and  distend  it. 

Persistent  vomiting  is  in  some  cases  due  to  kinking  or  twisting  of  the 
distal  loop;  in  others,  to  failure  of  peristalsis  in  the  proximal  loop;  in  still 
others,  to  contraction  of  the  opening  in  the  stomach-wall  (Chlumsky  on 
Gastro-enterostomy  in  the  Breslau  Clinic;  article  by  Charles  L.  Gibson,  in 
"  Annals  of  Surgery,  "  Aug.,  1S9S).  In  order  to  lessen  the  danger  of  vomiting 
after  gastro-enterostomy,  use  a  local  anesthetic  whenever  possible  (Fowler^. 

After  Billroth's  operation  (Fig.  405),  and  in  all  the  earlier  methods,  the 
contents  of  the  duodenum   certainly   pass   into  the  stomach,   mix   with   the 


794 


Diseases  and   Injuries  of  the  Abdomen 


stomach-contents,  and  usually,  but  not  always,  pass  into  the  efferent  loop.  In 
all  these  operations  there  is  great  danger  of  the  development  of  a  vicious  circle. 
Liicke  devised  an  operation  with  the  idea  of  preventing  such  a  complica- 
tion. In  the  Liicke  operation  the  direction  of  peristalsis  in  the  efferent 
loop  is  the  same  as  in  the  stomach  (Fig.  403).     McGraw  points  out  that 


Fig.  403. — Gastro-euterostomy  (after  Liicke). 


Fig.  404. — Implantation  of  duodenum  into 
jejunum  and  jejunum  into  stomach  (after 
Wolfier). 


the  crossing  of  the  loop  which  is  effected  is  dangerous.  The  Wolfler-Lucke 
operation  is  shown  in  Fig.  410.  Wolfler  devised  the  operation  pictured  in 
Fig.  405.  Von  Hacker's  posterior  operation  is  thought  by  some  to  be  less 
apt  than  the  anterior  method  to  be  followed  by  the  vicious  circle  (Fig.  411). 
Kocher  devised  an  operation  in  which  a  valve  is  formed,  but,  as  Fowler 
points  out,  this  valve  does  not  prevent  filling  of  the  duodenum  and  imbi- 
bition of  the  material  by  the  stomach;  and  further,  that  the  valve  does  not 

work  when  the  parts  become  cicatricial. 

The  combination  of  gastro-enterostomy  with 
entero-anastomosis  does  tend  to  prevent  the  vicious 
circle.  This  operation  is  shown  in  Figs.  408  and 
409.  The  defect  in  such  an  operation  is  that  there 
is  still  a  communication  between  the  stomach  and 
the  afferent  loop.  Fowler's  operation  (Fig.  411) 
corrects  this  defect.  McGraw's  operation  tends 
to  prevent  the  formation  of  a  vicious  circle. 

Treatment  oj  Persistent  Vomiting  ajter  Gastro- 
enterostomy.— If  vomiting  persists  in  spite  of  gas- 
tric lavage  and  rectal  feeding  after  the  operation  of  gastro-enterostomy  without 
entero-anastomo.sis,  open  the  abdomen  again  and  perform  anastomosis  between 
the  afferent  and  efferent  loops  of  intestine. 

Anterior  Gastro-enterostomy. — Senn's  Method. — A  median  incision  is 
made  through  the  abdominal  wall,  from  below  the  .xiphoid  cartilage  to  the 
umbilicus.  An  opening  is  made  in  the  lower  part  of  the  anterior  wall  ofthc 
.stomach  in  the  direction  of  the  long  axis  of  the  viscus  and  its  edges  are  stitched 
with  a  continuous  catgut  suture.  The  contents  of  the  jejunum  are  forced 
along  to  below  the  point  where  an  incision  is  to  be  made.  The  duodenal  loop  of 
jejunum  should  be  from  12  to  14  inches  in  length.     A  rubber  tube  is  fastened 


Fig.  405.— Billroth's  method  of 
gastro-enterostomy. 


Anterior   Gastro-enterostomy 


795 


around  the  bowel  above  this  point,  and  another  below  it;  an  incision  is  made 
in  the  long  axis  of  the  bowel,  and  the  margins  of  the  wound  are  sutured  in  the 
same  manner  as  the  stomach-wound.  Bone  plates  are  introduced  into  the 
stomach  and  intestine,  and  the  ligatures  are  tied  as  in  intestinal  anastomosis. 
Catgut  rings  or  rubber  rings  may  be  used.  Fig.  404  shows  Wolfler's  original 
method  of  gastro-enterostomy. 

Mayo's  Method  (Fig.  406). — Open  the  abdomen,  and  pick  up  the  small 
intestine  and  find  a  point  of  jejunum  about  14  inches  from  the  point  at 
which  it  emerges  from  under  the  mesocolon.  Effect  the  union  to  the  inferior 
border  of  the  stomach  close 
to  the  greater  curvature  and 
at  the  lowest  portion  of  the 
stomach  pouch.  When  the 
anastomosis  is  completed, 
the  stomach  pouch  is  funnel- 
shaped.  The  usual  custom 
has  been  to  place  the  open- 
ing higher  on  the  anterior 
wall.  It  sometimes  led  to 
the  formation  of  a  pouch  on 
the  anterior  wall,  did  not 
drain  the  stomach,  and 
caused  vomiting.  After  the 
performance  of  gastro-en- 
terostomy the  edges  of  the 
omentum  are  caught  upon 
each  side  of  the  anastomosis 
and  are  sutured  to  each  other 
and  to  the  stomach-wall  one 
inch  above  the  opening.  The 
edges  are  then  united  to  each 
other  in  a  downward  direc- 
tion for  about  three  inches 
so  as  to  form  an  apron  over 
the  anastomosis,  yet  not  con- 
nected with  it.  Catgut  is 
used  for  suturing.  If  leak- 
age occurs,  the  omentum  is 

adjacent  and  "available."  If  leakage  does  not  occur,  the  omentum  soon  re- 
turns to  its  normal  position  (Wm.  J.  Mayo,  in  "Annals  of  Surger}-, '"  Aug..  1902). 

Kocher's  Method  (Fig.  407). — After  opening  the  abdomen,  lift  up  the 
omentum,  pull  up  a  loop  of  intestine,  and  find  the  point  where  the  jejunum 
appears  from  under  the  mesocolon.  Select  a  loop  si.xteen  inches  from  the 
origin  of  the  jejunum  and  prepare  to  attach  it  to  the  stomach,  \\olfler 
showed  that  the  intestine  should  be  applied  to  the  stomach  in  such  a  manner 
that  the  direction  of  peristalsis  in  the  bowel  must  correspond  to  the  direction 
of  the  stomach-tide.  This  can  be  accomplished  by  having  the  proximal 
portion  of  gut  to  the  left,  and  the  distal  portion  to  the  right.  The  operation 
is  to  be  so  performed  that   after  its   completion   the  stomach-contents  pass 


Fig.  406. — Mayo's  method  of  gastio-enterostomy.  show- 
ing proper  and  improper  locations  of  opening  :  a.  Proper  po- 
sition, leaving  no  pouch;  b,  usual  position,  forming  intra- 
gastric pouch  ("Ainials  of  Surgery"). 


796 


Diseases  and   Injuries  of  the  Abdomen 


into  the  distal  portion  of  the  gut,  and  the  intestinal  contents  do  not  tend  to 
enter  the  stomach.  In  order  to  accomphsh  this  Kocher  hangs  the  intestine  to 
the  stoma ch-\A-all  in  such  a  manner  that  the  proximal  portion  of  the  loop  is 
posterior  and  ascending,  and  the  distal  portion  is  anterior  and  descending. 

The  bowel  is  hung  to  the  stomach  by  a 
continuous  serous  suture  of  silk,  the  ends 
of  which  are  left  long.  The  intestine  is 
opened  by  a  curved  incision,  the  con- 
vexity of  which  is  downward.  The 
stomach  is  opened  so  that  the  convexity 
of  the  cut  is  upward.  The  valve-like 
portion  of  the  bowel-wall  is  sutured  to 
the  stomach  below  the  incision  in  that 
viscus.  The  two  openings  are  well  ap- 
proximated l:)y  sutures. 

Operation  by  McGraw's  Elastic 
Ligature. — The  intestine  and  stomach 
are  sutured  together  by  Lembert  stitches. 
The  elastic  cord  is  passed  through  the 
stomach  and  then  the  bowel,  in  the  long 
axis  of  each,  and  is  tightly  tied,  and 
the  knot  is  fastened  with  a  silk  thread. 
Another  row  of  Lembert  sutures  buries 
the  silk  cord  from  sight.  The  cord  cuts 
through  in  from  forty-eight  to  seventy- 
two  hours  and  makes  the  anastomosis. 
Thus  the  danger  of  infection  is  greatly  lessened,  for  when  the  anastomosis 
opening  is  formed  it  is  completely  encompassed  by  firm  adhesions.  Further, 
the  danger  of  the  formation  of  a  vicious  circle  is  greatly  lessened  because 
there  is  no  communication  beween  the  stomach  and  bowel  for  between  forty- 
eight  and  seventy-two  hours,  the  period  in  which  vomiting  of  the  type 
previously  described  is  most  apt  to  occur. 


Fig.  407. — Kocher's  method  of  gastro- 
enterostomy :  a,  Places  of  posterior  annular 
suture  through  entire  wall  of  stomach  and 
intestine;  i.  places  of  anterior  annular 
suture  through  the  entire  wall  ;  c,  valve  at 
the  jejunum  by  arch-formed  incision ;  d, 
posterior  annular  suture  of  the  serosa  ;  e, 
thread  ends  for  continuing  anterior  suture 
of  the  serosa. 


Fig.  408. — Jaboulay's   method   of  gastro-enter- 
ostomy. 


Fig.  409. — Braun's  method  of  gastro-enterostomy. 


Gastro-duodenostomy. — This  operation  was  devised  by  Jaboulay  in 
1892.  It  aims  to  obviate  some  of  the  objections  to  pyloroplasty  and  at  the 
same  time  to  retain  the  advantages  this  operation  possesses  over  gastro- 
jejunostomy. It  has  never  become  popular  with  surgeons,  and  Finney's 
method  of  pyloroplasty  is  much  more  satisfactory. 


Posterior  Gastro-enterostomy 


797 


Posterior  Gastro-enterostomy. — In  a  thin  subject  with  a  long  mesocolon 
posterior  gastro-enterostomy  is  to  be  chosen,  but  if  the  mesentery  is  short  or 
contains  much  fat,  or  if  the  vascular  loop  coming  from  the  superior  mesenteric 
artery,  and  which  supplies  the  transverse  colon  with  blood,  is  small,  so  that 
on  opening  the  posterior  layer  of  the  gastro-colic  omentum  would  be  close  to  the 
artery,  the  anterior  operation  is  employed  (Wm.  J.  ^Slayo,  in  "Annals  of 
Surgery,"  Aug.,  1902).  If  a  Murphy  button  is  used,  the  posterior  operation 
is  selected.  The  operation  is  performed  as  follows:  After  the  abdomen  has 
been  opened  the  stomach  and  omentum  are  raised;  a  portion  of  the  upper 
jejunum  is  seized,  emptied,  and  tied  with  tubes  as  previously  described.  The 
portion  selected  should  be  at  least  ten  inches  below  the  emergence  of  the 
jejunum  from  under  the  mesocolon.  A  spot  is  selected  on  the  transverse 
mesocolon  where  there  are  no  vessels  and  an  opening  is  made  through  the 
mesocolon  with  a  dry  dissector.  The  posterior  wall  of  the  stomach  is  pulled 
into  the  opening  and  sutured  to  its  edges.  This  prevents  do\M-iward  displace- 
ment of  the  stomach  and  obstruction  of  the  loop  of  gut.  The  sutures  are  so 
inserted  that  a  tlap  is  formed  of  the  mesenteric  margin  to  protect  the  line  of 


Fig.  410. — Wolfler-Liicke  method  of  gastro- 
eiiterostomv. 


Fig.  411. — Von  Hacker's  posterior  gastro-enteros- 
tomv. 


junction  of  the  anastomotic  opening  (Willy  Meyer).  An  anastomosis  is  then 
performed.  Regurgitation  is  less  common  after  posterior  than  after  anterior 
gastro-enterostomy.  In  250  posterior  operations  in  Czerny's  clinic  there  was 
not  one  case  of  regurgitant  vomiting.  One  hundred  and  seventy  cases  were 
button  operations  and  45  were  by  sutures  alone  (Peterson).  A'on  Hacker 
had  one  instance  of  regurgitation  in  60  posterior  operations. 

Operation  by  the  Murphy  Button. — Gastro-enterostomy  ma}'  be  quickly 
performed  by  the  use  of  a  large-sized  Murphy  button.  Murphy  says  that  in 
some  reported  cases  the  button  has  slipped  back  into  the  stomach,  but  this 
accident  can  be  prevented  by  the  use  of  an  oblong  button  and  by  making  the 
anastomosis  on  the  posterior  stomach-wall.  The  same  surgeon  advises  us  to 
scarify  the  peritoneum  to  hasten  union,  and  says  supporting  sutures  about  the 
button  are  not  required,  except  when  considerable  tension  exists.  There  is  no 
question  that  an  anastomosis  on  the  anterior  wall,  accomplished  by  a  !Murphy 
button,  can  be  speedily  performed.  Anastomosis  on  the  posterior  wall  cannot 
be  so  performed  speedily,  and  it  sacrifices  to  some  extent  the  great  advantage 


798 


Diseases  and   Injuries  of  the  Abdomen 


of  the  button  operation — that  is,  speed.  In  spite  of  the  reported  cases,  we  can 
positively  assert  that  the  danger  of  the  button  producing  grave  trouble  is  slight. 
In  some  cases  it  drops  into  the  stomach  and  remains  there,  but  seems  to  do  no 
harm.  In  other  cases  it  takes  a  long  time  to  pass.  In  one  of  the  author's 
cases  it  did  not  pass  until  the  eighty-sixth  da}-.     If  it  does  not  pass  in  two  or 

three  weeks,  the  rectum  should 
be  explored  with  the  finger 
from  time  to  time  to  see  if  it  is 
lodged  there.  The  a-rays  may 
determine  whether  the  button 
is  in  transit.  If  the  wall  of  the 
stomach  is  thick,  the  incision 
should  be  made  in  the  stom- 
ach-wall before  the  suture  is 
passed,  and  this  suture  should 
pick  up  only  a  small  portion  of 
the  stomach-wall,  otherwise 
the  button  may  be  retained  in 
place  for  a  very  long  time 
(Wm.  J.  Mayo).  "In  many 
cases  in  which  the  button 
passes,  vomiting  with  symp- 
toms of  obstruction  may  ap- 
pear in  the  second  or  third 
week  while  it  is  in  transit. 
Gastric  lavage  and  rectal  feed- 
ing for  a  day  or  two  cause 
these  symptoms  to  subside"  (Wm.  J.  Mayo,  in  "Annals  of  Surgery,"  Aug., 
1902).  Mayo  considers  the  suture  operation  as  good  as  the  button,  and 
thinks  the  results  are  about  the  same.  Mikulicz  says  that  in  the  suture 
operation  entero-anastomosis  is  necessary,  but  not  in  the  button  operation, 


Fig.  412. — Fowler's  method  of  gastro-enterostomy. 


Fig.  413.— Wolfler's  method  of  gaslixjgastro.stomy  for  hour-glass  stomach,  showing  the  anastomotic 

openings. 


because  the  button  while  in  place  prevents  angulation.  The  last-named 
surgeon  uses  the  button  in  malignant  cases  and  the  suture  in  benign  cases. 
Czerny  is  an  advocate  of  the  button.  Every  button  should  be  tested  before  it 
is  used.     Mayo  finds  nearly  20  per  cent,  of  Inittons  imperfect  and  dangerous. 


Gastroplication 


799 


Fowler's  Method  (Fig.  412). — Anastomose  the  posterior  wall  of  the 
stomach  to  jejunum  and  do  an  entero-anastomosis  between  the  afferent  and 
efferent  loops  of  jejunum.  Pass  a  No.  20  silver  wire  two  or  three  times 
around  the  afferent  loop  of  jejunum  and  draw  it  sufficiently  tight  to  occlude 
the  lumen  without  strangulating  the  wall  of  the  gut.  The  ends  are  twisted, 
cut  short,  rolled  into  a  flat  coil,  the  cut  ends  being  in  the  coil.  (See  Geo. 
Ryerson  Fowler  on  the  "  Circulus  Vitiosus''  following  gastro-enterostomy, 
"Annals  of  Surgery, "  Nov.,  1902.)  This  operation  positively  prevents  the 
entrance  of  material  from  the  duodenal  loop  into  the  stomach  and  also  drains 
that  loop. 

Qastrogastrostom y  is  an  operation  performed  for  hour-glass  contraction 
of  the  stomach,  a  condition  which  occasionally  ensues  on  the  heahng  of  an 
ulcer.  In  this  operation  an  anastomosis  is  effected  between  the  pyloric  and 
cardiac  ends  (Fig.  413).  Wolfe,  Watson,  Wolfler,  and  Eiselberg  have  per- 
formed this  operation.  Weir  and  Foote  maintain  that  double  gastro-enter- 
ostomy, "tapping    each    sac,"  is  a  preferable  procedure.*     In  some  cases 


Fig.  414. — Bircher's  method  of  gastroplication. 


an  operation  identical  with  pyloroplasty  can  be  performed  (incision  of  the 
constriction  in  the  direction  of  the  long  axis  of  the  stomach  and  suturing 
vertically — gastroplasty).  Watson  folds  the  two  stomachs  over  each  other, 
using  the  narrow  isthmus  as  a  hinge;  sutures  the  pouches  together  and 
leaves  the  ends  of  the  sutures  long.  He  incises  the  anterior  wall  of  the  ante- 
rior stomach  in  order  to  obtain  access  to  the  double  septum  between  the  two 
pouches.  He  makes  an  anastomosis  opening  through  the  double  septum, 
sutures  the  edges  and  closes  the  wound  in  the  anterior  wall  of  the  anterior 
stomach. 

Gastroplication  (Brandt's  Operation  of  Stomach=reefing  for 
Dilated  Stomach). — Apply  sutures  in  the  anterior  wall  so  as  to  form  reefs, 
then  tear  through  the  great  omentum  and  apply  sutures  in  the  posterior  wall. 
The  sutures  pass  through  the  serous  and  muscular  coats.  A  continuous 
suture  may  be  used  on  the  anterior  wall  and  another  on  the  posterior  wall, 

*  F.  S.  Watson,  in  Boston  Med.  and  Surg.  Jour.,  April  2,  1896;  Weir  and  Foote, 
Medical  News,  April  25,  1896. 


8oo 


Diseases  and   Injuries   of  the   Abdomen 


or  numerous  interrupted  sutures  may  be  inserted.     Tliis  operation  is  of  ques- 
tionable value,  and  must  never  be  used  if  stenosis  of  the  pylorus  exists,  and 
stenosis  of  the  pylorus  is  the  most  common  cause  of  gastric  dilatation. 
Bircher's  method  of  gastroplication  is  shown  in  Fig.  414. 

Gastropexy  (Buret's  Operation  for  Qastroptosis).— It  has  been 

shown  by  Duret  that  dyspepsia  of  a  peculiarly  severe  type  may  be  produced 
by  prolapse  or  downward  displacement  of  the  stomach.  In  this  condition  he 
advises  the  following  operation:  Perform  a  median  laparotomy,  but  do  not  in- 
cise the  peritoneum  in  the  upper  portion  of  the  wound.  Expose  the  stomach 
and  fix  it  bv  means  of  a  silk  suture  to  the  undivided  but  exposed  peritoneum. 
The  suture  should  be  parallel  to  the  lesser  curvature  and  near  the  pylorus 
should   be   horizontal.*     Buret's  operation,  the  operation  of  Rovsing,  and 


Fig.  415. — Beyea's  operation  for  gastroptosis  :  i,  Position  of  one  suture  of  first  row  ;  2,  one  suture 
of  second  row ;  3,  one  suture  of  third  row.  Others  of  each  row  introduced  at  intervals  to  and 
including  the  gastrophrenic  ligament. 


the  operation  of  Hartman,  fix  and  distort  the  stomach.     Beyea  has  devised 
an  operation  which  is  free  from  this  objection. 

Beyea's  Operation  for  Qastroptosis. — Insert  three  rows  of  interrupted 
silk  sutures  through  the  gastrohepatic  omentum  and  the  gastrophrenic  liga- 
ment. Each  suture  is  passed  from  above  downward  and  the  row  begins  at 
the  right  and  passes  to  the  left  (Fig.  415).  When  the  sutures  are  tied,  a  fold 
or  plication  is  formed  in  the  ligaments,  the  sup|)()rts  of  the  stomach  are  short- 
ened, and  the  viscus  is  elevated  to  a  normal  position  without  any  disturbar.ce 
of  its  physiological  mobility  ("Univ.  of  Penna.  Med.  Bull.,"  Feb.,  1903). 

Duodenostomy  and  Jejunostomy. — It  has  been  suggested  that  one  of 
the  above  operations  should  be  [jcrformed  in  a  case  of  pyloric  obstruction  in 

*  Rev.  de  Chir. ,  June,   i8g6. 


Enterectomy  8oi 

\Thich  pylorectomy  is  not  feasible.  Duodenostomy  is  an  easy  operation  because 
of  the  mobility  of  the  pylorus  and  first  part  of  the  duodenum,  and,  it  is  not  only 
easier,  but  is  safer  than  jejunostomy,  because  it  makes  the  fistula  above  the 
opening  of  the  common  bile-duct  (''  Bull,  et  Mem.  de  la  See.  de  Chir.  de  Paris," 
No.  39,  1901).  Cackove  advocates  the  operation  in  some  cases  of  gastric  ulcer 
with  repeated  hemorrhages  and  some  cases  of  gastric  cancer.  In  the  latter 
cases  he  asserts  that  the  mortality  is  about  the  same  as  from  gastro-enterostomy 
and  the  prolongation  of  life  is  greater  ("  Arch.  f.  klin.  Chir.,  "  Bd.  l.w.  Heft  2). 
Hartman's  case  of  duodenostomy  lived  two  months.  The  operation  was  per- 
formed for  extreme  cicatricial  stenosis  of  the  pylorus  due  to  swallowing 
hydrochloric  acid.  Moynihan  points  out  that  if  the  operation  is  done  at  all 
the  indication  for  jejunostomy  is  cancer  involving  the  entire  stomach  or 
leather-bottle  stomach.  He  operated  on  2  cases.  One  lived  one  month  and 
one  seven  weeks  (B.  G.  A.  Moynihan,  "Brit.  Med.  Jour.,"  June  28,  1902). 

Jacobson  disapproves  of  both  procedures,  and  objects  particularly  to 
duodenostomy,  because  it  involves  a  portion  of  the  intestine  which  is  difficult 
to  deal  with,  and  because  important  fluids  escape  constantly  from  the  fistula.* 

The  same  author  objects  to  jejunostomy  because  of  the  inevitable  leakage 
of  nutritive  fluids. 

Reported  cases  of  duodenostomy  and  jejunostomy  certainly  do  not  indicate 
that  the  operations  prolong  life  to  any  considerable  degree. 

Enterectomy,  or  Resection  of  the  Intestine  with  Approxima= 

tion  by  Circular  Enterorrhaphy.— How  much  of  the  intestine  can  be  re- 
moved without  the  patient  dying  from  lack  of  nutrition  ?  The  question  is  not 
settled.  It  has  been  stated  that  the  removal  from  an  adult  of  more  than  six 
and  two-thirds  feet  produces  intestinal  disturbance,  and  that  a  child  tolerates 
the  removal  cf  a  piece  relatively  larger  better  than  does  an  adult.  Certain 
it  is  that  great  lengths  have  been  successfully  removed,  and  the  patients  have 
not  only  lived,  but  have  been  well  nourished.  Ruggi  removed  eleven  feet 
successfully.  Hayes  removed  eight  feet  four  and  one-half  inches  from  a  boy 
of  ten  years  of  age,  and  the  patient  was  well  eight  months  later.  Dressman 
reported  26  cases  in  each  of  which  more  than  three  feet  three  inches  had  been 
removed  (Alexander  Blaney,  in  "Brit.  Med.  Jour.,"  Nov.  16,  1901).  Blaney 
adds  7  cases  from  literature,  and  tells  us  that  in  9  of  the  t,^  cases  death 
occurred  soon  after  operation. 

Alexander  Blaney,  in  the  previously  quoted  article,  reviews  the  subject 
of  the  resection  of  great  lengths  of  intestine.  He  tells  us  that  how  much  re- 
mains after  a  resection  is  important  but  uncertain.  It  is  uncertain  because,  as 
Treves  has  shown,  the  length  of  the  intestine  varies  from  fifteen  feet  six 
inches  to  thirty-one  feet  ten  inches. 

Resection  of  the  jejunum  is  much  more  dangerous  than  resection  of  an 
equal  length  of  ileum.  If  resection  is  employed,  all  diseased  or  injured  bowel 
must  be  removed  irrespective  of  ultimate  bad  consequences  (Blaney).  The 
operation  is  performed  as  follows:  After  opening  the  abdomen  isolate  the 
loop  of  intestine  we  intend  to  resect.  Push  a  rubber  tube  through  the 
mesentery  close  to  the  bowel,  above  the  seat  of  operation,  and  pass  a  rubber 
tube  through  the  mesentery  below  the  seat  of  operation.  Empty  this  segment 
of  bowel  by  squeezing  and  stroking,  tighten  the  rubber  tubes,  and  clamp  them 
*  Jacobson' s  "  Operations  of  Surgery." 
51 


802 


Diseases  and   Injuries  of  the  Abdomen 


to  keep  the  bowel  empty  (Fig.  416).  Instead  of  tubes,  strips  of  iodoform 
gauze  may  be  used  to  encircle  the  bowel.  The  diseased  intestine  is  resected, 
each  incision  being  carried  through  a  healthy  segment,  and  care  being  taken 
that  the  cuts  are  so  arranged  that  at  each  end  a  blood-vessel  from  the 
mesentery  reaches  the  edge  of  the  cut  bowel.  Otherwise  repair  can 
scarcely  occur.  The  lumen  of  each  end  of  the  divided  gut  is  irrigated  with 
salt  solution.  The  divided  surfaces  are  approximated  by  a  double  row  of 
sutures — a  continuous  suture  for  the  mucous  membrane,  and  Lembert's, 
Dupuytren's,  or  Cushing's  suture  to  efifect  inversion.  Thoroughly  satisfac- 
tory approximation  can  be  effected  by  one  row  of  Halsted  sutures.  If  a  re- 
dundant fold  of  mesentery  is  left,  it  can  be  stitched  at  its  raw  edge  (Fig. 
417).  Many  surgeons  remove  a  V-shaped  piece  of  mesentery  and  tie  the 
divided  mesenteric  vessels  (Fig.  416).  The  tubes  are  removed,  and  the 
wound  is  cleansed,  closed,  and  dressed. 

Senn  effects  invagination  by  means  of  a  bone  ring  (Fig.  419). 

If  the  two  segments  of  bowel  are  unequal  in  size,  the  narrow  part  of  the 
bowel  should  be  cut  obhquely  and  the  larger  part  should  be  cut  transversely. 


Fig.  416. — Excision  of  bowel ;  first  step 
( Esmarch  and  Kowalzig). 


I\^, 


//     / 


f/'ll|\\\^i|^ 


;'//,/]'. -^^ 


Fig.  417. — Excision  of  bowel  with  enteror- 
ihaphy  and  stitching  of  the  redundant  mesen- 
tery ;  second  step  (Esmarch  and  Kowalzig). 


To  meet  this  compHcation  Billroth  devised  lateral  implantation.  Suppose  the 
cecum  has  been  resected;  its  lower  end  is  closed  by  Lembert  sutures,  an  open- 
ing is  made  in  the  long  axis  of  the  periphery  of  the  colon  opposite  the  attach- 
ment of  the  mesocolon,  and  the  end  of  the  ileum  is  sutured  into  this  incision. 
This  is  called  end-to-side  approximation,  .or  implantation.  It  is  used  in  the 
sigmoid,  in  the  cecum,  and  in  any  intestinal  segment  in  which  the  circulation 
is  deficient.  Eugene  A.  Smith  ("Amer.  Med.,"  May  10,  1902)  sums  up  the 
advantages  of  end-to-side  approximation  as  follows:  The  .strain  of  peristalsis 
is  le.ss  than  in  end-to-end  union;  the  circulation  of  each  end  of  the  bowel  and 
the  parts  of  bowel  adjacent  is  better;  each  cut  edge  of  mesentery  is  free  to 
recover  its  circulation,  and  there  is  no  dead  space  at  the  mesenteric  jjorder  to 
lead  to  leakage. 

Senn  advises  the  in.sertion  of  an  anastomosi.s-ring  in  the  ileum,  the  in- 
vagination of  the  colon  as  the  ring  is  ])ulled  into  place,  and  firm  suturing  of  the 
line  of  junction.  By  Senn's  method  the  ileum  may  be  im])lanled  into  the  end 
of  the  colon  or  into  a  slit  in  the  wall  of  the  large  bowel  after  the  end  of  the 
colon  has  been  clo.sed.  In  .some  cases,  where  one  portion  of  bowel  is  larger 
than  the  other,  lateral  anastomosis  is  the  preferable  method.     For  a  full  week 


End-to-end  Approximation 


803 


after  an  intestinal  resection  the  patient  is  fed  chiefly  by  nutrient  enemata. 
During  the  first  twenty-four  hours  nothing  is  given  by  the  stomach  but 
bits  of  ice,  and  for  the  next  six  days  but  a  Httle  hquid  food  is  allowed  to  be 
swallowed. 

The  use  of  Murphy's  button  permits  of  rapid  approximation  after  resection 
(Fjff.  418,6  and  c).  This  button  closely  approximates  the  portions  of  the  in- 
testine within  its  bite,  rapid  adhesion  taking  place.     The  diaphragm  of  tissue 


Fig.  418.— Resection  of  intestine  .  a,  ^,   i:  :  ~       the  button  ;  c.  the  two  ponions  clamped 

together  ;  (/,  introduction  of  the  sutures  for  holdint;  each  hall  of  the  button  in  place.  The  lower  figure 
shows  the  completed  union  of  the  intestine  by  the  Murphy  button  ;  the  slit  in  the  mesentery  has  been 
closed  by  linear  union  (after  Zuckerkandl). 


undergoes  pressure-atrophy,  and  liberates  the  button,  which  is  passed  per 
anum.  It  is  claimed  that  the  button-opening  contracts  but  slightly.  For  end- 
to-end  or  side-to-side  approximation  of  the  small  intestine  a  No.  3  button  is 
used.  For  similar  operations  on  the  large  intestine  a  Xo.  4  button  is  employed 
(Murphy).  After  the  resection  one-half  ot  a  button  is  inserted  into  each  seg- 
ment, and  is  held  in  place  by  a  purse-string  suture  of  silk  which  passes  through 
all  the  coats  (Fig.  418).  The  redundant  mucous  membrane  is  tucked  in  or 
clipped  off,  so  that  it  will  not  be  interposed  between  the  serous  surfaces.     The 


8  04 


Diseases   and    Injuries  of   the   Abdomen 


serous  surfaces  are  S' 


Fig.  419. — Senn's  modification  of  Jobert's  invagina 
tion  method  :  A,  Upper  end  lined  with  ring  ;  B,  invag 
ination  sutures  in  place  ;   C,  lower  end. 


cratched  with  a  needle  and  the  halves  of  the  button  are 
locked  (Fig.  418).  It  is  not 
necessary  to  surround  the  mar- 
gin of  junction  with  sutures. 
Murphy  says  that  liquid  nourish- 
ment should  be  given  as  soon  as 
the  patient  has  recovered  from 
the  effect  of  the  ether,  and  that 
the  bowels  should  be  moved  at 
an  early  period,  and  frequent 
evacuations  should  be  main- 
tained. If  "the  button  does  not 
pass  in  four  weeks,  examine  the 
rectum  for  it.*  The  situation  of 
the  button  can  be  ascertained  by 
the  A--rays.  An  objection  to  the 
button  is  that  it  introduces  a 
foreign  body  which  must  pass  per  rectum  to  complete  the  operation  success- 
fully. It  may  not  pass,  but 
trouble  does  not  of  neces- 
sity follow.  But  in  some 
cases  its  retention  leads  to 
trouble,  and  obstruction 
ensues.  If  the  caliber  of 
the  button  blocks  before 
dislodgment,  obstruction 
follows;  hence  the  rule  to 
give  saline  purgatives  the 
day  after  the  operation. 

Some  surgeons  have 
sought  to  make  a  button 
whicii  would  come  apart 
and  be  absorbed  after  it 
had  accomplished  its  pur- 
pose. The  best  of  these 
appliances  is  Frank's  coup- 
ler, which  is  made  of  bone, 
the  compression  being  fur- 
ni.shed  by  rubber.  In  this 
apparatus,  howev'er,  the 
amount  of  pressure  ob- 
tained is  always  uncertain 
and  the  rubber  is  apt  to 
wear  out.  The  button 
gives  a  lower  mf)rtality 
than  the  suture  operation, 

and  many  surgeons   now  u.se  it  who  once  condemned  it.     Czerny  is  a  strong 
advocate  of  the  button. 

*Jolin  B.  Murphy,  in  Med.  News,  T'eb.  9,  1895. 


Fig.  420.— Maunsell's  method  of  anastomosis  (after  Wigffin). 


End-to-end  Approximation 


805 


After  intestinal  resection  Halsted  performs  circular  enterorrhaphv  by 
means  of  his  mattress  sutures. 

Maunsell  has  devised  a  most  ingenious  method  of  circular  enterorrhaphv. 
The  two  portions  of  bowel  are  attached  by  two  fixation  sutures  which  penetrate 
all  the  coats  (Fig.  420).  An  incision  one  and  one-half  inches  in  length  is  made 
through  the  wall  of  the  proximal  segment  of  gut,  about  one  inch  from  its  edge. 


Fig.  421. — Robson's  decalcified  bone  bobbin. 


Fig.   422. — Allingham's   decalcified   bone 
bobbin. 


Fig.  423. — Harris's  method  of  circular  enterorrhaphv 


The  fixation  sutures  are  brought  through  this  opening,  traction  is  made  upon 
them,  the  distal  portion  of  the  bowel  is  invaginated  into  the  proximal  portion, 
and  the  ends  emerge  from  the  opening,  their  peritoneal  surfaces  being  in 
contact  (Fig.  420).  Sutures  of  silk  are  passed  through  both  sides  of  the  area 
of  invagination,  the  threads  are  caught  up  in  the  center,  cut,  and  tied  on  each 
side.  The  fixation  sutures  are  cut  off.  The  invagination  is  reduced  by 
traction.     The  longitudinal  cut  is  closed  bv  Lembert  sutures. 


8o6 


Diseases  and   Injuries  of  the  Abdomen 


A.  W.  Mayo  Robson  performs  circular  enterorrhaphy  and  brings  the 
ends  of  the  gut  together  over  a  bobbin  of  decalcified  bone  (Fig.  421). 
AUingham  uses  a  bone  bobbin  the  shape  of  two  cones  joined  at  their 
apices.  The  bobbin  is  decalcified,  except  an  area  at  the  center  (Fig.  422). 
Kocher  performs   circular  enterorrhaphy  as  follows:   A  fixation   suture    is 


Fig.  424.— Use  of  Halsted's  inflated  rubber  cylinder  in  circular  enterorrhaphy. 


introduced  through  the  bowel  at  the  mesenteric  attachment  and  another  is 
inserted  at  an  opposite  point.  The  intestinal  ends  are  approximated  by  a 
continuous  silk  suture,  which  passes  through  all  of  the  coats,  but  which  includes 
more  of  the  serous  than  of  the  mucous  coat.  The  suture-line  is  overlaid  by  a 
continuous  Lembert  suture  which  includes  the  serous  and  a  portion  of  the 

muscular  coat.  Harris  removes 
a  portion  of  mucous  membrane 
from  the  distal  end  by  means  of 
a  curet.  Three  needles  are 
threaded  with  fine  silk.  The 
first  needle  is  pushed  through 
the  bowel-wall  to  one  side  of 
the  mesentery.  The  point  of 
the  needle  picks  up  a  portion  of 
the  distal  end  transversely.  The 
needle  is  u.sed  as  a  lever  to  invag- 
inate "  the  di.stal  end  into  the 
proximal  end.  The  .same  pro- 
cedure is  carried  out  with  the 
other  needles.  When  invagina- 
tion is  efTected  the  needles  are 
pulled  through  and  the  threads  are  tied.  The  free  end  of  the  bowel  is  now 
sutured  to  the  invaginated  part  by  interrupted  inversion  sutures  or  by  a  con- 
tinuous inversion  suture  broken  once  (Fig.  423).* 

*  Chicago  Med.  Record,  Jan.,  1S97. 


Fig.  425. — Suture  of  the   mesentery  after  circular  en- 
terorrhaphy (Halsted). 


End-to-end  Approximation 


807 


Some  surgeons  employ  inflatable  rubber  cylinders  in  making  an  end-to-end 
anastomosis  (Halsted,  Downes,  and  others).  The  method  was  devised  bv 
Treves,  but  was  subsequently  abandoned  by  him.  Halsted  maintains  that 
the  use  of  the  inflatable  rubber  cylinder  enables  the  surgeon  to  finish  the  opera- 
tion more  quickly  and  to  dis- 
pense with  clamps;  arrests  the 
vermicular  motion  of  the  in- 
testine; makes  easy  the  ad- 
justment of  two  pieces  of  in- 
testine of  unequal  size;  and 
renders  it  possible  to  apply 
stitches  rapidly,  evenly,  and 
securely.*  Three  presection 
sutures  are  inserted;  a  portion 
of  bowel  and  a  V-shaped  piece 
of  mesentery  are  resected,  the 
mesenteric  incision  being  so 
made  as  to  leave  a  vessel  un- 
cut at  ea;ch  edge  to  supply 
each  end  of  the  divided  in- 
testine. The  mesenteric  ves- 
sels are  hgated  and  the  ends 

of  the  bowel  are  pulled  together  by  the  presection  stitches,  two  of  which  are 
tied.  The  collapsed  rubber  cyhnder  is  pushed  into  the  bowel  by  means  of 
forceps  and  is  inflated  with  a  syringe  (Fig.  424).  Twelve  mattress  sutures 
are  inserted,  the  bag  is  collapsed  and  withdrawn  and  the  sutures  are  tied. 


Fig.  426. — Laplace's  forceps  for  intestinal  anastomosis. 


Fig.  427. — End-to-end  anastomosis  with  the  aid 
of  Laplace's  forceps. 


Fig.  428. — Senn's  entero-anastomosis  :  A, 
Senn's  bone  plate;  B,  intestinal  anastomosis;  C, 
operation   complete. 


the  Stitch  a  being  tied  first  (Fig.  424).  The  slit  in  the  mesentery  is  sewed 
in  such  a  way  that  the  mesenteric  vessels  which  nourish  the  bowel  are  not 
interfered  with  (Fig.  425). 

Connell  has  devised  a  method  which  places  the  knots  in  the  lumen  of  the 

*Phila.  Med.  Jour.,  Jan.  S,  1S98. 


8o8 


Diseases  and   Injuries  of   the  Abdomen 


bowel  (F.  Gregory  Connell,  "Medicine,"  x\pril,  igoi).  He  maintains  tliat 
the  placing  of  the  knots  within  the  lumen  of  the  gut  has  the  following  advan- 
tages: there  is  no  foreign  body;  the  suture  passes  away  early;  adhesions  to 


Fig.  429. — Method  of  passing  the  silk  sutures  Fig.  430. — O'Hara's  anastomosis  forceps 

in  inserting  the  rings  of  Abbe.  (about  one-third  original  size). 


Fig.  431. — Showing  the  manner  of  placing  forceps  in  resection  of  bowel;  dotted  lines  show  the  in- 
cision to  be  made  (O'Hara). 


neighboring  organs  are  few;  the  serous  ap])roximation  is  perfect;  the  suture 
line  is  more  .secure;  the  septum  is  smaller  and  the  danger  of  necrosis  is  le.ss. 
The  suture  is  shown  in  Plate  9. 

Laplace  has  devised  forceps  which  greatly  facilitate  suturing,  which  make 


End-to-end  Approximation 


809 


it  easy  to  obtain  an  even  suture-line,  and  which  can  be  withdrawn  after  the 
suturing  is  finished,  the  small  opening  through  which  the  instrument  emerged 
being  closed  with  a  stitch  (Figs.  426,  427).  By  aid  of  Laplace's  forceps  the 
operation  can  be  neatly  and  rapidly  performed,  but  a  large  diaphragm  is 
formed,  a  considerable  area  is  exposed  to  infection,  the  tissues  of  the  diaphragm 
are  bruised  and  may  slough,  the  raw  ends  may  grow  together  and  cause 
obstruction,  and  it  seems  probable  that  considerable  contraction  will  follow. 
Another  objection  is  that  an  infected  instrument  is  withdrawn  from  the  bowel 


Fig.  432. — End-to-end  anastomosis.    Forceps  biouglit  together  and  held  by  serre-fine  (not  shown); 
sutures  introduced,  some  of  which  are  tied  (.O'Haraj. 


F'g-  433. — Showing  relative  size  of  incision  and  method  of  introducing  sutures  in  lateral  approxima- 
tion with  Murphy's  button. 


and  may  contaminate  the  peritoneum.  O'Hara's  forceps  permit  of  rapid 
and  accurate  suturing,  but  po.s.sess  the  same  disadvantages  as  the  Laplace 
forceps.  In  one  case  within  my  knowledge  absolute  obstruction  from  ad- 
hesion of  the  raw  edges  of  the  septum  followed  its  employment.  Figs. 
431  and  432  show  the  use  of  O'Hara's  forceps.  Of  the  operations  previ- 
ously set  forth,  I  prefer  the  simple  suture  as  employed  by  Halsted  (although 
distention  by  an  inflated  cylinder  is  not  a  necessary  adjunct)  or  the  operation 
with  the  ^lurphy  button. 


8io 


Diseases  and   Injuries  of   the   Abdomen 


Lateral  Intestinal  Anastomosis.— Approximation  may  be  effected  by 
other  methods  than  by  end-to-end  junction  or  implantation.  Lateral  anasto- 
mosis may  be  practised  after  intestinal  resection  or  may  be  done  without  pre- 


Fig.  434. — Suturing  intestines  in  apposition  be-      Fig.  435. — Showing  the  four-inch  incision  and  sew- 
fore  incision  (Abbe).  ing  of  the  edges  (Abbe). 

liminary  resection  for  the  purpose  of  short-circuiting  the  fecal  current  to  avoid 
an  obstruction.  After  lateral  anastomosis  the  parts  obtain  a  better  blood- 
supply  than  after  end-to-end  suturing,  because  in  the  former  operation  the 

mesenteric  vessels  are  not 
'^  ^  interfered  with.      Further, 

in  lateral  anastomosis  there 
is  little  tendency  to  cicatri- 
cial contraction.  It  has 
the  disadvantage  that  the 
diseased  structure  is  not 
removed. 

Operation  with 
Rings. — In  this  operation 
a  portion  of  bowel  above 
the  obstruction  and  a  loop 
below  the  obstruction  are 
brought  into  the  wound. 
These  segments  are  emp- 
tied, and  are  kept  empty 
by  fastening  around  them 
rubber  tulles  or  iodoform 
strips.  Two  tubes  are 
needed  for  each  looj)  of 
bowel.  Pack  in  gauze 
pads.  Make  an  incision 
in  one  loop,  in  the  long  a.xis 
of  the  bowel,  on  the  surface 
away  from  the  mesentery; 
permit  the  contents  to  es- 
cape externally;  irrigate 
this  segment  with  .saline  solution;  and  introduce  the  bone  plate  of  Senn  (Fig. 
428,  a)  or  Abbe's  catgut  ring  (Fig.  429 j.  Calyx-eyed  needles  are  u.sed  to  pass 
the  silk,  and  the  threads  of  the  ring  are  carried  through  the  coats  of  the  bowel 
and  are  gathered  together  in  the  I)ite  of  a  pair  of  forceps.     The  other  loop  of 


Fig.  436. — Halsted's  operation  for  lateral  anastomosis,  show- 
ing four  steps  of  same  (Jessett,  from  Halsted). 


Lateral  Anastomosis 


8ii 


Fig.  437. — Represents  the  ends  of  the  intesthie  in  posi- 
tion and  grasped  by  the  artery  forceps.  The  first  row  of 
sutures  has  been  partially  applied,  the  septum  partly  cut 
away,  and  the  second  row  of  overhand  sutures  begun,  a,  b. 
are  the  two  ends  of  the  intestine  ;  c,  c' ,  the  first  row  of 
sutures  (Gushing)  ;  d,  the  second  row  of  sutures  (over- 
hand); e,  the  septum  ;  /  and  g,  the  mesentery  (J.  Shelton 
Horsley). 


intestine  is  treated  in  a  similar  manner.  The  two  segments  of  intestine  are 
so  brought  together  that  the  two  wounds  are  opposite  each  other,  the  posterior 
sutures  being  tied  first,  the 
upper  ne.xt,  then  the  lower, 
and  finally  the  anterior 
threads.  The  ends  of  the 
threads  are  cut  off  and  the 
entire  anastomosis  is  sur- 
rounded by  a  layer  of  Lem- 
bert  or  Halsted  sutures  or  is 
encircled  by  Cushing's  suture. 
Fig.  428,  B,  shows  an  intes- 
tinal anastomosis  partly  fin- 
ished, and  Fig.  428,  c,  shows 
an  anastomosis  complete.  Fig. 
429  shows  the  passing  of  the 
sutures  when  the  catgut  rings 
of  Abbe  are  employed.  After 
an  intestinal  resection,  each 
end  can  be  closed  and  anas- 
tomosis effected  as  described 
above.  Lateral  anastomosis 
can  be  accomplished  with  a 

Murphy  button,  the  intestine  being  prepared  for  the  button   as  is  shown  in 
Fig.  433- 

Abbe's   method  of  anastomosis   without   mechanical  aid   is  as  follows: 

After  resecting  the  bowel  and  mes- 
entery and  closing  the  ends  of  the 
bowel  he  places  the  extremities  side 
by  side  and  applies  two  rows  of  a 
Dupuytren  suture,  one-quarter  of 
an  inch  apart.  These  rows  of 
sutures  are  an  inch  longer  than  the 
slit  in  the  bowel  will  be  (Fig.  434), 
the  thread  at  the  end  of  each  row 
being  left  long.  An  incision  is  made 
in  the  bowel,  one-quarter  of  an  inch 
from  the  sutures,  both  rows  of 
threads  being  on  the  same  side  of 
the  cut.  This  incision  is  four  inches 
long.  The  other  portion  of  the 
bowel  is  then  incised  in  the  same 
way.  The  adjacent  cut  edges  are 
united  by  a  whip-stitch  which  goes 
through  all  the  coats,  and  the  free 
cut  edges  are  stitched  in  the  same 
manner  (Fig.  435).  The  surgeon  now  utilizes  the  long  threads  of  the  first 
sutures,  and  brings  the  serous  surfaces  of  the  opposite  sides  together  bv  means 
of  Dupuytren's  suture.     Halsted  performs  anastomosis  as  folk)ws:  He  places 


Fig.  438.— Operation  nearly  completed.  The 
septum  has  been  cut  away,  and  the  row  of  over- 
hand sutures  has  been  brought  almost  to  its  point 
of  commencement.  The  cut  also  shows  the  first 
row  of  sutures  (Gushing)  as  it  should  be  continued 
after  the  overhand  sutures  are  finished  (J.  Shelton 
Horsley). 


8l2 


Diseases  and   Injuries  of  the  Abdomen 


the  two  portions  of  bowel  with  their  mesenteric  borders  in  contact.  Six 
quilted  sutures  of  silk  are  introduced,  tied,  and  cut  off  (Fig.  436,  a).  At 
each  end  of  this  row  of  sutures  two  quilted  sutures  are  introduced,  tied,  and 


Fig.  439. — Lateral  anastomosis  with  the  aid  of  Laplace's  forceps. 


cut  (Fig.  436,  b).  A  number  of  quilted  sutures  are  introduced,  as  is  shown 
in  Fig.  436,  c.  The  intestinal  openings  are  made  with  scissors,  and  the 
sutures  last  introduced  are  tied  and  cut  off  (Fig.  436,  d). 

J.  Shelton  Horsley  has  suggested  an  ingenious  method  of  intestinal  anasto- 
mosis which  secures  for  the  su- 
tured portion  a  greater  diameter 
than  that  normal  to  the  intes- 
tine.* After  resection  of  the  in- 
testine and  a  V-shaped  piece  of 
mesentery,  the  ends  of  the  bowel 
are  placed  side  by  side,  the  open- 
ings being  in  the  same  direction, 
and  are  clamped  in  place  (Fig. 
437).  The  first  stitch  approxi- 
mates the  two  limbs  of  the  bowel 
near  the  mesenteric  attachment, 
is  carried  obliquely  for  about 
two  inches  to  the  border  oppo- 
site the  mesenteric  attachment, 
and  continued  over  the  other 
side  (Hg.  437).  The  septum  is 
cut  away,  a  margin  being  left 
one-third  of  an  inch  wide.  The 
edge  of  the  shelf  made  by  cutting  the  sej^tum  is  sutured.  When  the  suture 
reaches  the  end  of  the  shelf  it  is  continucrl  by  iiivaginating  the  rest  of  the 
resected  ends  (Fig.  438). 

*  New  York  rolyclinic. 


Fig.  440. — Withdrawal  of  Laplace's  forceps. 


Consideration  of  Methods  of  Intestinal  Approximation        813 

Bodine's  method  of  intestinal  anastomosis  is  referred  to  on  page  818. 
Laplace,  of  Philadelohia,  has  devised  an  operation  in  which  temporary 
approximation  is  effected  by  means  of  forceps,  the  instrument  being  with- 
drawn before  the  abdomen  is  closed.  Junction  of  two  segments  of  intestine 
can  be  quickly  and  neatly  effected  by  this  method  and  the  suture  line  is 
even  and  secure.  The  objections  are  that  an  infected  instrument  is  with- 
drawn from  the  bowel  and  may  contaminate  the  surface;  that  the  septum  is 
tightly  squeezed  and  this  septum  may  slough,  or  may  become  infected,  con- 
ditions which  will  be  followed  by  infection  of  the  suture  line;  and  that 
contraction  of  the  collar  may  ensue.  The  operation  is  more  liable  to  be 
followed  by  leakage  or  by  partial  or  complete  obstruction  than  is  the 
operation  without  forceps.  Figs.  439  and  440  illustrate  the  use  of  Laplace's 
forceps  in  lateral  anastomosis. 

Consideration  of  Methods  of  Intestinal  Approximation. — The  best 
method  of  uniting  a  divided  intestine  is  a  matter  of  dispute.  The  Murphy 
button  can  be  applied  with  great  rapidity,  and  rapid  operation  is  of  immense 
importance  in  intestinal  work.  The  opening  left  by  the  Murphy  button  is 
small  (too  small,  some  surgeons  think),  but  it  does  not  strongly  tend  in  most 
instances  to  contract  because  the  tissue-diaphragm  is  separated  by  tissue- 
atrophy  and  not  by  inflammatory  gangrene.  Occasionally  the  opening  made 
by  the  button  contracts  and  gives  trouble;  occasionally  the  lumen  of  the 
button  blocks  with  feces;  occasionally  the  button  is  retained,  this  latter 
complication  being  especially  frequent  after  anterior  gastro-enterostomy.  If 
the  button  is  used,  liquid  food  should  be  given  soon  after  the  effect  of  the 
anesthetic  has  passed  off,  and  movement  of  the  bowels  should  be  obtained 
at  an  early  period  after  operation  and  frequent  evacuations  should  be  main- 
tained. The  button  gives  better  results  in  end-to-end  approximation  than 
in  lateral  anastomosis.  Laplace's  forceps,  O'Hara's  forceps,  the  decalcified 
bone  plates  of  Senn,  the  catgut  rings  of  Abbe,  the  catgut  strands  inside  of 
rubber  tubing  of  Brokaw,  Chaput's  button,  Allingham's  bone  bobbin,  Rob- 
son's  bone  bobbin,  Frank's  coupler,  Clark's  bobbin,  tubes  or  plates  of 
potato  and  carrot,  and  rings  or  plates  of  leather,  all  have  their  adherents. 
Of  mechanical  appliances  the  best  are  Murphy's  button,  the  bone  ring, 
Laplace's  forceps,  and  the  inflatable  rubber  cylinder.  Of  recent  years  many 
surgeons  have  abandoned  all  mechanical  aids,  and  have  returned  to  closure 
by  simple  sutures.  The  ideal  operation  is  without  mechanical  contriv- 
ances. But  such  devices  are  time-savers,  and  to  lessen  the  time  of 
operation  will  often  save  life.  What  method  to  follow  must  be  deter- 
mined in  each  particular  case  by  a  study  of  the  necessities  of  the  situation. 
Nevertheless,  it  may  be  possible  to  formulate  a  few  general  rules:  If  the 
condition  of  the  patient  is  excellent  and  the  bowel  is  in  a  fairly  healthy  con- 
dition well  above  and  well  below  the  seat  of  trouble,  end-to-end  approxima- 
tion should  be  performed  by  simple  circular  enterorrhaphy.  If  the  condition 
of  the  patient  is  such  as  to  make  haste  necessary,  use  a  Murphy  button. 
If  the  bowel  below  the  seat  of  trouble  is  much  contracted,  and  haste  is  neces- 
sary, do  not  use  a  Murphy  button,  but  use  Senn's  bone  plate,  or  Robson's 
bobbin.  If  haste  is  not  imperatively  necessary,  do  simple  enterorrhaphy. 
If  the  surgeon  is  obliged  to  join  a  very  much  distended  bowel  to  a  very 
much   contracted  bowel,  perform  end-to-side  approximation  (implantation) 


8i4 


Diseases   and   Iniuries  of  the  Abdomen 


with  the  bone  plate  of  Senn,  by  simple  suturing,  or  else  effect  side-to-side 
junction  by  the  method  of  Abbe.* 

Local  Intestinal  Exclusion. — This  operation  was  introduced  by  Salzer 
in  1 89 1.  It  excludes  the  fecal  current  from  a  portion  of  the  intestine.  In 
complete  exclusion  the  intestine  is  cut  through  above  and  below  the  diseased 
portion  and  the  ends  of  the  healthy  gut  are  united  to  each  other  or  the  end 
of  one  portion  of  gut  is  implanted  into  the  side  of  the  other.  Both  ends 
of  the  excluded  portion  may  be  fastened  to  the  skin,  making  a  double  fistula 
(Von  Eiselberg) ;  the  distal  end  or  the  proximal  alone  may  be  fastened  to 
the  skin,  the  other  end  being  closed  by  sutures  and  replaced  within  the  abdo- 
men. Sometimes  each  end  is  closed  and  dropped  back,  and  a  fistula  is 
made  in  the  middle  of  the  excluded  portion  to  permit  of  drainage.  Some 
operators  close  each  end  by  suture  and  drop  them  back,  and  do  not  drain  the 
excluded  portion ;  and  others  aim  at  the  same  end  by  suturing  together  the 
two  ends  of  the  excluded  part.    It  seems  wisest  to  suture  both  ends,  or  at  least 


Fig.  441. — Operation  of  complete  exclusion  of  the  cecum  :  a  and  b.  Lines  of  incision  ;  f  is  implanted 
into  c  ;  e  and  d  are  sutured  to  the  abdominal  wall. 


one  end  to  the  skin  (LeDentu,  in  "  Rev.  de  Gyn.  et  de  Chir.,"  Jan.  and  Feb., 
1899).  It  is  true  this  makes  a  permanent  fistula,  but  if  it  is  not  done  the 
loop  may  become  distended  with  secretion  containing  .virulent  bacteria,  a 
condition  which  may  ■  lead  to  perforation  and  death.  Exclusion  is  rarely 
performed  upon  the  small  intestine.  It  is  best  suited  to  the  large  intestine. 
If  it  is  done  at  all,  complete  exclusion  is  the  best  operation  (Fig.  441). 
Partial  exclusion  is  rarely  satisfactory.  The  operation  has  been  done  instead 
of  colostomy  in  cases  of  intestinal  oljstruction,  ]jut  it  is  best  suited  to  in- 
flammat(;ry  areas  or  tumors,  irremovable  because  of  adhesions  or  some 
other  cause.  After  the  operation  the  diseased  area  may  improve  because 
of  drainage  and  freedom  from  irritant  fecal  matter.  In  many  cases  it  can 
be  irrigated  through  the  fistula.  Sometimes  the  diseased  part  improves 
sufficiently  after  a  time  to  permit  of  exlirj^ation. 

*  See  the  di.scus.sion  of  ihi.s  .subject  by  the  late  J.  Greig  Smith  in  his  "  Abdominal  Sur- 
gery." 


Epiplopexy  8 1  5 

Surgical  Treatment  of  Ascites  Resulting  from  Hepatic  Cirrho= 
sis  (Epiplopexy). — The  portal  system  communicates  with  the  vena  cava  Idv 
means  of  a  number  of  small  vessels.  Normally  only  an  insigniticant  amount 
of  portal  blood  passes  by  this  route  to  the  general  circulation.  When 
cirrhosis  obstructs  the  flow  of  blood  through  the  liver,  the  radicles  of  com- 
munication between  the  portal  system  and  the  vena  cava  enlarge  and  an 
increased  amount  of  blood  is  thus  sent  direct  to  the  systemic  circulation. 
Adhesions  develop  between  the  parietal  peritoneum  and  some  of  the  viscera 
and  the  collateral  circulation  is  further  increased.  Thus,  Natnre  seeks 
to  prevent  ascites.  If,  however,  the  obstruction  to  the  passage  of  portal 
blood  becomes  so  great  that  "  the  collateral  circulation  is  no  longer  able 
to  maintain  an  equiHbrium  in  the  blood-pressure  in  the  portal  radicles, 
the  pressure  thus  rises  to  a  point  at  which  transudation  takes  place  and 
ascites  develops"  (M.  L.  Harris,  paper  read  before  Chicago  Medical  Society, 
Feb.,  1902).  The  theory  above  set  forth  is  the  "mechanical  theory";  but 
as  Harris  points  out,  increased  portal  tension  is  not  the  only  factor  concerned 
in  the  production  of  ascites,  chronic  inflammatory  changes  in  the  peritoneum 
being  "materially  instrumental"  in  maintaining  ascites  by  lessening  the 
absorbing  power  of  the  peritoneum.  Influenced  by  the  mechanical  theory 
of  causation,  Talma,  of  Utrecht,  devised  an  operation  to  cure  ascites  by 
establishing  more  free  communication  between  the  portal  system  and  the 
systemic  circulation.  Drummond  and  Morison  about  the  same  time  devised 
a  like  procedure  independently.*  In  some  cases  the  abdomen  has  been 
opened  and  the  omentum  sutured  in  the  abdominal  wound ;  in  others,  to 
the  anterior  abdominal  waU  (epiplopexy).  The  gall-bladder  may  be  sutured 
to  the  abdominal  wall  as  well  as  the  omentum.  The  Hver  and  spleen,  under 
surface  of  the  diaphragm,  and  parietal  peritoneum  about  the  liver  and  spleen 
are  usually  rubbed  harshly  with  a  piece  of  gauze.  Drainage  is  not  to  be 
used.  It  does  not  appear  to  contribute  any  favorable  chances  and  it  exposes 
the  patient  to  the  danger  of  infection. 

The  operation  ought  to  be  performed  early,  before  the  onset  of  chronic 
inflammation  of  the  peritoneum.  In  a  great  majority  of  cases  the  operation 
proves  futile,  and  not  uncommonly  death  soon  follows  from  compHcations  or 
because  the  disease  is  very  far  advanced.  In  exceptional  cases  the  operation 
proves  of  distinct  benefit. 

Harris,  in  the  paper  previously  quoted,  collected  46  cases.  Twenty- 
three  of  these  wer£  instances  of  alcoholic  cirrhosis.  Thirty  per  cent,  were 
dead  within  fourteen  days;  52  per  cent,  were  dead  within  two  months;  56 
per  cent,  were  dead  within  six  months.  Of  the  late  deaths,  ascites  had 
returned  in  all.  At  the  end  of  one  year  or  longer  13  per  cent,  had  recovered 
from  the  ascites.  The  remaining  30  per  cent,  were  either  unimproved  or 
were  said  to  be  improved  with  some  ascites. 

Of  the  group  of  mixed  cases  constituting  the  remainder  of  those  Harris 
collected,  10  per  cent,  were  dead  in  four  days,  25  per  cent,  were  dead  in 
four  months.  In  40  per  cent,  nb  improvement  took  place.  In  10  percent, 
the  report  was  too  early  to  give  any  information.  About  15  per  cent,  were 
free  of  ascites  after  one  year  or  longer,  and  5  per  cent,  were  cured  of  intestinal 
hemorrhage,  ascites  never  having  been  present. 

*Brit.  Med.  Jour.,  .Sept.  19,  1896. 


8i6  Diseases   and   Injuries  of  the  Abdomen 

Operation  for  Intussusception. — Air  distention  and  liydrostatic  pres- 
sure are  uncertain;  in  an  advanced  case  may  rupture  tlie  gut;  even  in  a 
recent  case  may  fail  or  may  reduce  the  bulk  of  the  intussusception,  but  not 
its  apex.  RusseU  ("IntercoL  Med.  Jour,  of  Australasia,"  March  20,  1902) 
alludes  to  the  uncertainty  of  the  method.  He  used  hydrostatic  pressure 
in  5  cases.  Two  died  and  two  recovered.  In  one  case  the  method  failed 
and  operation  was  then  performed.  It  is  safer  and  better  to  operate  early; 
but  if  the  conservative  plan  is  tried  and  fails,  operation  should  certainly 
be  done  at  once,  because  an  early  operation  enables  the  surgeon  to  easily 
effect  reduction,  and  also  because  early  complications  are  unusual.  The 
incision  is  made  in  the  mid-line  above  the  umbilicus.  The  surgeon  endeavors 
bv  manipulation  to  reduce  the  intussusception  by  pushing  it  back,  not  by 
pulhng  it  out.  If  the  intussusception  is  gangrenous,  perform  intestinal 
resection  and  circular  enterorrhaphy.  The  same  rule  maintains  when  malig- 
nant disease  of  the  gut  exists  (D'Arcy  Power).  It  is  inadvisable  to  make 
an  artificial  anus.  Maunsell's  operation  is  suited  to  cases  of  irreducible 
intussusception.  It  is  performed  as  follows:  A  longitudinal  incision  is  made 
in  the  intussuscipiens.  The  intussusception  is  gently  pulled  upon  and  is 
caused  to  protrude  from  this  opening.  Two  straight  needles  threaded  with 
horse-hair  are  passed  so  as  to  transfix  the  base,  and  one-fourth  of  an  inch 
above  the  needles  the  intussusception  is  cut  oft".  The  needles  are  carried 
completely  through,  the  sutures  are  hooked  up  in  the  middle  and  cut,  and 
the  two  ends  are  tied  on  each  side.  These  sutures  unite  the  intussusception 
to  the  intussuscipiens.  The  two  surfaces  are  now  carefuUy  approximated 
bv  sutures.  The  sutures  are  cut.  The  stump  is  replaced.  The  longitudinal 
incision  is  closed  with  Lembert  sutures.* 

Rus-sell  reports  16  cases  operated  upon:  12  recovered  and  4  died.  In 
every  one  of  the  4  fatal  cases  the  diagnosis  was  not  made  until  the  disease 
had  lasted  several  days.  In  2  of  the  successful  cases  the  diagnosis  was  made 
late  ("Intercolonial  Med.  Jour,  of  Australasia,"  March  20,  1902). 

Senn's  Operation  for  Fecal  Fistula. — Suture  the  opening  trans- 
versely with  Czerny  sutures  of  silk  in  order  to  prevent  infection.  Cleanse 
the  surface  thoroughly.  Open  the  abdomen  and  separate  the  edges  of  the 
bowel  from  the  parietes.  Deliver  the  portion  of  bowel  which  contains  the 
fistula  and  apply  Lembert  sutures  over  the  Czerny  sutures.  Another  method 
is  to  open  the  abdomen  above  the  fi.stula,  insert  the  fingers,  cut  out  the  skin 
and  tissues  around  the  fistula  in  an  elliptical  course,  leaving  them  attached 
to  the  bowel,  draw  the  bowel  from  the  abdomen,  pack  gauze  around,  remove 
the  tissues  adherent  to  it,  and  suture  the  fistula  transversely  (Hearn). 

Enterostomy  is  the  making  of  an  artificial  anus.  If  performed  in  the 
large  bowel,  it  is  called  colostomy.  In  some  cases  of  intestinal  obstruction 
it  is  necessary  to  open  the  small  intestine,  and  if  this  is  required  the  artificial 
anus  should  be  made  as  near  as  possible  to  the  cecum.  The  nearer  to  the 
stomach  it  is  made  the  more  apt  is  the  patient  to  die  of  lack  of  nourishment. 
The  anus  may  be  made  in  the  middle  line  or  in  the  right  iliac  region.  The 
bowel  is  fixed  and  opened  as  directed  under  colostomy.  In  acute  intestinal 
obstruction  it  may  be  necessary  to  open  the  bowel  at  once.  In  such  a  case 
Paul's  tube  is  very  useful.  Paul's  lube  is  made  of  glass,  is  bent  to  a  right 
*T.  Pickering  Pick,  Quarterly  Med.  Jour.,  Jan.,  1897. 


Inguinal   Colostomy 


817 


angle,  and  has  a  rim  near  each  end.  The  large  tube  is  used  in  the  colon,  the 
small  tube  in  the  small  intestine.  A  small  opening  is  made  in  the  intestine, 
the  tube  is  introduced,  and  is  tied  in  place  by  a  silk  suture  which  .surrounds 
all  of  the  coats  of  the  bowel,  a  quantity  of  feces  is  caught  in  a  basin,  a  rubber 
tube  is  fastened  to  the  gla.ss  tube,  and  fluid  feces  are  collected  in  a  bottle 
under  anti.septic  fluid.*  In  from  three  or  four  days  to  a  week  the  tube  be- 
comes loose  and  can  be  removed. 

Inguinal  Colostomy. — Maydl's  Operation. — In  this  operation  a  verti- 
cal or  oblique  incision  four  inches  long  is  made  over  the  portion  of  colon 
to  be  incised.  In  all  cases  where  it  is  possible,  do  a  left  inguinal  colostomy. 
In  right  inguinal  colostomy  it  is  difficult  to  deliver  the  bowel  as  in  Maydl's 
operation  because  of  shortness  or  absence  of  mesocolon  at  this  point  of  the 
colon.  Right  inguinal  colostomy  is  occasionally  performed  for  chronic 
amebic  dysentery.  It  puts  the  colon  at  rest  and  permits  of  free  irrigation. 
It  is  kept  open  until  the  dysentery  is  well  (Francis  W.  Murray,  "Annals 
of  Surgery,"  May,  1901).  It  has  also  been  employed  for  the  treatment 
of  ulceration  of  the  colon.  After  the  incision  on  the  left  side  the  colon  usually 
bulges  into  the  wound,  but  if  it  does 
not  it  may  easily  be  found  by  follow- 
ing with  the  finger  the  parietal  peri- 
toneum outward,  backward,  and  in- 
ward, the  first  obstruction  it  en- 
counters being  the  mesocolon. 
Draw  the  colon  out  of  the  wound 
until  its  mesenteric  attachment  is 
level  with  the  abdominal  incision. 
Push  a  glass  bar  through  a  slit  in 
the  mesocolon  near  the  bowel,  and 
wrap  the  ends  of  the  bar  with  iodo- 
form gauze  to  prevent  slipping.  In- 
stead of  the  bar,  a  piece  of  gauze  can 
be  employed,  or  a  bridge  of  skin  can 

be  made  under  the  bowel  by  suturing  the  two  skin  edges.  The  two  parts 
of  the  flexure  are  stitched  together  by  sutures  which  penetrate  to  and  catch 
the  submucous  coat  (Fig.  442).  Stitch  the  serous  coat  of  the  bowel  to  the 
parietal  peritoneum.  Whenever  possible,  wait  from  twenty-four  to  forty- 
eight  hours  before  opening.  The  colon  is  opened  by  the  cautery  or  by  scissors. 
If  the  artificial  anus  is  to  be  permanent,  make  a  transverse  incision  through 
the  bowel.  Cut  one-fourth  way  through  the  colon  when  it  is  first  opened, 
and  entirely  across  at  a  later  period.  If  the  artificial  anus  is  to  be  tem- 
porary, the  incision  is  longitudinal.  Maydl's  operation  has  great  advan- 
tages; it  is  quick,  certain,  reasonably  safe,  satisfactorily  prevents  fecal 
accumulation  below  the  opening,  and  is  rarely  followed  by  absolute  fecal 
incontinence.  In  many  cases  the  bowels  move  but  two  or  three  times  a  day. 
The  movements,  however,  come  quickly  with  but  little  warning.  Sometimes 
there  is  no  warning.  If  diarrhea  develops,  there  will  be  fecal  incontinence 
as  long  as  it  lasts.  An  air-pad  covered  with  gauze  and  held  in  place  by  a 
firm  belt  is  the  best  form  of  permanent  apparatus  to  wear. 

*Paul,  in  Liverpool  Med.-Chir.   lour.,  lulv,  1S92. 
52 


Fig.  442. — Inguinal  colu?>toniy  (alter  Zuckerkandl). 


8i8 


Diseases   and   Injuries  of   the  Abdomen 


Bodine's  Operation. — Bodine's  method  of  colostomy  permits  of  a  future 
restoration  of  the  fecal  current  by  an  easily  performed  anastomosis.  This 
surgeon  maintains  that  the  spur  after  colostomy  should  reach  to  and  remain 
at  the  level  of  the  skin,  a  condition  impossible  of  attainment  by  hanging  the 
bowel  over  a  rod  or  piece  of  gauze,  because  a  spur  thus  formed  is  not  thick 
and  rigid  and  is  inevitably  dragged  below  the  skin-level,  and  when  this  drag- 
ging has  taken  place  some  fecal  matter  will  pass  into  the  bowel  below  the 
artificial  anus.  Bodine  opens  the  abdomen,  sutures  the  parietal  peritoneum 
to  the  skin,  seeks  for  the  lesion,  and  draws  it  with  six  inches  of  healthy  bowel 
out  of  the  incision.  He  lays  the  limbs  of  the  loop  side  by  side.  He  inserts 
a  silk  stitch,  beginning  at  the  point  where  exsection  is  to  be  made,  and  for  six 
inches  unites  the  two  segments  close  to  their  mesenteric  borders.     The  loop 


Fig.  443.  —  Bodine's  method  of  colostomy, 
showing  one  side  of  the  loop  after  it  has  been  su- 
tured, passed  back  into  the  cavity  and  stitched 
into  the  abdominal  wound.  The  lesion  is  left  pro- 
truding, and  the  dotted  line  indicates  where  the 
protrusion  is  to  be  clipped  off. 


Fig.  444. — Bodine's  method  of  colostomy, 
showing  the  septum  to  be  divided  in  restoring 
the  fecal  current ;  Grant's  clamp  in  position 
for  the  division.  { In  permanent  colostomy  this 
septum  remains  as  a  rigid  and  effective  spur.) 


is  dropped  into  the  abdomen  until  the  beginning  of  the  suture  is  on  a  level 
with  the  skin,  and  at  this  point  it  is  fastened  to  the  abdominal  wound  with  a 
continuous  catgut  suture.  The  protruding  lesion  is  cut  off  along  the  dotted 
line  (Fig.  443).  The  artificial  anus  is  thus  established.  When  it  is  desired 
to  close  the  artificial  anus,  divide  the  septum  with  scissors  or  a  Grant  clamp, 
and  close  the  alxiominal  wound  (Fig.  444).* 

Lumbar  Colostomy. — Lumbar  colostomy  is  a  most  unsatisfactory  opera- 
tion. It  does  not  completely  intercept  the  fecal  current,  and  leaves  the 
patient  in  a  condition  of  wretched  discomfort  because  fecal  incontinence  is 
inevitable.  A  patient  who  has  had  lumbar  colostomy  performed  upon  him 
either  gets  no  benefit  becau.se  the  feces  pass  into  the  bowel  below  the  opening 
which  was  made  to  intercept  them  or  else  they  pour  out  of  the  opening  un- 
*  New  York  Polyclinic,  Feb.  15,  1897. 


Cholecystotomy 


819 


controlled,  making  the  poor  unfortunate  a  living  horror  to  himself  and  others. 
It  is  rarely  performed  at  the  jjresent  day. 

The  incision  for  Operations  upon  the  Qall=bladder  and  Bile= 
ducts. — I  have  employed  several  methods,  but  am  most  content  with  Bevan's 
incision  (Fig.  445).  The  primary  portion  of  the  incision  is  shaped  like  the 
italic  letter  /.  It  is  by  the  side  of  or  through  the  right  rectus  muscle,  and  is 
shown  by  the  double  line  in  Fig.  445.  The  primary  incision  is  used  for  ex- 
ploration and  cholecystotomy.  The  primary  incision  is  from  three  to  four 
inches  long,  and  the  extended  portions,  shown  by  heavy  lines  in  Fig.  445,  are 
added  if  required  (Arthur  Dean  Bevan,  "Annals  of  Surgery,"  July,  1899). 
This  incision  gives  most  satisfactory  exposure,  its  edges  can  be  separated 
without  tension,  and  it  injures  but  few  of  the  nerves  of  the  abdominal  walls. 

Cholecystotomy  is  the  oper- 
ation of  opening  the  gall-bladder 
in  order  to  remove  gall-stones  or 
secure  drainage.  It  is  performed 
in  cases  of  acute  cholecystitis;  in 
hydrops  of  the  gall-bladder;  in 
gall-stone  cases  in  which  jaun- 
dice has  lasted  for  four  weeks  or 
more,  and  in  colic  of  the  gall- 
bladder with  fever,  the  colic  having 
recurred  a  second  or  third  time 
(Carl  Beck).  The  operation  com- 
pleted in  one  stage  is  performed 
as  follows:  The  patient  is  placed 
recumbent  with  a  sand-pillow 
under  the  back.  Bevan's  incision 
is  made  (Fig.  445).  The  peri- 
toneum is  opened.  If  the  gall- 
bladder is  distended,  it  is  sur- 
rounded with  pads  and  aspirated, 
and  is  then  opened.  Gall-stones 
are  removed  by  forceps,  the  scoop, 

or  irrigation.       The    gall-ducts    are        Fig.   445.— incision  for  the  surgery  of  the  bile-tracts 

examined    by  the  fingers  external  (Bevan). 

to  them,  and  are  sounded,  if  pos- 
sible. If  a  stone  is  wedged  in  the  duct,  try  to  manipulate  it  back  into  the  gall- 
bladder. If  this  fails,  introduce  an  instrument  from  the  gall-bladder  and  break 
up  the  stone;  if  this  fails,  open  the  duct,  remove  the  stone,  and  close  the  incision 
in  the  duct  (A.  W.  Mayo  Robson).  The  only  way  to  be  certain  that  stones 
have  been  entirely  removed  from  the  cystic  duct  is  to  insert  a  finger  and  dilate. 
Sounds  are  unreliable.  After  the  removal  of  all  stones  and  fragments  pass  a 
rubber  tube  which  has  no  side  perforations  into  the  gall-bladder,  cut  it  off 
level  with  the  cutaneous  surface,  purse  up  the  cut  in  the  gall-bladder  around 
the  tube  by  means  of  a  catgut  suture,  and  suture  the  gall-bladder  to  the 
abdominal  aponeurosis.  If  sutured  to  the  skin,  a  permanent  biliary  fistula 
is  apt  to  follow.  It  will  seldom  follow  if  the  gall-bladder  is  sutured  to  the 
aponeurosis.     The  drainage-tube  can  usually  be  dispensed  with  in  from  one 


820  Diseases  and   Injuries   of  the   Abdomen 

week  to  ten  days.     It  should  not  be  dispensed  with  until  the  bile  becomes 
sterile. 

Some  surgeons  have  advocated  immediate  suture  of  the  gall-bladder  after 
removing  a  stone.  This  is  not  advisable,  because  small  calculi  may  be  in  the 
ducts,  and  minute  fragments  of  stone  are  often  left  in  the  bladder,  and  the 
drainage  will  remove  them  and  reheve  the  diseased  condition  of  the  gall-ducts 
and  bladder.  Further,  the  operation  with  immediate  suture  is  decidedly 
more  dangerous. 

It  is  advised  by  some  that  the  operation  of  cholecystotomy  be  performed 
in  two  stages.  First,  the  bladder  is  exposed  and  sutured  to  the  parietal  peri- 
toneum. When  adhesion  takes  place  the  gall-bladder  can  be  opened  without 
risk  of  infecting  the  general  peritoneal  surface.  Riedel  advocates  operation 
in  two  stages,  and  so  did  Christian  Fenger  in  certain  cases.  The  two-stage 
operation  is  objectionable  because  it  does  not  permit  of  satisfactory  explora- 
tion of  the  ducts.  The  fistula  which  is  left  by  cholecystotomy  usually  closes 
spontaneously,  but  may  not.  If  it  does  not  close  and  the  secretion  is  pure 
mucus,  it  is  evident  that  the  cystic  duct  is  absolutely  blocked  and  cholecys- 
tectomy should  be  performed. 

If  the  secretion  from  a  fistula  is  bile  and  the  common  duct  is  not  ob- 
structed, separate  the  edges  of  the  gall-bladder  opening  from  the  parietal 
peritoneum,  endeavoring  to  avoid  entering  the  abdominal  cavity,  and  close 
the  fistula  with  Lembert  or  Halsted  sutures.  If  the  secretion  is  bile  and 
the  common  duct  is  obstructed  permanently,  perform  cholecystenterostomy. 
In  214  cases  of  cholecystotomy  for  stone  in  the  gall-bladder,  in  the  cystic 
duct,  or  both,  Mayo  had  2  deaths  (Wm.  J.  Mayo,  "  Annals  of  Surgery," 
June,  1902). 

Cholecystenterostomy  consists  in  making  an  anastomosis  between 
the  gall-bladder  and  intestine,  preferably  the  duodenum.  It  is  employed  in 
cases  of  irremovable  obstruction  of  the  cystic  or  common  duct.  It  is  done 
chiefly  in  cases  of  malignant  obstruction.  It  is  not  a  suitable  operation  for 
gall-stones  impacted  in  the  common  duct  because  it  does  not  remove 
the  cause  of  trouble,  infection  of  the  bile-passages  is  apt  to  follow,  and 
the  fistula  is  liable  to  contract.  In  those  rare  cases  of  common  duct  obstruc- 
tion from  gall-stones,  in  which  the  gall-bladder  is  distended  and  the  patient  is 
desperately  ill,  it  may  be  done  (Robson).  In  such  a  case  Robson  attaches 
the  gall-bladder  to  the  colon  because  the  operation  is  easier  and  because  he 
considers  it  as  useful  as  the  attachment  to  the  duodenum.  Cholecystenter- 
ostomy can  be  done  most  rapidly  and  successfully  by  means  of  a  small  Murphy 
button.  Before  the  gall-bladder  is  incised  it  is  aspirated.  The  operation 
is  shown  in  Fig.  446,  and  is  similar  in  performance  to  intestinal  anastomosis. 

Cholecystectomy  is  the  extir])ation  of  the  gall-bladder.  Its  perform- 
ance may  be  demanded  by  the  existence  of  phlegmonous  inJiammation  or 
gangrene,  ulceration,  "in  chronic  cholecystitis  from  gall-stones  where  the  gall- 
bladder is  shrunken,  and  too  small  to  safely  drain,  and  where  the  common 
duct  is  free  from  obstruction  "  (A.  W.  Mayo  Robson),  in  empyema  with  greatly 
damaged  walls,  in  fistula  associated  with  irremediable  obstruction  of  the  cystic 
duct,  the  common  duct  being  free,  and  in  some  wounds. 

The  peritoneum  which  covers  the  gall-bladder  must  be  divided  just  below 
the  liver,  the  gall-bladder  is  dissected  from  the  liver  until  the  cystic  duct  is 


Choledochotomy 


821 


reached,  the  duct  is  Hgated  with  silk  and  divided,  the  stump  is  touched  with 
pure  carboHc  acid  and  is  covered  with  a  layer  of  peritoneum  fastened  by 
sutures  of  fine  silk.  Wm.  J.  Mayo  reports  t,;^  cases  of  cholecystectomv  with 
I  death  ("Annals  of  Surgery,"  June,  1902). 

Removal  of  the  Mucous  Membrane  of  the  Qall=bladder.— Mayo 

has  suggested  the  removal  of  all  the  mucous  membrane  of  the  gall-bladder 
as  an  occasional  substitute  for  cholecystectomy.  A  positive  objection  to  the 
operation  is  that,  as  glands  pass  from  the  mucous  coat  to  and  through  the 
muscular  coat,  it  is  impossible  to  absolutely  remove  the  mucous  membrane 
of  the  gall-bladder  alone  (Emil  Ries). 

Choledochotomy  is  the  operation  of  incising  the  common  duct  for  the 


Fig.  446.— Showing  method  of  holding  parts  while  approximating  a  Murphy  button  in  cholecystenter- 

osloniv. 


removal  of  a  stone.  It  is  also  called  choledocholithotomy.  It  was  first  per- 
formed by  Courvoisier  in  1890. 

Cases  upon  which  this  operation  is  done  are  often  deeply  jaundiced  and 
there  is  grave  danger  of  fatal  oozing  of  blood.  In  one  of  my  cases  this  hap- 
pened. The  patient  was  laboring  under  stones  in  the  common  duct,  asso- 
ciated with  cancer  of  the  head  of  the  pancreas.  If  jaundice  e.xists,  endeavor 
to  pre\ent  hemorrhage  by  employing  Robson's  plan:  Give  bv  the  mouth  from 
30  to  60  grains  of  chlorid  of  calcium  three  times  a  day  during  the  twenty-four 
or  forty-eight  hours  preceding  the  operation,  and  60  grains  by  enema  three 
times  a  day  for  the  forty-eight  hours  following  the  operation. 

When  ready  to  operate,  a  sand-bag  should  be  placed  under  the  lower  ribs. 
This  will  bring  the  liver  at  least  two  inches  nearer  to  the  abdominal  wound. 


822 


Diseases  and   Injuries   of  the   Abdomen 


The  abdominal  incision  must  be  longer  than  that  employed  for  cholecys- 
totomy.  The  pylorus  and  stomach  are  drawn  to  the  left,  the  colon  and  omen- 
tum are  drawn  downward,  and  the  liver  and  ribs  are  lifted  strongly  upward. 
"  The  operator  should  now,  after  having  separated  adhesions,  have  a 
good  view  of  the  common  duct  within  the  free  border  of  the  lesser  omentum, 
and  on  inserting  his  left  index-finger  into  the  foramen  of  Winslow,  or  on 
grasping  the  duct  between  the  index-tinger  and  thumb,  he  can,  without  diffi- 
culty, bring  the  duct  well  within  reach,  the  concretion  making  a  distinct  pro- 
jection." *  A  longitudinal  incision  is  made,  the  stone  is  removed,  and  a  probe 
is  introduced  into  the  duct  to  determine  whether  other  stones  are  present. 

If  possible,  suture  the  incision  in  the  duct.     This  procedure  is  rendered 
easier  by  the  use  of  Halsted's  hammer,  which  draws  the  duct  toward  the  sur- 
face and  keeps  it  under 
A  1   \  control  (Fig.  447). 

Interrupted  sutures 
of  fine  silk  are  used. 
The  muscular  and  serous 
coats  may  be  included  in 
each  suture,  and  over 
this  layer  Lembert  or 
Halsted  sutures  are  ap- 
plied. A  drainage-tube 
is  inserted  and  a  piece 
of  iodoform  gauze  is 
placed  upon  the  suture 
fine,  the  other  end  being 
brought  out  of  the  ab- 
dominal wound.  This 
precaution  is  taken  be- 
cause leakage  may  occur. 
If  it  is  found  impossible 
to  suture  the  wound  in 
the  duct,  carry  a  glass 
tube  down  to  the  opening  and  surround  it  with  iodoform  gauze,  or  make  an 
incision  into  the  right  loin  after  the  plan  of  Rutherford  Morison,  and  carry  a 
tube  into  the  right  kidney  pouch,  which  is  the  most  dependent  part  of  the 
peritoneal  cavity  when  the  patient  is  recuml)ent. 

Robson  ("Lancet,"  April  12,  1902)  has  performed  the  operation  of  chole- 
dochotomy  si.xty  times.  In  10  cases  he  manipulated  the  stone  back  into  the 
gall-bladder  and  removed  it  through  an  incision  in  that  viscus  by  means  of  a 
scoop.  The  above  manoeuver  is  impossible  unless  the  cystic  duct  is  dilated. 
In  30  cases  he  crushed  the  stones  between  his  finger  and  thumb,  but  this  is 
only  possible  when  the  stones  are  soft,  and  it  has  the  objection  that  it  may 
leave  fragments.  If  a  stone  is  lodged  in  t!ie  common  duct  and  cannot  be 
manipulated  back  into  the  gall-bladder,  choieclochotomy  should  be  per- 
formed. Robson's  mortality  in  60  cases  oi  choledochotomy  was  16.6  per 
cent.  Since  1900  his  mortality  has  been  7.1  per  cent.  Before  that  it  was 
23.8  per  cent. 

*A.  W.  Mayo  Robson's  "Treatise  on  Diseases  of  tiie  (^all-bladder  and  Bile-ducts." 


Fig.  447. — Suture  of  duct  over  Halsted"s  hammer. 


Splenectomy  823 

Duodenocholedochotomy  (McBumey's  Operation;  the  Transduodenal 
Route). — In  1891  McBurney  proposed  this  method  for  the  removal  of  gall- 
stones impacted  near  the  papilla  ("Annals  of  Surgery,"  Oct.,  1898).  Mc- 
Bumey's  original  suggestion  was  to  open  the  duodenum,  dilate  or  incise  the 
papilla,  remove  the  stone,  and  suture  the  duodenum.  When  the  stone  is  not 
impacted  at  the  outlet,  but  is  lodged  a  little  higher  up,  and  when  dense  adhe- 
sions render  access  by  the  ordinary  supraduodenal  route  difficult  or  impossible, 
the  anterior  wall  of  the  duodenum  may  be  opened  longitudinally,  the  posterior 
wall  of  the  duodenum  and  the  common  duct  incised  over  the  stone,  the  stone 
removed,  the  duodenum  and  common  duct  sutured  together  (internal  chole- 
dochoduodenostomy),  and  the  anterior  wall  of  the  duodenum  closed.  (See 
Charles  Otto  Thienhaus,  in  "Annals  of  Surgery,"  Dec,  1902.)  This  last- 
mentioned  modification  of  McBurney's  operation  was  first  performed  by 
Kocher.  Robson  opposes  the  transduodenal  route  and  says  he  has  abandoned 
it  because  of  the  danger  of  sepsis.  Thienhaus  ("Annals  of  Surgery,"  Dec, 
1902)  opposes  this  view  of  Robson  and  shows  that  in  29  operations  bv  the 
transduodenal  route  there  were  but  2  deaths. 

Splenectomy. — This  operation  is  performed  for  wounds  and  rupture 
of  the  spleen,  cysts,  floating  spleen,  and  non-leukemic  splenic  hypertrophy. 
It  should  not  be  performed  if  leukemia  exists.  In  42  cases  of  splenectomy 
for  leukemic  hypertrophy  collected  by  Fevrier  ("Rev.  de  Chir.,"  Nov.,  1901) 
there  were  only  4  recoveries,  and  in  2  of  these  cases  the  nature  of  the  trouble 
was  doubtful.  The  same  author  states  that  during  the  preceding  ten  years 
splenectomy  has  been  performed  for  malarial  spleen  eighty-six  times,  with  a 
mortality  of  17.4  per  cent.  It  is  to  be  noted  that  the  operation  does  not  cure 
the  malaria.  Fevrier's  statistics  show  16  splenectomies  for  idiopathic  en- 
largement of  the  spleen,  with  3  deaths.  In  46  splenectomies  for  rupture  of 
the  spleen  there  were  23  deaths  (Fevrier).  The  incision  is  from  the  anterior 
superior  spine  of  the  ilium  to  the  ribs  (Bryant).  The  peritoneum  is  opened. 
Adhesions  are  divided  between  ligatures.  If  the  spleen  is  adherent  to  the 
pancreas,  it  may  be  necessary  to  remove  a  fragment  of  the  last-named  organ 
(Esmarch).  Ligate  the  suspensory  ligament  and  cut  it.  Bring  the  spleen 
well  out  of  the  wound.  Surround  it  with  gauze  pads.  Transfix  the  pedicle 
with  stout  silk.  Tie  it  firmly,  leaving  the  ends  of  the  ligature  long  for  a  time, 
and  cut  through  the  pedicle  beyond  the  ligature.  Ligate  the  vessels  separately 
with  catgut.  Cut  off  the  long  ends  of  the  silk  hgature  and  drop  the  pedicle 
back,  unless  apprehensive  of  bleeding,  when  it  may  be  fastened  to  the  surface. 
The  wound  is  closed  without  drainage. 

About  two  weeks  after  the  removal  of  a  normal  spleen  certain  definite 
changes  happen  in  adults  but  not  in  children.  These  changes  last  for  sev- 
eral weeks  and  are  manifested  by  enlargement  of  the  lymph-glands,  tender- 
ness of  bones,  and  blood-changes,  loss  of  weight,  weakness,  thirst,  polyuria, 
abdominal  pain,  elevation  of  temperature,  and  rapid  pulse.*  Tizzoni  says 
that  these  changes  are  not  obvious  in  children,  because  in  them  compen- 
satory organs  act  at  once,  whereas  in  adults  compensatory  organs  act 
slowly  and  with  painful  effort.  Such  symptoms  are  noticed  when  the 
spleen  is  removed  because  of  a  wound  or  a  rupture,  but  rarelv  after  re- 
moval of  a  diseased  spleen.     It  is  likely  that  compensating  organs  become 

*Ballance,  in  Practitioner,  April,  1S9S  ;    II.  Martyn  Jordan,  in  Lancet,  Jan.  22,  1S98. 


824  Diseases  and   Injuries   of   the   Abdomen 

active  when  the  spleen  is  diseased,  and  consequently  are  in  full  operation 
when  such  a  spleen  is  removed.  After  partial  splenectomy  these  conditions 
do  not  arise  (Jordan).  Changes  can  be  prevented  after  splenectomy  by  the 
administration  of  tablets  of  extract  of  spleen  and  red  bone-marrow  (Ballance). 

Abdominal  Hernia  or  Rupture. — This  condition  is  a  protrusion  of 
peritoneum  containing  at  times  or  permanently  any  viscus  or  part  of  a  viscus 
from  the  abdominal  cavity.  MacCormac  says  the  term  implies  that  the  pro- 
truded viscus  is  covered  with  integument;  hence  a  protrusion  of  viscera 
through  a  wound  does  not  constitute  a  hernia.  A  hernia  has  three  parts — 
the  sac,  the  sac-contents,  and  the  sac-coverings.  The  sac  is  formed  of  peri- 
toneum. A  congenital  sac  is  due  to  developmental  defect,  and  is  found  only 
in  the  inguinal  or  umbihcal  region.  An  acquired  sac  is  due  to  intra-abdominal 
pressure  bulging  the  peritoneal  covering  of  an  abdominal  ring  and  con- 
verting it  into  a  pouch.  The  sac  comprises  a  body,  a  neck,  and  a  mouth. 
A  sac  once  formed  is  almost  certain  to  persist,  because  it  adheres  by  its  outer 
surface  to  surrounding  parts,  and  hence  the  sac  of  a  hernia  is  usually  irreduc- 
ible even  when  the  contents  are  reducible.  The  neck  of  the  sac  is  due  to  the 
constriction  through  which  the  sac  passes;  it  becomes  furrowed  and  folded, 
and  the  adhesion  of  these  folds  causes  thickening  and  rigidity.  Hernia  of  the 
bladder  or  of  the  cecum  may  have  no  sac,  or  but  a  partial  sac.  The  contents 
oj  the  sac  depend  chiefly  on  the  situation,  a  portion  of  the  ileum  being  the 
usual  contents.  The  colon,  the  stomach,  the  great  omentum,  the  bladder, 
and  other  structures  may  enter  the  hernial  sac.  An  enterocele  contains  only  in- 
testine; an  epiplocele  contains  only  omentum;  an  entero-epiplocele  contains 
both  omentum  and  intestine;  a  cystocele  contains  a  portion  of  the  bladder. 
The  coverings  0}  the  sac,  which  vary  with  its  situation,  will  be  set  forth  during 
the  consideration  of  special  forms  of  hernia.  In  old  hernite  the  layers  are 
never  distinct,  fat  and  muscle  waste,  tissues  adhere,  and  the  skin  stretches 
and  atrophies.  The  sac  of  an  old  hernia  occasionally  becomes  tuberculous, 
and  the  disease  may  remain  local  in  the  hernial  sac  or  spread  to  the  general 
peritoneum.  Renault  tells  us  that  tuberculosis  oj  a  hernia  is  made  manifest 
by  increase  in  size,  pain  on  pressure,  and  loss  of  body-weight. 

Causes  oj  Hernia. — Hernia  is  a  common  trouble.  According  to  Berger, 
in  1000  people  4.4  per  cent,  suffer  from  hernia.  It  occurs  at  all  periods  of 
life,  and  hereditary  predisposition  sometimes  seems  to  exist.  The  male  sex  is 
three  times  as  liable  to  hernia  as  the  female  sex.  That  increase  of  intra- 
abdominal tension  is  a  common  cause  in  children  has  been  amply  demon- 
strated. (See  Hernia  in  Childhood,  page  846.)  Excessive  length  of  the 
mesentery  has  been  assigned  as  a  cause.  In  some  instances  a  mass  of  fat 
forms  and  advances  before  the  hernia,  and  seems  to  bear  a  causative  relation 
to  it.  Lucas-Championniere  explains  this  as  follows:  when  a  person  begins 
to  take  on  fat,  it  is  deposited  not  only  under  the  skin,  but  also  in  the  omentum, 
mesentery,  and  subperitoneal  tissues.  This  semifluid  fat  is  easily  influenced 
by  pressure.  The  deposit  of  fat  within  the  abdomen  lessens  the  size  of 
that  cavity,  intra-abdominal  pressure  is  increased,  and  fat  protrudes  at  any 
weak  spot  in  the  wall.  The  protruding  mass  of  fat  adheres  to  and  makes 
traction  upon  the  peritoneum,  and  this  membrane  is  drawn  upon  to  form 
a  sac,  and  the  sac  is  surrounded  by  fat.  This  method  of  formation  is  fre- 
quently  noticed   in   umbilical   hernia-,   and   occasionally   in   inguinal   hernix-. 


Reducible   Hernia  825 

Any  laborious  occupation  predisposes  to  rupture.  Any  condition  which 
weakens  the  abdominal  wall  predisposes  (muscular  relaxation  from  ill-health, 
relaxation  of  abdominal  walls  following  the  termination  of  pregnancy,  the 
removal  of  a  large  tumor,  or  tapping  for  ascites,  and  wounds  or  abscesses 
of  the  abdominal  wall).  The  common  cause  is  repeated  muscular  effort 
which  increases  intra-abdominal  tension  (straining  at  stool,  coughing,  lifting 
weights,  jumping,  the  sexual  act,  and  straining  to  make  water).  The  sac 
exists  for  a  longer  or  shorter  time  before  the  hernia  enters  it.  The  sac  of 
a  congenital  hernia  is  present  at  birth;  the  sac  of  an  acquired  hernia  gradu- 
ally forms.  A  sac  may  exist  for  years  and  yet  remain  empty.  When  bowel 
or  omentum  enters  it  from  some  strain  or  effort,  the  parts  were  long  prepared 
to  receive  the  extruded  mass.  This  extrusion  may  occur  gradually;  it  may 
occur  suddenly.  If  it  occurs  suddenly,  the  sufferer  believes  that  his  hernia 
was  formed  then  and  there,  but,  as  a  matter  of  fact,  the  extrusion  of  bowel 
or  omentum  and  its  entrance  into  the  sac  are  but  the  last  of  a  long  series 
of  antecedent  and  preparatory  changes.  Finally,  a  hernia  appears,  and 
usually  does  so  during  effort.  In  rare  cases,  traumatism  may  cause  a  hernia 
immediately,  no  sac  existing  before  the  accident.  It  does  so  in  the  in- 
guinal region  bv  stretching  or  tearing  the  internal  ring,  the  inguinal  canal 
at  once  enlarging.  Such  a  condition  is  a  true  traumatic  hernia,  traumatism 
being  the  sole  cause  and  not  simply  the  exciting  cause. 

The  old  and  erroneous  idea  was  that  a  hernia  was  always  formed  by 
tearing  of  the  peritoneum;  hence  the  term  rupture.  An  ordinary  non-trau- 
matic hernia,  when  the  bowel  suddenly  and  for  the  first  time  enters  the  sac, 
is  the  seat  of  some  pain,  but  the  pain  is  not  disabling  and  the  lump  disappears 
on  recumbency.  In  many  cases  the  bowel  or  omentum  gradually  finds  a 
way  into  the  sac,  and  in  such  cases  pain  is  usually  trivial  and  often  absent. 
In  true  traumatic  hernia  there  is  violent  pain,  collapse,  vomiting,  inability 
to  walk  'and  stand,  and  the  mass  does  not  return  to  the  belly  on  recumbency, 
but  must  be  reduced  by  taxis  or  operation.  All  congenital  hernia^  are  due 
to  structural  defects.  Hernis  are  divided  clinically  into  reducible,  irreducible, 
incarcerated,  inflamed,  and  strangulated. 

Reducible  Hernia. — In  this  form  of  hernia  the  contents  of  the  sac  can 
be  reduced  into  the  abdominal  cavity.  At  a  known  hernial  opening  the 
patient  has  a  smooth  enlargement  (narrower  above  than  below),  which 
began  to  grow  above  and  extended  downward.  A  distinct  neck  can  often 
be  felt.  In  enterocele,  straining,  lifting,  or  standing  enlarges  the  mass;  the 
protrusion  becomes  smaller  and  may  disappear  on  lying  down;  cough  causes 
impulse  or  succussion;  the  protrusion  is  elastic,  and  may  be  tympanitic 
on  percussion,  and  on  reduction  the  mass  suddenly  disappears  and  there 
is  a  gurgling  sound.  In  epiplocele  the  mass  is  often  irregular  and  com- 
pressible, and  feels  boggv  rather  than  elastic;  musKTular  effort  does  not  have 
much  influence  in  enlarging  it;  impulse  on  coughing  is  slight;  percussion 
gives  a  dull  note,  and  reduction  is  accomplished  gradually  and  produces 
no  gurgling  sound.  In  entero-epiplocele  some  parts  of  the  mass  are  smooth, 
ekstic,  and  tympanitic,  others  are  dull  on  percussion,  irregular,  and  flabby; 
but  the  diagnosis  of  this  especial  form  is  uncertain.  The  victims  of  reducible 
hernia  complain  of  some  pain  on  exertion,  of  dyspepsia,  and  often  of  con- 
stipation. 


826  Diseases   and   Injuries   of  the   Abdomen 

\Mien  a  hernia  is  beginning  to  form  there  is  often  premonitory 
uneasiness.  The  patient  complains  of  muscular  pain  in  the  lower 
abdomen,  and  this  condition  may  exist  for  weeks  before  it  is  recognized 
that  a  hernia  is  present.  An  inguinal  hernia  can  be  recognized  before 
it  protrudes  from  the  external  ring.  The  tip  of  the  finger  is  inserted 
in  the  ring  and  the  patient  is  asked  to  cough.  If  a  hernia  has  entered 
the  canal,  succussion  will  be  detected  on  coughing.  In  a  healthy  man  the 
external  ring  should  admit  the  tip  of  the  httle  finger,  but  not  the  end  of  the 
index-finger.  If  the  end  of  the  index-finger  can  be  made  to  enter  the  ring, 
that  aperture  is  dilated;  and  even  if  there  is  no  hernia  in  the  canal,  in  future 
a  hernia  will  probably  descend.  In  a  man,  if  the  surgeon  desires  to  examine 
the  ring,  he  inverts  the  skin  of  the  scrotum  over  the  finger  and  carries  the 
finger  to  or  in  the  ring.  When  the  hernia  first  appears,  there  may  be  pain, 
faintness,  and  some  sick  stomach;  but  often  there  is  no  pain  or  any  discom- 
fort. 

Treatment  oj  Reducible  Hernia. — Palliative  Treatment.  —  Prevent  con- 
stipation, forbid  sudden  strains  and  violent  exercise,  and  order  a  truss. 
The  continued  employment  of  a  truss  in  young  persons  may  bring  about 
a  cure.  The  day  truss  should  be  applied  before  rising  in  the  morning 
and  be  removed  after  lying  down  at  night,  when  a  light  truss  should  be 
substituted.  A  special  truss  is  apphed  before  bathing.  In  very  fat  people 
there  is  always  trouble  in  adjusting  a  truss.  A  femoral  hernia  is  more  difficult 
to  keep  reduced  than  an  inguinal  hernia.  In  a  hernia  in  which  the  gut  is 
replaceable,  but  a  portion  of  omentum  is  irreducible,  it  is  difficult  to  maintain 
reduction  of  the  gut  with  a  truss,  and  an  operation  should  be  performed. 
In  an  oblique  inguinal  hernia  the  pad  of  the  truss  fits  over  the  internal  ab- 
dominal ring;  in  a  direct  inguinal  hernia,  over  the  external  abdominal  ring; 
in  a  femoral  hernia,  over  the  femoral  ring  at  the  level  of  Gimbernat's  liga- 
ment. MacCormac's  method  of  measuring  for  a  truss  is  as  follows:  in  either 
inguinal  or  femoral  hernia  start  the  tape  from  the  lower  part  of  the  hernial 
opening,  carry  it  up  to  the  anterior  superior  iliac  spine  of  the  same  side, 
then  take  it  around  the  body,  one  inch  below  the  crest  of  the  ilium,  to  the 
other  anterior  superior  iliac  spine,  and  then  to  the  upper  part  of  the  hernial 
opening.*  A  well-fitting  truss  will  keep  the  hernia  up  even  when  the  patient 
sits  in  a  position  to  relax  the  abdominal  walls  and  coughs  and  strains.  A 
truss  is  always  uncomfortable  at  first,  but  a  person  usually  becomes  accus- 
tomed to  it.  It  should  be  kept  scrupulously  clean,  and  borated  talc  powder 
should  Ijc  dusted  upon  the  skin  under  the  pad  at  least  once  a  day.  A 
truss  which  does  not  keep  the  hernia  up  or  which  causes  pain  does  harm. 
Too  strong  a  spring  tends  to  enlarge  the  hernial  orifice,  and  thus  aggravates 
the  case.  Even  after  an  apparent  cure  with  a  truss  the  instrument  must 
be  worn  for  a  long  time. 

Radical  treatment  seeks  to  permanently  cure  by  plugging  the  mouth  of 
the  sac  or  by  obliterating  the  canal  of  descent.  Radical  operations  should 
be  performed  when  a  strangulated  hernia  is  operated  upon,  in  ordinary 
cases  of  reducible  hernia  in  which  a  truss  is  very  painful  or  does  not  keep 
the  bowel  up,  in  most  cases  of  irreducible  hernia,  and  in  any  case  which 
has  occasional  attacks  of  obstruction.     It  used  to  be  believed  that  a  cure 

*Treves'.s  "  Matmal  of  Surgery,"  "  Hernia." 


Reducible   Hernia 


!27 


would  fail  if  the  subject  was  under  three  years  of  age,  but  Coley  and  others 
have  proved  that  it  is  a  very  successful  operation  in  children.  It  is  rarely 
recommended  under  the  age  of  four,  because  in  two-thirds  of  the  cases  a 


Fig.  44S. — Inguinal  hernia  of  large  size  (duration  sixteen  years). 


Fig.  449. — The  case  shown  in  figure  44S,  six  months  after  operation. 


truss  will  cure.  It  is  advised  after  the  age  of  four  when  a  truss  has  failed, 
when  there  is  irreducible  omentum,  or  when  there  is  a  reducible  hydrocele 
which  prevents  the  truss  from  folding  (Wm.  B.  Coley,  in  "  Annals  of  Surgery, " 


828  Diseases  and   Injuries   of  the   Abdomen 

June,  1903).  The  radical  operation  is  almost  without  danger  in  properly 
selected  cases  and  is  one  of  the  most  successful  of  surgical  procedures.  We 
are  justified  in  doing  the  operation  upon  an  individual  under  fifty  years 
of  age  and  free  from  complications,  purely  to  relieve  him  or  her  from  the 
annoyance  of  wearing  a  truss.  If,  however,  a  patient  is  sixty  years  of  age 
or  over,  and  a  truss  keeps  the  hernia  up  satisfactorily,  the  operation  should 
not  be  performed  unless  it  is  demanded  by  some  complication.  Organic 
diseases  of  the  heart,  lungs,  and  kidneys  are  contraindications.  Enormous 
herniae  are  unfavorable  for  operation.  Restoration  is  difficult  or  impossible, 
the  forcible  handling  produces  much  shock,  and  recurrence  is  to  be  expected. 
Restoration  is  difficult  or  impossible  because  the  abdominal  cavity  has  con- 
tracted and  holds  with  difficulty  or  cannot  hold  the  huge  hernia.  As  J.  L. 
Petit  said,  the  hernia  has  forfeited  the  right  of  domicile.  In  an  operation 
for  an  enormous  hernia  a  great  quantity  of  omentum  will  require  removal, 
and  it  may  be  necessary  to  resect  a  considerable  piece  of  intestine.  If  we 
decide  to  operate  upon  an  enormous  hernia,  treat  the  patient  some  time 
before  with  the  object  of  making  him  lose  flesh.  The  absorption  of  mesenteric 
fat  lessens  intra-abdominal  pressure.  That  operation  may  succeed  in  such 
cases  is  shown  by  Figs.  448  and  449.  In  any  operation  for  the  radical  cure  of 
inguinal  hernia  always  remember  that  the  bladder  may  be  part  of  the  hernia, 
and  be  on  the  lookout  for  it.  As  a  rule,  it  is  covered  with  cellular  fat,  which 
differs  in  color  and  consistence  from  omental  fat  and  from  other  fat  which 
may  be  found  about  a  hernia.  It  was  the  author's  misfortune  on  two  occa- 
sions to  open  a  bladder  in  operating  upon  an  inguinal  hernia.  In  each  case 
the  bladder  was  sutured,  and  both  patients  recovered. 

The  success  of  an  operation  for  the  radical  cure  of  a  hernia  depends 
upon  the  attainment  of  primary  union.  Primary  union  is  favored  by  wearing 
gloves  while  operating;  by  cutting  the  parts  with  a  sharp  knife  instead  of 
tearing  them  with  a  dissector;  by  removing  some  fat  and  any  superfluous 
tissue-fragments;  by  tying  the  stitches  firmly,  but  not  tightly  (a  tight  stitch 
causes  necrosis  and  creates  a  point  of  least  resistance);  by  careful  closure; 
by  dressing  with  pressure;  and  by  keeping  the  patient  recumbent  for 
three  weeks. 

A  truss  is  not  to  be  used  after  operation.  Wm.  B.  Coley("Annals  of  Surg.," 
June,  1903)  has  operated  upon  1075  cases  of  inguinal  and  femoral  hernia. 
In  his  report  he  does  not  consider  operations  performed  within  the  last  six 
months,  and  so  presents  a  study  of  1003  cases.  Of  these,  937  cases  were 
inguinal,  66  cases  were  femoral.  In  the  1003  cases,  647  were  traced  and 
were  found  well  from  one  to  eleven  years  aftef  operation;  705  were  well 
six  months  to  eleven  years;  460  were  well  from  two  to  eleven  years.  If 
the  patient  is  well  one  year  after  operation  he  will  probably  remain  well. 
This  is  proved  by  Coley's  study  of  relapses,  an  investigation  which  shows 
that  65  per  cent,  of  relapses  occur  within  six  months  of  operation  and  80  per 
cent,  within  the  first  year.  Only  13!  per  cent,  occur  from  one  to  two  years, 
and  only  6§  per  cent,  after  two  years.  Coley  had  2  deaths  in  1075  cases 
(less  than  one-fifth  of  i  per  cent.).  After  Bassini's  operation  there  are  about 
I  per  cent,  of  relapses. 

Lannelongiie's  Method. — Lannelongue  has  for  certain  ca.se.s  returned  to 
the  old  injection  plan,  using  a  10  per  cent,  solution  of  chlorid  of  zinc  instead 


Reducible  Hernia 


829 


of  white  oak  bark.  Tlie  hernia  is  first  reduced  and  is  held  up  by  an  assistant 
who  closes  the  internal  ring  with  a  finger,  and  also  holds  the  cord  aside. 
Several  injections  of  10  minims  each  are  thrown  in  the  region  of  the  internal 
pillar,  the  region  of  the  external  pillar,  and  into  the  canal  behind  and  outside 
of  the  cord.  The  surgeon  must  be  careful  that  no  zinc  solution  escapes 
into  the  subcutaneous  tissue.  The  effect  of 
the  chlorid  of  zinc  is  to  cause  the  formation 
of  quantities  of  fibrous  tissue.  It  is  scarcely 
to  be  expected  that  a  cure  so  produced  will 
be  permanent  in  an  adult,  though  it  may  be 
in  a  child. 

Macewen's  Operation  for  Inguinal 
Hernia. — The  instruments  required  in  this 
operation  are  scalpels,  a  blunt,  straight  bis- 
toury, a  dry  dissector,  a  grooved  director,  scissors,  a  hernia  director  (Fig.  450, 
b),  hernia  needles  (Fig.  450,  a),  dissecting  forceps,  toothed  forceps,  hemo- 
static forceps,  an  aneurysm  needle,  blunt  hooks,  half-curved  needles,  needle- 
holder,  and  chromicized  catgut  sutures.    The  patient  lies  recumbent,  the  thigh 


Fig.  450. — A,  Hernia  needles;  E,  hinged 
liernia  director. 


Fig.  451. — Macewen's  operation  for  radical  cure  of  inguinal  hernia  a  Stripping  of  the  sac  ;  B, 
purse-string  suture  ;  c,  fastening  the  purse-string  suture  ;  d,  passing  and  i  tMii"  the  sutures  for  the 
internal  ring. 


being  abducted  and  partly  flexed  and  resting  on  a  pillow  beneath  the  knee. 
The  bowel  is  reduced,  and  an  incision  three  inches  long  is  made  in  the  direction 
of  the  inguinal  canal,  the  center  of  the  incision  corresponding  to  the  external 
ring.     The  sac  is  freed  from  its  attachments  below  and  is  lifted  up.     The  sur- 


830 


Diseases  and   Injuries   of  the   Abdomen 


geon  introduces  a  linger  into  the  inguinal  canal  and  separates  the  sac  from  the 
cord  and  from  the  walls  of  the  canal,  and  then  carries  the  finger  through  the 
internal  ring  and  separates  the  peritoneum  for  one  inch  about  the  periphery 
of  this  aperture  (Fig.  451,  a).  A  chromicized  catgut  stitch  is  fastened  to 
the  lowest  portion  of  the  sac,  and  is  passed  through  the  sac  several  times, 
so  that  pulling  on  the  stitch  will  purse  the  sac  (Fig.  451,  b).  The  free  end 
of  this  stitch  is  carried  through  the  internal  ring  into  the  belly,  and  is  pushed 
out  through  the  abdominal  muscles  one  inch  above  the  internal  ring,  the 
skin  being  pushed  aside  so  as  to  escape  perforation  by  the  needle.  The 
thread  is  tightened  so  as  to  fold  up  the  sac  and  pull  it  into  the  belly.  This 
plugs  the  ring  (Fig.  451,  c).  The  thread  is  handed  to  an  assistant  to  keep 
tight  until  the  sutures  are  introduced  into  the  ring,  when  the  sac  is  perma- 
nently anchored  by  taking  several  stitches  in  the  external  oblique  muscle. 
A  strong  catgut  suture  is  passed  with  a  Macewen  needle  through  the  conjoined 
tendon  from  below  upward,  the  ends  of  this  suture  being  carried  through 
Poupart's  ligament  and  the  outer  border  of  the  internal  ring  from  within 
outward.  This  suture  is  tightened,  and  closes  the 
internal  ring.  The  external  ring  is  sutured  and  the 
skin  is  stitched  (Fig.  451,  e). 

In  congenital  hernia  the  sac  is  divided  in  its  mid- 
dle, and  the  lower  part  is  closed  by  stitches  of  chromic 
catgut,  forming  a  tunica  vaginalis.  The  upper  part  of 
the  sac  is  slit  posteriorly  to  permit  the  escape  of  the 
cord,  and  is  closed  by  stitches  of  chromic  catgut. 
The  operation  is  finished  as  in  the  acquired  form 
(Fig.  452).  After  Mace  wen's  operation  the  patient 
should  stay  in  bed  for  at  least  three  weeks,  and  must 
not  work  for  eight  or  nine  weeks.  Workmen  after 
this  operation  should  always  wear  for  a  time  a  pad 
and  a  spica  bandage.  Children  require  no  pad.  Never 
apply  a  truss,  as  strong  pressure  will  produce  atrophy  of  the  curative  scar. 

Bassini's  Operation  for  Oblique  Inguinal  Hernia. — (See  E.  Wyllys  An- 
drews, in  "Med.  Record,"  Oct.  28,  1899,  who  describes  from  personal  ob- 
servation how  Bassini  does  his  operation.  I  have  drawn  upon  his  description 
in  the  following  section.)  Bassini's  operation  displaces  the  spermatic  cord 
from  the  old  canal  and  places  it  in  a  new  canal,  and  this  new  canal  is  oblique. 
The  instruments  employed  are  the  same  as  for  Macewen's  operation,  except- 
ing the  special  needles,  which  are  not  needed.  Curved  and  rounded  needles 
are  employed  to  insert  the  stitches.  The  suture  material  is  kangaroo-tendon 
or  chromicized  catgut.  Silk  or  silver  wire  is  apt  to  make  trouble — it  may 
be  long  after  the  operation.  The  patient  is  placed  supine  with  the  thighs 
extended.  An  incision  is  made  parallel  to  Poupart's  ligament  and  extending 
from  the  external  ring  to  a  point  external  to  the  internal  ring.  The  incision 
is  about  one  and  one-half  inches  above  the  ligament  and  is  from  five  to  seven 
inches  in  length.  By  this  incision  the  aponeurosis  of  the  external  oblique 
and  the  pillars  of  the  external  ring  are  exposed.  All  bleeding  is  arre.sted, 
the  aponeuro.sis  is  inci.sed  in  the  direction  of  its  fibers  and  from  above  down- 
ward, and  the  inguinal  canal  is  opened.  The  aponeurosis  of  the  external 
oblique  is  dissected  up  with   a  blunt  instrument  until   Poupart's  ligament 


Fig.  452. — Macewen's 
operation  for  the  radical 
cure  of  congenital  hernia. 


Reducible   Hernia 


S31 


is  exposed.  We  speak  of  this  ligament  as  the  shelf.  A  mass  containing 
the  sac  of  the  hernia,  the  cord,  the  cremaster  muscle,  and  considerable  fat 
is  lifted  up.  Bassini  employs  blunt  dissection.  Coley  advocates  the  use  of 
the  knife.  Masses  of  fai  and  usually  the  cremaster  muscle  are  removed. 
The  sac  is  isolated  first  at  its  neck  and  the  neck  is  stripped  from  the  inner 
aspect  of  the  internal  ring  for  the  distance  of  four-fifths  of  an  inch.  The 
object  of  this  stripping  is  to  permit  the  removal  of  the  sac  at  a  high  level. 
High  removal  obviates  the  leaving  of  a  funnel-shaped  depression  of  peri- 
toneum. Such  a  depression  predisposes  to  relapse.  The  sac  is  opened  at 
the  fundus,  the  interior  is  investigated,  and  if  the  contents  are  reducible 
they  are  restored  to  the  abdominal  cavity  and  the  neck  of  the  sac  is  clamped 
high  up.  If  adherent  masses  of  omentum  are  found,  the  adhesions  are 
separated,  bleeding  is  arrested,  and  the  omentum  is  restored  to  the  abdo- 
men unless  it  is  in  a  hard  and  thick  mass,  when  it  is  tied  off  and  removed. 


Fig.  453. — A-c,  Bassini's  operation  for  the 
cure  of  inguinal  hernia. 


Fig.  454. — Bassini's  operation  (deep  sutures),  show- 
ing extra  suture  above  tlie  cord. 


Bassini  ties  off  the  neck  of  the  sac  above  the  clamp  with  a  strong  ligature 
of  silkworm-gut.  If  the  sac  is  large  and  thick,  he  also  threads  both  ends 
of  a  ligature  upon  a  needle,  passes  the  strand  through  the  stump,  and  ties 
around  over  the  first  loop.  (See  E.  Wyllys  Andrews,  "Med.  Record, "  Oct. 
28,  1899.)  Dr.  Coley  and  many  other  operators  prefer  to  tie  oft"  the  sac  with  a 
catgut  suture  rather  than  with  silkworm-gut  or  silk.  It  is  my  usual  custom  to 
employ  black  silk,  catching  it  to  prevent  slipping  by  running  a  stitch  through 
the  wall  of  the  neck  of  the  sac.  After  ligating  the  neck  of  the  sac  the  sac  is  cut 
across  and  removed.  The  cord  is  now  lifted  out  of  the  way  (Fig.  453,  .a),  the 
inner  surface  of  Poupart's  ligament  is  exposed  by  retraction,  and  the  deep 
sutures  are  passed  (Fig.  453,  b).  Bassini  uses  silk  which  has  been  boiled 
in  glycerin.  Most  American  operators  use  kangaroo-tendon  or  chromic 
catgut.  The  sutures  nearest  to  the  pubes  are  inserted  first.  The  first  suture 
— and  sometimes  also  the  second — includes  part  of  the  rectus  sheath  and 
rectus  muscle.     Each  stitch  includes  the  internal  oblique  and  transversalis 


832 


Diseases   and    Injuries   of   the   Abdomen 


muscle  in  the  upper  edge  and  the  shelf  of  Poupart's  hgament  below  the 
lower  margin,  and  from  four  to  six  stitches  are  passed  behind  the  cord.  The 
last  stitch  narrows  the  internal  ring  so  that  it  fits  tightly  around  the  cord  (E. 
Wyllys  Andrews,  "Med.  Record,"  Oct.  28,  1899).  Coley's  rule  for  passing 
this  suture  is  to  insert  it  so  "  that  it  just  touches  the  lower  border  of  the  cord 
when  the  latter  is  brought  vertically  to  the  plane  of  the  abdomen"  ("Annals 
of  Surgery,"  June,  1903).  Coley  always  places  a  suture  above  the  cord, 
and  believes  it  tends  to  prevent  relapse  (Fig.  454).  The  sutures  are  tied 
from  above  downward.  The  cord  is  laid  upon  this  new  floor  and  the  apon- 
eurosis of  the  external  oblique  is  sutured  over  it.  Coley  uses  a  continuous 
suture  of  tine  kangaroo-tendon  and  closes  the  skin  with  interrupted  sutures 
of  catgut.     Drainage  is  not  used.     The  wound  is  covered  with  a  roll  of 


Fig.  455. — The  skin  incision,  retractors  in  the 
lower  angle  of  the  wound  dislocating  the  opening 
in  the  skin  and  subcutaneous  fat  downward,  ex- 
posing the  aponeurosis  of  the  external  oblique 
and  external  ring.  The  dotted  line  within  the 
wound  represents  the  direction  of  the  division  of 
aponeurosis  of  external  oblique  (Bloodgood). 


Fig.  456. — The  aponeurosis  of  external  ob- 
lique has  been  divided  and  retracted,  uncovering 
the  internal  oblique  muscle  and  inguinal  canal. 
The  lines  on  the  muscle  represent  the  direction 
and  extent  of  the  division.  The  dotted  line  in  the 
inguinal  canal  is  the  direction  and  extent  of  the 
division  of  the  coverings  of  sac  (Bloodgood). 


iodoform  gauze  and  some  pieces  of  sterile  gauze,  and  compression  is  made 
by  strips  of  adhesive  plaster,  and  a  piece  of  adhe.sive  plaster  run  from  one 
thigh  to  the  other  acts  as  a  shelf  for  the  testicles  to  rest  upon.  The  adhesive 
plaster  is  overlaid  with  dry  gauze,  and  this  is  covered  with  absorbent  cotton 
and  the  dressing  is  retained  in  place  by  a  firm  .spica  of  the  groin  (Coley's 
dressing).  The  wound  is  dressed  on  the  seventh  day  anrl  the  patient  is 
kept  in  bed  for  two  weeks  and  is  allowed  to  get  about  in  two  and  one-half 
weeks  to  three  weeks,  wearing  a  bandage  until  four  weeks  after  operation. 
In  this  operation  some  surgeons  treat  the  sac  as  in  Macewen's  operation, 
carrying  out  the  rest  of  the  procedure  as  directed  above.  In  a  pure  Bassini 
operation  the  funnel-.shaped  depression  in  the  peritoneum  as  the  point  of 
emergence  of  the  cord  may  remain  and  predi.spose  to  hernia,  but  the  use  of 
Macewen's  plan  for  treating  the  .sac  obviates  this. 


Reducible   Hernia 


833 


Halsted's  Operation  (as  described  by  J.  C.  Bloodgood,  in  "Johns  Hop- 
kins Hosp.  Reports,"  vol.  vii). — The  skin  incision  is  not  parallel  to  Poupart's 
ligament,  but  at  an  angle  of  25 
degrees  to  it  (Fig.  455).  Pou- 
part's hgament  is  well  exposed 
to  within  2  cm.  of  the  pubic  spine. 
The  aponeurosis  of  the  external 
oblique  muscle  is  divided.  Free 
the  lower  border  of  the  internal 
oblique  muscle  and  divide  the 
edge  of  the  muscle  at  a  right 
angle  to  its  fibers  (Fig.  456),  and 
as  far  as  possible  from  the  hnea 
semilunaris.  The  coverings  of 
the  sac  near  the  neck  are  picked 
up  with  mouse-toothed  forceps 
and  are  divided.  The  division 
of  the  fasciae  is  continued  from 
the  neck  of  the  sac  downward 
toward  the  pubes.  The  sac  is 
then  lifted  from  the  inguinal 
canal  and  it  brings  with  it  "the 

larger  bundle  of  veins  and  the  vas  deferens"  (Fig.  457).     The  sac  is  separated 
from  the  veins  and  the  vas  with  a  knife  or  scissors,  and  the  separation  is  carried 


F'g-  457— The  internal  oblique  muscle  and  ihe 
coverings  of  the  sac  have  been  divided,  the  sac  with 
the  veins  and  vas  deferens  are  drawn  out  of  the  wound 
preparatory  to  the  excision  of  the  sac  and  the  ligation 
and  excision  of  the  veins  (Bloodgood). 


Fig.  458. — The  method  of  excision  of  veins  in 
operations  for  hernia  and  varicocele.  The  vas 
deferens  and  its  "  immediate  "  vessels  and  the 
mesocord  have  not  been  disturbed  (Bloodgood). 


Fig.  459. — The  insertion  of  the  deep  silver 
wire  sutures,  one  above  and  four  below  the 
cord.  The  veins  have  been  ligated  and  ex- 
cised. The  mesocord  has  been  torn  gently  in 
its  center  only  (Bloodgood). 


to  and  beyond  the  neck  of  the  sac.     In  "  certain  cases  the  larger  bundle  of  veins 
is  separated  from  the  vas  deferens,  ligated  and  excised  "  (Fig.  458).      Whether 
53 


S34 


Diseases  and   Injuries   of   the   Abdomen 


the  veins  are  excised  or  not,  the  sac  is  opened,  its  contents  reduced,  the  opening 

into  the  peritoneal  cavity  closed 
with  a  continuous  silk  suture,  and 
the  excess  of  sac  excised.  During 
the  entire  operation  the  vas  and 
its  vessels  "  should  be  handled 
very  little,  and  should  not  be  torn 
from  their  bed  in  the  inguinal 
canal."  Every  point  of  bleed- 
ing should  be  hgated.  At  this 
stage  the  vas  is  gently  picked  up 
and  a  blunt-pointed  hook  is  used 
to  tear  the  mesocord.  The  freed 
vas  is  lifted  into  the  upper  angle 
of  the  divided  internal  oblique 
muscle,  and  is  held  there  until  the 
sutures  are  inserted.  The  deep 
sutures  of  silver  wire  are  next 
inserted.  Usually  five  are  needed. 
The  upper  one  is  passed  first. 
These  sutures  are  shown  in  Fig. 
459.  The  cord  emerges  from  the 
cut  in  the  internal  oblique  muscle 
between  the  first  and  second  su- 
tures. Sutures  No.  i  and  No.  2 
pierce  the  mesocord,  but  care  is 
taken  to  see  that  they  do  not  in- 
jure the  vas  or  its  vessels.  Each  suture  is  drawn  upon  and  twisted  about  six 
times.  The  cut  twisted  ends  are 
caught  with  forceps  and  turned  in. 
The  skin-wound  is  closed  with  a 
subcuticular  stitch  of  silver  wire.  It 
is  covered  with  silver  foil  and  dry 
gauze,  and  often  a  plaster-of-Paris 
bandage  and  splints  are  used,  "the 
splints  extending  from  just  above 
the  knee  to  near  the  costal  margins." 
Halsled^s  Operation  plus  Blood- 
good's  Method  oj  Transplanting  the 
Rectus  Muscle. — (See  Jos.  C.  Blood- 
good,  in  "Johns  Hopkins  H()S]>. 
Reports,"  vrji.  vii.)  When  the  con- 
joined, tendcjn  is  very  thin  or  oblit- 
erated, the  ordinary  operation  is  not 
enough.  Insufficiency  of  the  con- 
joined tendon  is  known  to  exist  when 

a  finger  does   not  meet  any  obstrUC-  Fig.  461.— The  tnuisplanted  rectus  included  by 

tion  after  passing  through  the  exter-      ^'^*  ^''='-:''  ^"'"'■^^-    '"  ''^'^  iiiusu-atio..  the  cord  ha.s 

.  :  .  Ijeeii  excised  in  order  to  demonstrate  the  operation 

nal  abdominal  ring,  but  can   be  in-      more  clearly  (Bioodgood). 


Fig.  460.— The  method  of  transplanting  the  rectus 
muscle.  The  sac  has  been  e.xcised  and  the  peritoneal 
cavity  closed ;  internal  oblique  muscle  has  been  di- 
vided, the  rectus  exposed  and  transplanted  ;  at  this 
stage  the  wound  is  ready  for  the  deep  sutures.  This 
illustration  shows  how  perfectly  the  transplanted 
rectus  muscle  lines  the  lower  half  of  the  wound 
(Bioodgood). 


Reducible   Hernia 


835 


Gntenor 
Oup.Spi 
Process 


Fig.  462.- 


Ferguson's  operation  :  The  semilunar  skin  incision 
("Jour.  Am.  Med.  Assoc"). 


troduced  for  some  distance  into  the  abdominal  cavity  (Bloodgood).  To  meet 
this  condition  of  affairs,  Bloodgood  devised  "  a  plastic  operation  on  the  rectus 
muscle,  bringing  this  muscle  down  and  suturing  it  with  the  other  available  tis- 
sue to  Poupart's  ligament  and  to  the  aponeurosis  of  the  external  oblique  from 
the  arch  of  the  pubis  up  to 
the  position  of  the  trans- 
planted cord"  (Bloodgood, 
in  previously  mentioned  re- 
port). The  first  steps  of 
the  operation  are  identical 
with  those  previously  de- 
scribed, but  before  the  in- 
sertion of  the  deep  stitches 
the  rectus  sheath  is  exposed 
and  divided  in  the  direction 
of  the  muscle-fibers,  from 
the  pubic  insertion  upward 
for  5  cm.  The  muscle 
bulges  from  the  cut  and  is 
caught  with  silk  sutures 
(Fig.  460).  Deep  sutures 
are   now  introduced  as  in 

Halsted's  operation,  except  that  they  include  the  rectus  and  its  sheath  (Fig. 
461).  The  operation  is  completed  as  is  Halsted's.  I  have  performed  this 
operation  a  number  of  times  with  entire  satisfaction. 

Kocher's   Operation. — Kocher  exposes   the   aponeurosis   of   the   external 

oblique,  makes  a  small  in- 
cision through  the  aponeu- 
rosis above  and  external  to 
the  internal  ring,  and 
draws  the  sac  through  this 
incision  and  sutures  it  in 
place. 

Fowler^ s  operation  is  as 
follows:  an  incision  is  made 
parallel  with  Poupart's 
ligament  from  the  spine  of 
the  pubis  to  the  level  of  the 
internal  ring,  and  a  flap  is 
turned  up.  The  inguinal 
canal  is  opened  and  the 
sac  and  cord  isolated.  The 
sac  is  opened,  its  contents 
reduced,  it  is  cut  off,  and 
its  edges  grasped  with  forceps.  The  deep  epigastric  arterv  and  vein  are  sought 
for,  each  is  tied  in  two  places  and  divided  between  the  ligatures.  The  index- 
finger  is  introduced  into  the  belly,  and  on  this  as  a  guide  the  floor  of  the 
canal  is  divided  (transversalis  fascia,  subserous  tissue,  and  peritoneum). 
The  cord  is  placed  in  the  peritoneal  cavity.     The  edges  of  the  opening  are 


LX-A-SSP 


Fig.  463. — Ferguson's  operation  :  Flap  turned  back  expos- 
ing the  aponeurosis  and  the  sac  of  the  hernia  ("Jour.  Am. 
Med.  Assoc"). 


836 


Diseases  and   Injuries   of  the   Abdomen 


sutured  so  that  broad  serous  surfaces  are  approximated,  through-and-through 
sutures  being  passed  from  side  to  side.  The  cord  is  brought  out  at  the  inner 
end  of  the  incision,  the  lower  angle  of  the  cut  being  at  such  a  level  that  the 
cord  curves  upward  and  forward  as  it  leaves  the  abdomen.     The  inguinal 

canal,  the  gap  in  the  apo- 
neurosis, and  the  skin- 
wound  are  closed.* 

Ferguson'' s  Operation. — 
In  studying  a  number  of 
recurrences  after  operation, 
A.  H.  Ferguson  observed 
that  a  hernial  protrusion  is 
apt  to  return  at  the  upper 
and  outer  portion  of  the 
scar,  above  the  cord  and 
near  Poupart's  ligament. 
When  he  operated  upon 
relapsed  cases,  he  discov- 
ered a  slit  of  the  aponeu- 
rosis of  the  external  ab- 
dominal wall,  through 
which  the    sac  and    some 


Fig.  464. — Ferguson's  operation  :   Dealing  with  the  sac  and  its 
contents  ("Jour.  Am.  Med.  Assoc"). 


A.s.sp, 


fat  protruded.  In  order 
to  determine  the  cause  of  the  failure  of  these  operations,  he  thought  it  proper 
to  make  a  semilunar  incision,  and  raise  a  flap  of  skin,  fascia,  and  aponeurosis 
of  the  external  oblique.  On  doing  this,  he  was  surprised  to  find  an  angle 
between  the  lower  border  of  the  internal  oblique  muscle  and  the  inner  aspect 
of  Poupart's  hgament  absolutely  unprotected  by  the  internal  oblique  or 
the  transversalis  muscle. 
In  some  cases  this  angle 
extended  upward  and  out- 
ward to  the  anterior  supe- 
rior ihac  spine.  He  there- 
fore determined  positively 
that  the  cause  of  a  rup- 
ture's returning  in  this 
angle  after  an  operation 
for  radical  cure  is  deficient 
origin  of  the  internal  ob- 
lique muscle  and  of  the 
transversalis  mu.scle  at 
Poupart's  ligament.  He 
is  now  persuaded  that  in 
all  ca.ses  of  hernia  there  is 
a  deficient  origin  of  these 

muscles,  and  he  has  demonstrated  the  same  thing  in  a  series  of  dissections  in 
the  inguinal  regicm.  Ferguson  describes  his  operation  as  follows  ("Jour. 
Am.  Med.  Assoc,"  July  i,   1899):    He  begins  his  incision  over  Poupart's 

■■^' Annals  of  Surgery,  Nov.,  1897. 


ig.  465. — Ferguson's   operation  :  Suture  of  the  slack  in  the 
transversalis  fascia  ("Jour.  Am.  Med.  Assoc"). 


Reducible    Hernia 


837 


ligament,  an  inch  and  a  half  below  the  anterior  superior  iliac  spine,  carries  it 
inward  and  downward  in  a  semilunar  curve,  and  termmates  it  over  the  con- 
joined tendon,  near  the  pubic  bone.  This  incision  goes  down  to  the  aponeu- 
rosis of  the  external  oblique,  and  the  flap,  with  its  fat  and  fascia,  is  turned 
downward  and  outward  (Figs.  462  and  463).  The  next  step  is  to  incise  the  ex- 
ternal abdominal  ring  to  the  intercolumnar  fascia  and  separate  the  longitudinal 
fibers  of  the  external  oblique  over  the  inguinal  canal  to  beyond  the  internal  ring, 
at  a  point  nearly  opposite  the  anterior  superior  spine  of  the  ilium.  Any  trans- 
verse fibers  that  may  be  encountered  are  severed.  The  separated  aponeurosis 
of  the  external  obHque  muscle  is  then  retracted.  One  has  then  brought  into 
view  the  contents  of  the  inguinal  canal,  the  hernial  sac  and  its  adhesions,  the 
spermatic  cord,  the  ilio-inguinal  nerve,  the  internal  abdominal  ring,  the  sub- 
serous fat,  the  cremaster  muscle,  the  conjoined  tendon,  the  internal  obhque 
and  its  deficient  origin  at  Poupart's  hgament,  the  transversalis  fascia,  and  the 
internal  surface  of  Poupart's  ligament.  The  sac  is  now  dissected  from  the 
cord  and  the  internal  ring.  It  is  opened  and  its  contents  are  inspected  and 
properly  dealt  with.  It  is 
tied  high  up  and  cut  off, 
and  the  stump  is  dropped 
into  the  abdomen  (Fig. 
464).  If  the  sac  is  congeni- 
tal it  is  divided  into  two 
parts;  the  distal  portion  is 
used  to  make  a  tunic  for  the 
testicle,  and  the  proximal 
portion  is  treated  as  above 
directed.  The  cord  is  not 
disturbed,  and  it  is  beyond 
doubt  that  Ferguson  is 
right  in  saying  that  the 
testicle  frequently  comes  to 
harm  after  operations  that 
disturb  the  cord.  The 
veins    in  the   cord  should 

not  be  touched,  unless  a  varicocele  also  exists.  Any  excessive  quantity 
of  subserous  adipose  tissue  should  be  removed.  The  next  step  in  the 
operation  is  to  restore  the  structures  to  their  normal  position;  and  one 
should  remember  that  in  the  transversalis  fascia  is  the  internal  ring.  In 
hernia  the  internal  ring  is  large  and  the  transversalis  fascia  bulges  out- 
ward; one  must,  therefore,  take  up  the  slack  in  this  fascia  and  make  a  well- 
fitting  ring  for  the  cord,  by  means  of  a  catgut  suture,  either  interrupted 
or  continuous  (Fig.  465).  After  this  has  been  accomplished,  the  internal 
oblique  and  transversalis  muscle  are  sutured  to  the  internal  aspect  of  Poupart's 
ligament,  after  the  lower  borders  of  the  muscles  have  been  freshened  and 
Poupart's  ligament  has  been  scarified.  The  sutures  must  be  carried  two- 
thirds  of  the  way  down  Poupart's  ligament,  which  is  about  the  normal  ori- 
gin of  this  muscle  in  the  female  (Fig.  466).  The  next  step  is  to  suture  the 
edges  of  the  divided  aponeurosis  of  the  external  oblique;  this  restores  the  ex- 
ternal abdominal  ring.     The  skin-flap  is  then  carefully  sutured. 


Fig.  466. — Ferguson's  operation  :  Suture  of  the  internal 
oblique  and  of  the  transversalis  muscle  to  the  internal  aspect 
of  Poupart's  ligament  ("  Jour.  Am.  Med.  Assoc"). 


8^8 


Diseases  and   Injuries   of  the   Abdomen 


Radical  Cure  of  Umbilical  Hernia. — The  resuhs  of  operations  for  um- 
bilical hemiae  have  not  been  satisfactory.     Recurrences  are  frequent.     This 

_  is  probably  due  to  the  fact 

that  most  of  the  subjects 
are  fat,  and  that  the  mus- 
cles are  thin  and  flabby. 
The  usual  operation  may 
be  thus  described:  Make 
an  eUiptical  incision 
through  the  skin  around 
the  mass.  Endeavor  to 
separate  the  sac  from  the 
superficial  tissues.  If  this 
cannot  be  done,  open  the 
sac  and  separate  it  from 
the  contents.  Even  if  the 
sac  can  be  stripped  from 
the  skin,  always  open  it 
and  separate  the  contents. 
Return  any  bowel  which 
may  be  present,  and  do 
not  forget  that  there  may 
be  a  smaU  portion  of  bowel 
completely  encased  in 
omentum.  Tie  into  seg- 
ments and  cut  off  the 
superfluous  omentum  and  return  the  stump  into  the  belly.  Excise  the 
umbihcus  (omphalectomy).  Suture  the  peritoneum  with  a  continuous  catgut 
suture.  Close  the  musculofascial 
wall  with  two  layers  of  interrupted 
kangaroo-tendon  sutures  or  one 
layer  of  silver  wire  mattress  sutures. 
Close  the  skin  by  interrupted  sutures 
of  silkworm-gut  or  a  subcuticular 
stitch. 

Mayors  Operation. — This  is  a 
distinct  improvement  on  the  older 
operation.  Mayo  believes  that  the 
defect  in  the  old  operation  is  that 
the  recti  muscles  are  naturally  sep- 
arated at  the  level  of  the  umbilicus 
and  in  bringing  the  recti  together 
we  have  virtually  performed  muscle 
transplantation,  and  these  thin  mus- 
cles are  of  no  great  value  in  prevent- 
ing relapse,  and  in  a  large  hernia  it 

is  not  even  possible  to  cover  the  gap  by  muscle.  Mayo  now  operates  as 
follows:  Transverse  elliptical  incisions  are  made  around  the  umbihcus  and 
hernia  and  the  base  of  the  protrusion  is  exposed  (Fig.  467).     The  surface 


Fig.  467. — Mayo's  operation  for  the  radical  cure  of  umbilical 
hernia.     Exposure  of  hernia  and  lateral  incisions. 


Fig.  468. — Mayo's  operation  for  the  radical  cure  of 
umbilical  hernia.     Peritoneum  sutured. 


Reducible   Hernia 


839 


of  the  aponeurosis  is  cleared  for  one  and  one-half  inches  around  the  neck 
of  the  sac.  The  fibrous  and  peritoneal  coverings  of  the  hernia  are  divided 
by  a  circular  incision  around  the  neck  of  the  sac.     Intestine  is  freed  from 


Fig.  469. — Mayo"s  operation  for  the  radical  cure 
of  umbilical  hernia.     Aponeurosis  sutured. 


Fig.  470.— Mayo's  operation  for  the  radical 
cure  of  umbilical  hernia.  Aponeurosis  sutured 
second  time  with  eut  sutures. 


adhesions  and  placed  within  the  abdomen.  Omentum  is  hgated  and  re- 
moved vi^ith  the  sac.  The  margins  of  the  ring  are  grasped  and  overlapped 
in   order  to   indicate  in  which  wav   it   can   be   most  easily  done.      Thus 


Fig.  471. — Fabricius's  operation  for  the  radical  cure  of  femoral  hernia.    Neck  of  sac  shown.     Sac 
cut  away.     Dotted  line  shows  line  of  separation  of  Poupart's  ligament  and  fascia  lata  (Fowler). 


is  the  direction  of  the  closure  indicated.     An  incision  is  made  through  the 
fibrous  and  peritoneal  coverings  of  the  ring,  one  inch  or  more  transversely 

on  each  side,  and  the  peritoneum  is  stripped  from  the  under  surface  of  the 


840 


Diseases  and    Injuries   of   the   Abdomen 


upper  flap.     Several  mattress  sutures  of  silver  wire  are  introduced  one  inch 
above  the  edge  of  the  upper  flap  and  are  carried  through  the  margin  of  the 


Fig.  472. — Fabricius's   operation    for  femoral    hernia.      Fascia   lata   turned    back,   exposing    crural 
sheath  and  origin  of  pectineus  muscle  (Fowler). 


Fig- 473— F<^^"■ici'Js's  operation  for  femoral  hernia.  Crural  sheath  and  \fssels  retracted  and  kan- 
garoo-tendon sutures  applied  to  Poupart's  ligament  and  origin  of  pectineus,  ready  for  tying.  Two 
sutures  arc  placed  in  |)osilion  to  approximate  the  pillars  of  the  external  ring  (Fowler). 


lower  flap;  sufficient  traction  is  made  to  permit  of  the  closing  of  the  perito- 
neum with  a  continuous  catgut  suture  (Fig.  468).  When  this  has  been  accom- 
plished, the  silver  wire  sutures  arc  flrawn  so  as  to  slide  the  lower  flap  into 


Incarcerated  or  Obstructed   Hernia  841 

the  pocket  between  the  peritoneum  and  the  under  surface  of  the  upper  flap 
(Figs  469  and  470).  The  free  margin  of  the  upper  fiap  is  fixed  by  catgut 
sutures  to  the  aponeurosis  and  the  superficial  incision  is  closed  as  usual. 

Radical  Cure  oj  Femoral  Hernia. — Cheyne  ligates  the  neck  of  the  sac, 
stitches  the  stump  to  the  abdominal  wall,  dissects  out  a  flap  from  the  pec- 
tineus  muscle,  stitches  this  flap  to  Poupart's  ligament  and  to  the  abdomin;  1 
wall,  and  thus  fills  up  the  crural  canal.  Bassini  makes  an  incision  parallel 
with  Poupart's  ligament,  ties  the  neck  of  the  sac,  cuts  below  the  ligature, 
and  returns  the  stump  into  the  belly.  He  attaches  by  deep  sutures  Poupart's 
ligarnent  to  the  pectineal  aponeurosis  as  high  up  as  the  pectineal  eminence, 
the  cord  or  round  ligament  being  drawn  out  of  the  way.  Superficial  sutures 
are  passed  between  the  pubic  portion  and  the  iliac  portion  of  the  fascia  lata. 

The  Operation  oj  Fabricins. — The  operation  of  Fabricius  is  verv  satis- 
factory. It  is  performed  as  follows:  An  incision  is  begun  over  the  pubic  spine 
and  is  carried  outward  for  five  inches  parallel  with  Poupart's  ligament.  The 
sac  is  exposed,  isolated,  and  opened,  and  its  contents  are  reduced,  its  neck  is 
ligated,  the  sac  is  cut  off,  and  the  stump  is  dropped  back  (Fig.  471).  An  in- 
cision is  now  made  below  Poupart's  ligament  so  as  to  separate  this  structure 
and  the  fascia  lata,  and  the  flap  of  fascia  is  turned  down  (Fig.  472).  The 
crural  sheath  and  the  vessels  are  retracted  outward.  The  surgeon  is  careful 
not  to  injure  the  obturator  artery  and  vein.  The  origin  of  the  pectineus 
muscle  is  sutured  to  Poupart's  ligament.  The  lower  stitches  include  the 
periosteum  of  the  horizontal  ramus  of  the  pubes  as  well  as  the  beginning  of 
the  muscle  (Fig.  473).  Care  must  be  taken  in  passing  some  of  them  to  avoid 
injuring  the  deep  epigastric  vessels.  When  these  stitches  are  tied  the  femoral 
canal  is  obhterated.  The  flap  of  fascia  lata  is  sutured  to  the  aponeurosis 
of  the  external  oblique,  and  the  skin  is  sutured. 

Irreducible  Hernia. — The  swelling  in  irreducible  rupture  presents  the 
usual  evidences  of  hernia,  shows  an  impulse  on  coughing,  but  cannot  be  re- 
placed in  the  abdomen.  Sometimes  a  portion  is  reducible  and  a  portion  is 
irreducible.  A  hernia  may  become  irreducible  because  of  the  size  of  the  mass, 
because  of  adhesions,  or  because  of  excessive  growth  of  omental  fat.  An  irre- 
ducible hernia  is  liable  to  be  bruised  and  to  cause  much  distress  and  pain, 
and  is  always  a  menace  to  Hfe  because  of  the  danger  of  obstruction  and  strangu- 
lation. It  was  formerly  the  custom  to  support  a  small  irreducible  hernia  by  a 
hollow  padded  truss,  but  at  present  operation  is  advised.  A  large  hernia  of 
this  variety,  if  operation  is  refused,  must  be  carried  in  a  bag  truss.  The  patient 
must  not  take  very  active  exercise,  must  keep  the  bowels  regular,  and  must 
live  upon  a  plain  diet.  Most  cases  of  irreducible  hernia  should  be  treated 
by  operation. 

Incarcerated  or  Obstructed  Hernia.— Obstruction  takes  place  by  the 
damming  of  feces  or  of  undigested  food,  the  fecal  current  being  arrested, 
but  the  blood-current  in  the  wall  of  the  bowel  being  undisturbed.  Incarcera- 
tion is  commonest  in  irreducible  hernia,  umbilical  hernia,  and  during  the 
existence  of  constipation.  The  hernia  enlarges  and  becomes  tender,  painful, 
and  dull  on  percussion;  pressure  diminishes  it  in  size;  it  is  irreducible,  but 
still  presents  impulse  on  coughing.  The  abdomen  is  somewhat  distended 
and  painful;  there  are  nausea,  constipation,  and  not  unusually  slight  vomit- 
ing.    Constitutional  disturbance  is  trivial  and  constipation   is  not   absolute, 


842  Diseases  and   Injuries  of   the   Abdomen 

gas  at  least  usually  passing.  Vomiting  is  not  fecal.  The  treatment  is  rest 
in  bed  in  a  position  to  relax  the  belly,  an  ice-bag  over  the  hernia,  and  a  httle 
opium  for  pain.  Do  not  give  a  particle  of  food  for  twenty-four  hours;  when 
the  active  symptoms  subside  give  an  enema,  and  after  this  acts  a  dose  of 
castor  oil.  Do  not  employ  taxis,  as  bruising  the  bowel  may  produce 
strangulation.  If  improvement  does  not  rapidly  occur,  operate.  Prompt 
operation  saves  the  patient  from  the  danger  of  strangulation  and  cures 
the  hernia. 

Inflamed  Hernia. — Inflammation  of  a  hernia  is  local  peritonitis  due 
to  injury  of  an  irreducible  hernia.  The  mass  becomes  tender,  painful, 
and  hot.  In  enterocele  much  fluid  forms;  in  epiplocele  the  mass  becomes 
hard.  The  hernia  cannot  be  reduced;  there  is  constipation,  often  vomiting, 
usually  fever,  but  the  mass  still  shows  impulse  on  coughing.  Vomiting  is 
not  fecal.  Some  gas  is  usually  passed  through  the  bowels.  Constitutional 
symptoms  are  slight.  The  treatment  usually  recommended  is  rest  in  bed 
with  abdominal  relaxation,  an  ice-bag  to  the  tumor,  a  small  amount  of  opium 
by  the  mouth  if  pain  is  severe,  an  enema,  and,  after  this  acts,  a  saline.  In 
an  inflamed  hernia  there  is  great  danger  of  strangulation,  and  operation 
should  be  performed  in  preference  to  relying  upon  the  conservative  plan. 

Strangulated  hernia  is  a  condition  in  which,  if  the  hernia  contains 
bowel,  not  only  is  the  fecal  circulation  arrested,  but  the  circulation  of  blood 
in  the  bowel-wall  is  also  arrested.  The  bowel  is  irreducible  and  obstructed, 
and  the  blood  ceases  to  circulate.  If  the  hernia  contains  omentum,  the 
omental  vessels  are  tightly  constricted.  Strangulation  is  commonest  in  old 
inguinal  ruptures  in  active,  middle-aged  men,  and  is  more  frequent  in  entero- 
celes  than  in  epiploceles.  It  may  be  due  to  entry  into  the  sac  of  more  intestine 
or  omqntum,  which  has  been  forced  down  by  sudden  movement  or  violent 
effort.  It  may  be  due  to  active  peristalsis  or  to  congestion,  and  it  may  arise 
from  inflammation  or  from  incarceration.  The  constriction  is  usually  at 
the  neck  of  the  sac,  in  the  outside  tissues,  or  even  in  the  sac  itself.  In  an 
hour-glass  hernia  the  constriction  is  in  the  body  of  the  sac.  Adhesions  within 
the  sac  may  cause  strangulation.  Spasmodic  contraction  of  the  tissues 
about  the  neck  of  the  sac  is  an  exploded  hypothesis.  When  strangulation 
once  begins  the  hernia  swells,  a  furrow  forms  on  the  bowel  at  the  seat  of 
constriction,  the  bowel  and  omentum  below  the  constriction  become  deeply 
congested  and  edematous,  and,  finally,  the  hernia  passes  into  a  state  of  moist 
gangrene.  The  gangrene  may  be  in  spots  or  the  entire  mass  may  be  gan- 
grenous. The  sac  is  apt  to  inflame,  and  inflammation  furnishes  fluid  and 
lymph;  serum  accumulates  in  the  sac,  being  first  clear,  then  bloody,  and 
finally  brown  and  foul.  When  gangrene  is  once  established  the  bowel  is 
in  danger  of  rupturing.  At  the  point  of  contraction  there  may  be  a  line 
of  ulceration.  A  strangulated  femoral  hernia  becomes  gangrenous  more 
rapidly  than  does  a  strangulated  inguinal  hernia. 

Symptoms. — This  condition  is  sometimes  preceded  by  diarrhea  and 
uneasiness  or  pain  about  the  hernial  orifice.  When  strangulation  begins, 
the  victim  is  seized  with  pain  in  and  about  the  hernia  and  with  violent  colicky 
pain  about  the  umbilicus,  and  the  paroxysms  of  colic  become  more  and 
more  frequent,  until  finally  the  pain  may  become  continuous.  The  hernia 
is  found  to  be  irreducible;  larger  than  usual,  tender,  painful,  dull  on   per- 


Strangulated   Hernia  843 

cussion,  without  impulse  on  coughing,  and  the  skin  above  it  may  be  red- 
dened. Eructations  of  gas  are  frequent  and  generally  uncontrollable  vomiting 
and  prostration  come  on.  Vomiting,  as  a  rule,  is  an  early  symptom,  and  one 
w^hich  increases  in  severity  Occasionally  it  only  follows  the  swallowing  of 
liquids.  Not  unusually  there  is  retching  rather  than  vomiting.  In  rare  cases 
vomiting  does  not  begin  for  twenty-four  to  forty-eight  hours.  During  the 
course  of  a  strangulation  vomiting  may  cease  for  a  day  or  more,  and  it  not 
unusually  ceases  toward  the  end,  when  prostration  is  profound.  The  early 
vomiting  is  due  to  reflex  causes;  the  later  vomiting  is  due  to  waves  of  peris- 
talsis which  produce  regurgitation  (Alacready).  The  vomiting  is  first  of 
the  alimentary  contents  of  the  stomach,  next  of  mucus  and  bilious  matter, 
and  finally  of  the  contents  of  the  small  bowel  (fecal  or  stercoraceous  vomiting). 
Stercoraceous  vomiting  rarely  arises  until  strangulation  has  lasted  forty-eight 
hours,  and  may  not  appear  until  much  later.  "It  is  seldom  met  with  in 
inguinal,  more  often  in  femoral,  and  more  often  still  in  obturator  hernia" 
(Macready).  Prostration  is  a  marked  symptom  of  a  strangulated  hernia, 
and  it  increases  hour  by  hour  and  goes  on  to  collapse.  Early  in  the  case 
there  may  be  some  elevation  of  temperature,  but  later  it  becomes  normal 
or  subnormal.  The  pulse  is  small,  irregular,  rapid,  and  very  weak;  the 
extremities  cold;  the  face  Hippocratic.  Constipation  is  absolute,  no  gas  even 
being  passed,  though  in  the  very  beginning  there  may  be  some  diarrheal 
passages  from  below  the  constriction.  The  urine  is  scanty  and  high-colored, 
and  contains  only  a  small  amount  of  the  chlorids;  the  tongue  becomes  dry 
and  brown;  the  thirst  is  torturing;  and  the  patient  often  has  an  urgent 
desire  to  go  to  stool.  Pains  in  the  abdomen  and  in  the  hernia  become  more 
and  more  violent,  and  collapse  rapidly  increases.  When  gangrene  begins 
the  symptoms  apparently  lessen  in  violence:  there  is  a  "delusive  calm." 
Vomiting  usually  ceases,  though  regurgitation  may  take  its  place;  hiccough 
begins;  the  pain  abates  or  disappears;  the  pulse  becomes  very  feeble  and 
intermittent;  collapse  deepens,  and  delirium  is  usual.  It  is  a  safe  clinical 
rule  that  in  strangulated  hernia  cessation  of  pain  without  the  relief  of  con- 
striction, the  disappearance  of  the  lump,  or  the  use  of  opiates  means  that 
gangrene  has  begun.  In  some  cases  of  strangulation  there  are  muscular 
cramps  in  the  legs  (Berger).  In  children  convulsions  are  not  unusual.  In 
a  pure  omental  hernia  strangulation  produces  similar  but  less  decided  symp- 
toms. It  may  be  that  only  a  portion  of  the  circumference  of  the  bowel  is 
caught  and  constricted  in  a  hernial  orifice.  Such  a  condition  is  encountered 
occasionally  in  the  femoral  ring,  and  is  called  partial  enterocele  or  Richter's 
hernia.  The  name  Littre's  hernia  is  often  wrongly  given  to  this  condition. 
What  Littre  described  was  a  hernia  of  Meckel's  diverticulum.  In  a  strangu- 
lated Richter's  hernia  constipation  is  rarely  absolute  and  a  protrusion  is 
often  undiscovered. 

Treatment. — In  treating  strangulated  hernia  place  the  patient  upon  his 
back,  bend  the  knees  over  a  pillow,  and  rigidly  interdict  the  administration 
of  food.  An  attempt  is  to  be  made  to  effect  reduction  by  gentle  manipulation 
or  taxis.  In  applying  taxis  to  a  femoral  or  inguinal  hernia,  flex  and  adduct 
the  thigh  of  the  affected  side.  In  applying  taxis  to  an  umbilical  hernia, 
both  thighs  should  be  flexed  upon  the  abdomen.  Always  lower  the  shoulders 
and  head  and  raise  the  pelvis,  and  accomplish  this  l)y  lifting  tlie  foot  of  the 


844  Diseases   and    Injuries   of  the   Abdomen 

bed  and  placing  pillows  under  the  pelvis.  In  some  cases  raise  the  entire 
body  and  lower  the  head.  Grasp  the  neck  of  the  sac  with  the  fingers 
and  thumb  of  one  hand,  and  employ  the  other  hand  to  squeeze  the  hernia 
and  urge  it  toward  the  belly.  In  direct  inguinal  hernia  the  pressure  should 
be  backward  and  a  little  upward;  in  umbilical  hernia  it  should  be  back- 
ward; in  oblique  inguinal  hernia  it  should  be  upward,  outward,  and  back- 
ward; in  femoral  hernia  it  should  be  downward  until  the  hernia  enters  the 
saphenous  opening,  and  then  "backward  toward  the  pubic  spine"  (Mac- 
Cormac).  If  the  bowel  is  reduced,  it  passes  from  the  hand  wdth  a  sudden 
slip  and  enters  the  belly  with  an  audible  gurgle;  omentum,  when  reduced, 
slowly  glides  back  without  gurgling.  Taxis  is  never  to  be  continued  long, 
and  it  is  not  even  to  be  attempted  in  cases  of  great  acuteness,  in  cases  where 
strangulation  has  lasted  for  several  days,  in  cases  known  to  have  been  pre- 
viouslv  irreducible,  in  cases  associated  with  stercoraceous  vomiting,  or  in 
inflamed  or  gangrenous  herniae. 

If  taxis  fails,  obtain  the  patient's  permission  to  operate.  Anesthetize; 
trv  taxis  again  while  ether  is  being  dropped  upon  the  hernia  to  cause  cold; 
if  reduction  fails,  at  once  perform  herniotomy.  Taxis  possesses  certain 
dangers:  It  may  rupture  the  bowel;  it  may  rupture  the  neck  of  the  sac  and 
force  the  bowel  through  the  rent;  it  may  strip  the  peritoneum  from  around 
the  hernial  orifice  and  force  the  bowel  between  the  detached  peritoneum 
and  the  abdominal  wall;  it  may  reduce  a  hernia  into  the  belly  when  the 
bowel  is  still  strangulated  by  adhesions;  it  may  reduce  the  hernia  en  masse 
or  en  bloc,  the  sac  and  strictured  bowel  being  forced  together  through  the 
internal  ring.  By  reduction  en  bissac  is  meant  the  forcing  of  a  congenital 
hernia  into  a  congenital  pouch  or  diverticulum.  In  any  of  the  above  accidents 
strangulation  may  persist  after  apparent  reduction  by  taxis,  and  this  con- 
dition calls  for  instant  laparotomy — in  most  instances  through  the  hernial 
aperture.  If  taxis  is  successful,  put  the  patient  to  bed,  apply  a  pad  and 
bandage,  allow  no  food  until  vomiting  ceases,  merely  permit  him  to  suck 
bits  of  ice,  and  keep  him  on  a  liquid  diet  for  several  days.  At  the  end  of 
the  first  week  give  solid  food.  Do  not  disturb  the  bowels  for  a  few  days, 
but  if  they  have  not  acted  when  four  or  five  days  have  elapsed  since  the 
operation,  give  a  saline  cathartic  and  an  enema. 

Herniotomy. — If  there  has  been  stercoraceous  vomiting,  the  stomach 
mu.st  be  washed  out  before  giving  the  anesthetic,  and  during  the  adminis- 
tration of  the  anesthetic  the  head  should  be  turned  upon  its  .side.  In  most 
cases  a  general  anesthetic  can  be  given,  but  in  some  desperate  cases  it  is 
not  justifiable  to  give  ether  or  chloroform,  and  a  local  anesthetic  must  be 
u.sed  (eucain,  cocain,  or  Schleich's  fluid).  Wrap  the  patient  up  in  blankets. 
In  most  cases  try  gentle  taxis  for  a  brief  time  after  the  patient  has  been  anes- 
thetized, and  while  ether  is  being  dropped  upon  the  hernia  to  cause  cold. 
Never  try  taxis  if  stercoraceous  vomiting  has  occurred.  If  taxis  fails,  at 
once  sterilize  the  parts  and  operate.  The  instruments  required  in  herni- 
otomy are  a  scalpel,  a  hernia  knife  and  director  (Fig.  450,  b),  hemostatic 
and  dis.secting  forceps,  blunt  hooks,  scissors,  a  dry  dissector,  partly  curved 
needle,  a  needle-holder,  and  Murphy  buttons.  Drainage-tubes  should  be 
ready.  In  the  operalion  the  patient  lies  upon  his  back  with  the  shoulders 
raised,  the  surgeon  stanrling  to  the  patient's  right  side.     In  oblique  inguinal 


Herniotomy 


845 


hernia  it  has  been  the  custom  since  the  days  of  Scultetus  to  raise  a  fold  of 
skin  at  a  right  angle  to  the  axis  of  the  external  ring  and  transfix  it,  the  wound 
which  results  being  extended  until  it  becomes  three  inches  in  length.  This 
incision  possesses  no  special  merit.  It  is  better  to  cut  from  without  mward, 
and  to  make  the  same  incision  as  for  the  performance  of  a  radical. cure  in 
a  non-strangulated  case.  The  superficial  tissues  are  divided  until  the  sac  is 
reached,  and  no  attempt  is  made  to  specially  identify  them.  The  sac  must 
be  identified  and  it  is  known  by  the  fat  which  usually  covers  it,  by  the  ar- 
borescent arrangement  of  its  vessels,  by  the  fact  that  it  can  be  pinched  up 
between  the  finger  and  thumb,  and  the  layers  rolled  over  each  other,  and 
by  the  fluid  within  the  sac.  Should  the  sac  be  opened  ?  In  very  recent 
cases  it  may  not  be  actually  unnecessary,  but  if  there  is  any  doubt  as  to 
the  condition  of  the  bowel,  or  if  a  radical  cure  is  to  be  attempted,  open  the 
sac  and  be  certain  as  to  the  condition  of  its  contents.  As  there  is  always 
some  doubt  as  to  the  condition  of  the  contents,  and  as  a  radical  cure 
is  to  be  made,  make  it  a  rule  to  open  the  sac.  The  sac  is  opened 
and  the  contents  examined  for  fecal  odor  (which  is  not  unusual)  and  for 
gangrenous  smell;  the  thickness  of  the  bowel  is  estimated,  and  the  color 
and  luster  are  determined.  In  obhque  inguinal  hernia,  nick  the  constriction 
upward  and  outward,  as  shown  in  Fig.  474. 
In  direct  inguinal  hernia  the  cut  is  made  up- 
ward and  inward.  Always  pull  the  bowel 
down  and  examine  the  seat  of  constriction 
to  see  what  damage  has  been  inflicted  at 
that  point.  If  the  bowel  glistens,  if  the 
proper  color  comes  back  after  irrigation  with 
very  hot  water,  and  if  there  are  no  spots  of 
gangrene,  restore  the  bowel  to  the  abdomen, 
and  do  a  radical  cure.  If  the  bowel  is  in  a 
doubtful  condition,  fasten  it  to  the  incision, 
apply  a  dressing,  and  watch  the  development 

of  events.  If  the  bowel  is  gangrenous,  our  action  depends  upon  the  condition 
of  the  patient.  If  the  patient  is  in  good  condition,  resect  the  gangrenous 
portion,  and  perform  end-to-end  anastomosis  by  means  of  a  Murphy  button. 
If  the  patient's  condition  is  bad,  make  an  artificial  anus,  and  at  a  later  period 
perform  anastomosis.  An  artificial  anus  can  be  made  by  the  method  of 
Bodine  (page  818).  In  most  cases  in  which  it  seems  necessary  to  make  an 
artificial  anus  prepare  the  bowel  for  the  opening,  but  do  not  open  at  once, 
because  the  bowel  may  recover  in  a  day  or  two,  when  it  can  be  restored  to  the 
belly;  or  it  may  slough  and  form  an  artificial  anus.  In  such  doubtful  cases 
fasten  the  bowel  to  the  belly-wall  with  sutures,  dust  it  with  iodoform,  dress  it 
with  hot  antiseptic  fomentations,  and  await  future  developments.  Gangrenous 
omentum  recjuires  ligation  and  resection.  If  the  bowel  is  fit  to  reduce,  push  it 
just  inside  the  ring,  irrigate  the  parts,  insert  a  drain,  and  suture.  In  most  cases 
perform  a  radical  cure.  In  femoral  hernia  we  can  make  the  incision  one  inch 
internal  to,  and  parallel  with,  the  femoral  vessels,  and  crossing  the  tumor 
and  ligament  (Barker);  but  it  is  better  to  make  the  incision  of  Fabricius 
for  radical  cure.  Divide  the  constriction  by  cutting  upward  and  a  little 
inward.     In  umbilical  hernia  make  a  slightlv  curved  incision  a  little  to  one 


-Herniolomy  in  inguinal 
hernia. 


846  Diseases   and   Injuries   of  the   Abdomen 

side  of  the  middle  of  the  tumor,  open  the  sac,  separate  adhesions,  and  divide 
the  constriction  by  cutting  upward  or  downward,  and  sometimes  also  laterally. 

After  an  operation  for  strangulated  hernia  put  the  patient  to  bed;  bend 
the  knees  over  a  pillow;  give  no  food  by  the  mouth  for  thirty-six  hours  (Mac- 
Cormac),  only  allowing  bits  of  ice  to  suck,  and  give  nutrient  enemata 
containing  brandy.  Abdominal  pain  and  tenderness  call  for  the  administra- 
tion of  sahne  cathartics  and  enemata  containing  turpentine  or  oil  of  rue. 
The  enema  rutae  is  a  favorite  preparation  in  St.  George's  Hospital,  London. 
It  is  made  as  follows:  Take  sixteen  ounces  of  an  infusion  of  chamomile, 
warm  it,  and  pour  it  upon  .^iij  of  confection  of  senna  (Sheild).  If  there  is 
no  abdominal  pain  and  tenderness,  the  bowels  need  not  be  disturbed  for 
a  few  days;  but  if  at  the  end  of  four  or  five  days  they  have  not  acted,  give 
a  sahne  cathartic  and  an  enema.  Remove  the  drainage-tube  on  the  third 
dav.  At  the  end  of  about  three  weeks  get  the  patient  up.  If  a  radical  cure 
has  not  been  attempted,  apply  a  pad  and  a  spica  bandage  to  the  groin,  and 
later  a  truss.     A  truss  should  not  be  worn  if  a  radical  cure  has  been  made. 

Hernia  in  Childhood. — Hernia  is  extremely  common  in  children,  but 
it  is  an  interesting  fact  that  if  one  conducts  a  careful  investigation  of  hernia 
in  adults,  it  will  be  found  that  but  5  or  6  per  cent,  of  them  have  suffered  with 
the  hernia  in  childhood.  This  fact  seems  to  demonstrate  positively  that  the 
majority  of  cases  of  hernia  in  childhood  are  recovered  from.  A.  J.  Ochsner 
("Jour.  Amer.  Med.  Assoc,"  Dec.  22,  1900),  in  commenting  upon  the  fre- 
quency of  hernia  in  childhood,  alludes  to  Malgaigne's  statistics.  Malgaigne 
estimated  that  during  the  first  year  of  life  one  child  in  every  twenty-one 
has  hernia,  and  that  this  proportion  is  maintained  until  the  age  of  six  years. 
Then  it  diminishes  rapidly  until  the  age  of  thirteen,  at  which  age  there  is 
one  hernia  in  every  seventy-seven  children.  It  is  therefore  obvious  that  75 
per  cent,  of  all  herniae  in  children  of  six  years  will  heal  spontaneously  before 
the  age  of  thirteen.  Ochsner  states  that  95  per  cent,  of  hernise  in  children 
will  be  cured  without  operation.  He  points  out  that  between  the  ages  of 
thirteen  and  twenty  hernia  is  fairly  common  among  boys,  but  very  rare 
among  girls.  The  reason  for  this  tendency  to  cure  is  somewhat  uncertain. 
The  view  advocated  by  Thomas  C.  Martin  is  that,  as  the  pelvis  broadens, 
the  parietal  peritoneum  enlarges.  It  does  this  at  the  expense  of  the  mesen- 
tery, which  is  .shortened,  and  the  internal  abdominal  ring  is  displaced.  In 
a  very  instructive  analysis  of  this  condition,  Ochsner  shows  that  in  25  per 
cent,  of  cases  of  hernia  in  childhood  hereditary  weakness  exists;  that  the 
condition  is  commoner  among  the  poorer  classes  than  among  the  richer; 
that  in  many  cases  there  is  an  undescended  testicle;  and  that  the  chief  cause 
is  an  excess  of  intra-abdominal  pressure.  This  excess  of  intra-abdominal 
pressure  may  result  from  flatulent  distention  of  the  stomach  and  intestines, 
the  product  of  bad  feeding;  constipation  and  .straining;  straining  on  urinating 
due  to  the  existence  of  phimosis;  vomiting,  or  cough.  He  thinks  that,  as 
a  rule,  indigestion  causes  flatulence  and  pain;  that  the  child  cries;  that  this 
increa.ses  the  pressure;  that  the  mother  then  feeds  it,  in  order  to  keej)  it 
quiet;  and  that  this. makes  it  worse. 

I'reatment. — Strangulated  hernia;,  irreducible  herniae,  herniae  with  very 
large  rings,  cases  in  which  trusses  fail,  and  cases  associated  with  reducible 
hydrocele   require   operation    (Ochsner).     Most   cases   are   curable   without 


Varieties   of    Hernia  847 

operation,  the  ring  being  guarded  by  a  truss  of  rubber  or  a  pad  of  lamb's 
wool.  Ochsner  believes  that  many  cases  can  be  cured  by  keeping  the  child 
recumbent,  with  the  foot  of  the  bed  raised,  from  four  to  six  weeks.  If  phim- 
osis exists  it  should  be  operated  upon,  and  any  other  causative  condition 
should  be  treated  (cough,  vomiting,  constipation,  fliatulent  indigestion,  etc.). 
An  umbilical  hernia  can  usually  be  cured  by  the  use  of  a  cork.  The  cork 
should  be  one  inch  in  diameter  and  one  and  one-fourth  inches  in  length, 
and  shaped  like  a  cone.  The  smaller  end  is  pushed  into  the  ring  and  the 
cork  is  held  in  place  by  adhesive  plaster.  In  two  weeks  a  smaller  cork 
must  be  used,  and  in  six  or  eight  weeks  it  can  usually  be  dispensed  with. 

Varieties  of  Hernia. — In  direct  inguinal  hernia  the  bowel  passes  out 
through  Hesselbach's  triangle  internal  to  the  deep  epigastric  artery.  It 
enters  the  inguinal  canal  low  down,  and  passes  outside  the  conjoined  tendon 
or  forces  the  conjoined  tendon  before  it  or  splits  through  the  tendon.  The 
neck  of  the  sac  is  internal  to  the  deep  epigastric  artery.  The  coverings  of 
this  hernia,  when  it  passes  external  to  the  conjoined  tendon,  are  the  same 
as  those  of  an  indirect  inguinal  hernia,  except  that  the  transversahs  fascia 
instead  of  the  infundibuliform  process  of  the  transversahs  fascia  is  one  of  the 
layers.  When  a  direct  hernia  pushes  before  it  the  conjoined  tendon,  its 
coverings  are  skin,  superficial  fascia,  intercolumnar  fascia,  conjoined  tendon, 
transversahs  fascia,  subserous  tissue,  and  peritoneum. 

In  indirect  inguinal  hernia  the  bowel  passes  through  the  internal  ab- 
dominal ring  external  to  Hesselbach's  triangle  and  external  to  the  deep 
epigastric  artery.  It  passes  down  the  inguinal  canal  and  emerges  from 
the  external  ring;  it  may  enter  the  scrotum  or  labium  (scrotal  or  labial  hernia), 
or  it  may  not.  The  neck  of  the  sac  is  external  to  the  deep  epigastric  artery. 
Its  coverings  are  skin,  superficial  fascia,  intercolumnar  fascia,  cremaster 
muscle,  infundibuliform  fascia,  subserous  tissue,  and  peritoneum. 

Congenital  inguinal  hernia  is  a  portion  of  bowel  within  an  unclosed 
vaginal  process.  The  bowel  in  congenital  hernia  has  one  layer  of  peritoneum 
in  front  of  it.  The  testicle  is  posterior  and  below  (Fig.  475).  Always  re- 
member that  congenital  hernia  may  not  appear  for  several  months  after 
birth.  Congenital  hernia  conceals  or  buries  the  testicle;  acquired  hernia 
does  not.  If  a  vaginal  process  open  above  and  closed  below  contains  a 
hernia,  the  condition  is  called  hernia  into  the  junicular  process. 

If  the  funicular  process  is  closed  at  the  abdominal  end  but  not  below,  a 
hernia  in  a  special  sac  may  descend  back  of  the  vaginal  tunic.  This  condition 
is  known  as  infantile  hernia.  In  infantile  hernia  there  are  three  layers  of 
peritoneum  in  front  of  .the  bowel,  the  two  layers  of  the  vaginal  tunic  and  the 
one  layer  of  sac.     The  testicle  is  in  front  (Fig.  476). 

If  the  tunica  vaginalis  is  closed  above  and  not  below,  and  a  hernia  pushes 
down  the  vaginal  process  and  causes  it  to  double  on  itself,  the  condition 
is  known  as  encysted  injaniile  hernia  (Fig.  477). 

In  femoral  hernia  the  bowel  descends  along  the  femoral  canal,  and  the 
neck  of  the  sac  is  at  the  femoral  ring.  The  neck  of  a  femoral  rupture  is  always 
external  to  the  pubic  spine;  the  neck  of  an  inguinal  rupture  is  always 
internal  to  the  pubic  spine.  Femoral  hernia  is  never  congenital.  Its  cover- 
ings are  skin,  superficial  fascia,  cribriform  fascia,  crural  sheath,  septum  crurale, 
subserous  tissue,  and  peritoneum. 


848 


Diseases   and   Injuries  of  the   Abdomen 


Vmhilical  hernia  may  be  congenital  (the  ventral  plates  having  closed 
incompletely),  infantile  (the  cicatrix  of  the  umbilicus  having  stretched),  or 
acquired. 

Ventral  hernia  is  a  protrusion  through  any  part  of  the  anterior  abdominal 
wall  except  at  the  umbihcal  or  inguinal  regions.  A  ventral  hernia  may  be 
median  (hernia  of  the  linea  alba)  or  lateral.  The  treatment  is  radical  opera- 
tion. 

Epigastric  hernia  is  a  form  of  ventral  hernia.  In  this  condition  there  is 
a  protrusion  of  the  peritoneum  in  the  space  bounded  by  the  ensiform  cartilage, 
the  ribs,  and  the  umbilicus.  The  sac  of  peritoneum  may  be  empty,  may 
contain  omentum,  or  omentum  and  bowel.  The  stomach  very  rarely  passes 
into  the  sac.  The  protrusion  is  usually,  but  not  invariably,  through  the 
linea  alba. 

Cecal  hernia  is  very  uncommon  in  women.  It  is  usually  preceded  and 
caused  by  hernia  of  the  small  gut.  Usually  there  is  a  complete  sac,  but 
sometimes  the  sac  is  partial.     The  appendix  may  be  in  the  sac. 


Fig.  475. — Congenita!  her- 
nia :  7".  Testicle  ;  F,  P,  funicu- 
lar process  :  B,  bowel. 


Fig.  476. — Infantile  her- 
nia :  7",  Testicle  ;  T.v.,  tu- 
nica vaginalis;  5,  5,  sac; 
B,  bowel. 


Fig.  477. — Encysted  infantile 
hernia:  T,  Testicle ;  T.v.,\.\xnica. 
vaginalis  (represented  as  dis- 
tended;; 5',  .S,  sac  ;  .5,  bowel. 


In  properitoneal  hernia  the  sac  is  between  the  peritoneum  and  trans- 
versalis  fascia.  This  form  of  hernia  is  sometimes  produced  by  making  taxis 
on  an  inguinal  hernia,  when  the  internal  ring  is  small  or  is  blocked  by  an 
undescended  testicle.  In  properitoneal  inguinal  hernia,  which  is  the  most 
common  form,  there  are  two  sacs  detectable,  one  in  the  scrotum,  the  other 
parallel  with  Poupart's  ligament,  and  as  one  sac  is  emptied  the  other  distends 
(Breiter,  of  Zurich). 

In  interstitial  inguinal  hernia  the  hernia  sac  is  between  the  transversalis 
muscle  and  fascia,  or  between  the  external  and  internal  oblique  muscles,  or 
h)etween  the  fibers  of  the  internal  oblique  muscle  or  between  the  external 
oblique  muscle  and  the  transversalis  fascia,  the  internal  oblique  and  trans- 
versalis muscles  being  pushed  aside  (Sultan's  "Atlas  of  Abdominal  Hernias"). 

In  superficial  inguinal  hernia  the  sac  is  between  the  aponeurosis  of  the 
external  oblique  muscle  and  the  skin.  This  variety  of  hernia  is  always  con- 
genital and  the  testicle  is  invariably  misplaced. 

Obturator  hernia  passes  through  the  obturator  membrane  or  the  obturator 
canal,  and  is  felt  below  the  horizontal  ramus  of  the  pubes,  internal  to  the 
femoral  vessels. 


Diaphragmatic   Hernia  849 

Lumbar  hernia  occurs  at  the  edge  of  or  through  the  quadratus  lumborum 
muscle. 

Sciatic  or  gluteal  hernia  passes  through  the  great  sacro-sciatic  foramen, 
above  or  below  the  pyriformis  muscle. 

Pudendal  hernia  protrudes  into  the  lower  part  of  the  labium,  the  bowel 
having  descended  between  the  ischial  ramus  and  the  vagina. 

Perineal  hernia  presents  in  the  perineum,  between  the  rectum  and  the 
prostate  gland  or  between  the  rectum  and  the  vagina. 

Internal,  retroperitoneal,  or  intra-abdominal  hernice  include  hernia  into  the 
foramen  of  Winslow,  hernia  into  the  retroduodenal  jossce,  the  retrocecal  jossce, 
and  the  intersigmoid  fossa. 

Vaginal  hernia  is  associated  with  uterine  prolapse  or  ensues  upon  destruc- 
tion of  the  vaginal  wall. 

Richter's  hernia  is  the  catching  of  a  portion  of  the  circumference  of  the 
bowel.  It  is  also  called  partial  enterocele.  Strangulation  of  a  partial  entero- 
cele  does  not  produce  stercoraceous  vomiting  or  absolute  constipation,  and 
the  protrusion  is  barely  perceptible  or  cannot  be  palpated. 

Littre's  hernia  is  hernia  of  Meckel's  diverticulum. 

Rokitansky's  diverticular  hernise  are  due  to  separation  of  the  muscular 
fibers  of  the  bowel  permitting  the  sacculation  of  mucous  membrane  and 
peritoneum.  These  false  diverticula  may  be  no  larger  than  peas  or  may  be 
larger  than  walnuts,  and  there  may  be  scores  of  them  in  one  patient.  They 
may  produce  no  symptoms,  or  may  lead  to  peritonitis  or  to  symptoms  of  intes- 
tinal obstruction. 

Hernia  of  the  Bladder. — This  is  a  protrusion  of  a  portion  of  the  bladder- 
wall  through  a  hernial  opening.  The  protrusion  may  or  may  not  be  covered 
with  peritoneum.*  It  is  most  frequently  met  with  in  the  inguinal  region. 
Brunner  describes  three  forms:  (i)  entirely  without  a  peritoneal  covering 
(extraperitoneal);  (2)  partly  covered  with  peritoneum  (paraperitoneal — the 
commonest  form);  (3)  completely  covered  with  peritoneum  (intraperitoneal). 
The  bladder  may  constitute  the  hernia,  or  there  may  be  an  ordinary  hernia, 
and  also  a  cystocele.  In  an  inguinal  hernia  the  bladder  will  be  internal  and 
somewhat  behind  the  other  constituent  parts  of  the  protrusion.  Hernia  of 
the  bladder  is  much  more  common  in  men  than  in  women. 

A  hernia  of  the  bladder  may  become  strangulated.  In  some  cases  a 
diagnosis  of  hernia  of  the  bladder  can  be  made  by  the  fact  that  the  protrusion 
lessens  in  size  when  the  patient  micturates  and  increases  in  size  as  urine 
gathers,  or  when  the  bladder  is  injected  with  fluid.  The  treatment  should 
be  operative.  When  the  bladder  is  exposed,  it  is  replaced  with  or  without 
resection  of  a  portion. 

Diaphragmatic  Hernia. — The  majority  of  cases  are  congenital  and  in 
Qo  per  cent,  of  them  there  is  no  sac.  The  hernia  may  pass  through  a  natural 
opening  or  through  a  gap  due  to  congenital  defect.  The  hernia  is  most  com- 
mon on  the  left  side,  and  the  stomach  is  the  organ  usually  displaced.  When 
the  stomach  passes  suddenly  through  the  left  side  of  the  diaphragm,  there 
will  be  dyspnea,  cyanosis,  displacement  of  the  heart  to  the  right,  pain  in  the 
upper  abdomen,  thirst,  and  in  most  cases  rapid  death.  When  the  stomach  has 
entered  the  left  side  of  the  thorax,  there  is  a  tympanitic  note  on  percussing  the 

*  Brunner,  in    r)eutsch.  Zeit^chr.  f.  Chir.,  189S.  vol.  xlvii. 
54 


850  Diseases   and   Injuries  of  the   Abdomen 

thorax,  the  heart  is  displaced  to  the  right,  and  the  side  of  the  chest  is  unduly 
prominent.  In  250  cases  of  traumatic  diaphragmatic  hernia  collected  by 
Leichtenstern  the  diagnosis  was  made  before  death  in  but  5  cases.  Strangu- 
lation of  a  diaphragmatic  hernia  produces  severe  pain  in  the  upper  abdomen, 
violent  vomiting,  constipation,  boat-shaped  abdomen,  great  thirst,  rapid 
wasting,  and  the  excretion  of  a  very  small  amount  of  urea  (Mackenzie  and 
Battle,  "Lancet,"  Dec.  7,  1901). 

Treatment. — Open  the  belly  for  exploration.  If  hernia  is  found,  return 
it  to  abdomen;  open  the  chest  and  suture  the  diaphragm.  Mackenzie  and 
Battle,  Mikulicz,  Humbert,  and  others  have  operated  for  this  condition. 


Examination  of  the   Rectum 


;i 


XXVIII.   DISEASES  AND  INJURIES  OF  THE  RECTUM  AND 

ANUS. 


-Whenever  possible,  have 
the    administration  of    a 


Examination  of  the  Anus  and  Rectum. 

the  bowels   emptied    before    an    examination,   by 
cathartic  and    the    use 
of  an  enema. 

Place  the  patient  on 
the  left  side,  with  the 
knees  drawn  up  and  the 
pelvis  elevated  (the  left- 
lateral-prone  position  of 
Sims).  The  anus  is 
carefully  inspected,  the 
anal  folds  being  opened 
during  the  process.  By 
inspection  the  surgeon 
can  notice  the  external 
opening  of  a  fistula,  ex- 
ternal piles,  protruding 
internal  piles,  mixed 
piles,  pruritus,  dis- 
charge from  the  rec- 
tum, eczema,  fissure,  tumor,  ulcer,  condylomata,  or  abscess. 

Next,  a  digital  examination  of  the  rectum  is  made.     The  nail  of  the  index- 


Fig.  478. — Mathews'  self-retaining  rectal  speculum. 


47q. — Kelly's  rectal  specula. 


finger  is  filled  with  soap  and  the  finger  is  oiled  or,  better,  is  covered  with  a 
rubber  finger  which  is  oiled.  The  digit  is  gently  inserted  through  the 
sphincter,  the  patient  being  asked  to  strain  lightly  while  it  is  passing.     A 


8=52 


Diseases  and   Injuries  of  the   Rectum  and  Anus 


digital  examination  enables  the  surgeon  to  detect  an  ulcer,  a  polypus,  a  tumor, 
a  stricture,  and  to  determine  certain  points  regarding  the  condition  of  the 
prostate  in  the  male  and  the  uterus  in  the  female. 

Next,  in  some  cases,  the  rectum  must  be  examined  with  a  speculum.  It 
is  not  often  necessary  to  give  ether.  Mathews'  speculum  (Fig.  478)  is  very 
ser\dceable.  Sims's  duck-bill  speculum  is  a  valuable  instrument.  The 
speculum  is  warmed,  oiled,  and  slowly  introduced.  It  is  first  directed  toward 
the  umbilicus,  and  when  it  passes  the  sphincter  its  direction  is  gradually 
altered  until  it  is  toward  the  promontory  of  the  sacrum.  Illumination  is 
obtained  bv  direct  sunlight,  or  by  a  forehead  mirror  and  an  electric  light. 
This  examination  will  extend,  confirm,  or  disprove  the  findings  of  the  digital 


Fig.  480.— Examination  of  the  rectum  by  reflected  light  (Kelly). 

examination;  ulcers,  hemorrhoids,  and  mahgnant  growths  can  be  carefully 
examined,  and  the  condition  of  the  rectal  mucous  membrane  can  be  thor- 
oughly investigated. 

Marion  Sims  in  1845  demonstrated  the  ballooning  of  the  vagina  by  atmos- 
pheric pressure,  and  in  1870  Van  Buren  applied  this  method  to  the  rectum. 
Kelly  in  1895  put  forth  his  straight  tubes  and  described  in  detail  the  methods 
and  advantages  of  examination  by  them,  and  the  great  diagnostic  value  of 
ballooning  the  rectum.  Kelly's  method  of  examination  is  shown  in  Fig.  480. 
The  tubes  are  shown  in  Fig.  479.  It  is  not  necessary  to  give  ether.  The 
patient  is  placed  in  the  knee-chest  position  (Fig.  480).  A  tube  containing 
an  obturator  is  well  greased  with  vaselin.  "The  buttocks  are  drawn  apart, 
and  the  blunt  end  of  the  obturator  is  laid  on  the  anus,  which  is  also  coated 


Examination   of  the   Rectum 


853 


with  vasehn.  The  direction  of  the  instrument  should  be  first  downward  and 
forward,  and,  when  the  sphincter  is  well  passed,  up  under  the  sacral  promon- 
tory. The  moment  the  speculum  clears  the  sphincter  ani  and  the  obturator 
is  withdrawn,  air  rushes  in  audibly  and  distends  the  bowel."  The  bowel 
being  distended  with  air,  the  mucous  membrane  is  plainly  seen  as  the  tube 
is  slowly  withdrawn  and  the  light  is  reflected  into  the  speculum.  The  Kelly 
tube  must  be  used  with  great  care,  as  harm  may  be  done  by  it,  and  the  longest 
tube  should  only  be  used  in  exceptional  cases. 

I  use  with  the  greatest  satisfaction  Tuttle's  pneumatic  proctoscope  (Fig. 
481).  Dr.  Tuttle  describes  it  as  follows  ("Diseases  of  the  Anus,  Rectum, 
and  Colon,"  by  James  P.  Tuttle):  "This  instrument  is  composed  of  a  large 
cyhnder  (/),  into  one  part 
of  the  circumference  of 
which  is  fitted  a  small 
metallic  tube  closed  by  a 
flint-glass  bulb  at  its  distal 
end.  The  electric  lamp 
((/)  is  fitted  upon  a  long 
metallic  stem,  and  carried 
through  the  small  cylinder 
to  the  end  of  the  instru- 
ment as  shown  in  the  illus- 
tration. The  proctoscope 
is  introduced  through  the 
anus  with  the  obturator 
(a)  in  position.  As  soon  as 
the  internal  sphincter  is 
passed,  this  obturator  is 
withdrawn  and  the  bay- 
onet-fitting plug  (b),  which 
contains  either  a  plain  glass 
window  or  a  lens  focused  to 
the  length  of  the  instru- 
ment to  be  used,  is  inserted 
in  the  proximal  end  of  the 

instrument.  This  plug  is  ground  to  fit  air-tight  and  thus  closes  the  instru- 
ment perfectly.  The  plug  being  inserted  in  the  tube,  a  very  slight  pressure 
upon  the  hand-bulb  will  cause  inflation  of  the  rectal  ampulla  to  such  an  extent 
that  the  whole  rectum  can  be  observed  and  the  instrument  can  be  carried  up 
to  the  promontory  of  the  sacrum  without  coming  in  contact  with  the  rectal 
wall.  Further  dilatation  will  show  the  direction  of  the  canal  leading  into 
the  sigmoid,  and  by  a  little  care  in  manipulating  the  instrument  and  keeping 
the  gut  well  dilated  in  advance,  it  can  be  carried  up  into  this  portion  of  the 
intestine  without  the  least  traumatism  of  the  parts.  If  any  fecal  matter  ob- 
scures the  Hght  by  being  massed  or  smeared  over  the  glass  bulb  the  plug  can 
be  removed,  and  a  pledget  of  cotton,  introduced  with  a  long  dressing  forceps, 
will  wipe  this  off  so  that  the  plug  can  be  reintroduced  and  the  examination 
continued  with  very  slight  delay  or  inconvenience.  The  adjustable  handle 
(r)  fits  on  the  rim  of  the  instrument  and  thus  converts  it  into  a  Kelly  tube. 


Fig.  4S1. — Tuttle's  pneumatic  proctoscope:  a,  Obturator ; 
6,  plug  with  glass  window  closing  end  of  tube;  c.  handle;  d. 
cords  connecting  instrument  with  battery  ;  e,  inflating  appara- 
tus ;  y,  main  tube  of  proctoscope. 


854  Diseases   and   Injuries   of   the   Rectum  and  Anus 

This  instrument  is  operated  with  an  ordinary  dry  battery  of  four  cells.  It  is 
better,  however,  to  have  a  battery  with  six  cells,  as  it  will  not  require  being 
recharged  so  frequently. " 

If  a  patient  is  placed  in  the  knee-chest  position  and  anesthetized,  the 
sphincter  can  be  stretched  by  the  fingers,  and  the  rectum  will  distend  with  air 
and  can  be  easily  examined.  The  fingers  are  introduced  as  suggested  by 
Martin  (Fig.  48 2),  and  the  rectum  becomes  visible  when  they  are  separated 

(Fig.  483). 

Foreign  Bodies  in  the  Rectum. — It  is  not  at  all  unusual  for  hard 

undigested  articles  taken  with  the  food  to  lodge  in  the  rectum.  They  can 
usually  be  removed  through  a  speculum  by  means  of  forceps.  In  some  cases 
ether  must  be  given  and  the  sphincter  stretched;  in  others,  the  sphincter  must 
be  divided.  Sometimes  large  bodies  are  voluntarily  inserted  and  the  indi- 
vidual is  unable  to  remove  them.     Lewis  H.  Adler  ("Am.  Med.,"  July  20, 


Figs.  482,  4S3. — A  new  and  simple  method  of  proctoscopy  (Thomas  C.  Martin). 

1 901)  removed  the  valve  of  a  steam  radiator  pipe  from  the  rectum.  The 
small  end  was  one  and  one-half  inches  in  diameter;  the  large  end  was  two  and 
one-half  inches  in  diameter.  The  patient  had  been  in  the  habit  of  introducing 
it  frequently  and  removing  it  with  a  hook  of  galvanized  iron  wire.  Marma- 
duke  Shield  ("Lancet,"  Oct.  12,  1901)  reports  the  case  of  a  man  of  sixty 
years  of  age  who  forced  a  gaUipot  into  the  rectum.  The  pot  was  two  and  one- 
one-half  inches  in  diameter  and  two  and  three-fourths  inches  in  height.  The 
patient  broke  it  trying  to  get  it  out.  Shield  incised  the  rectum  from  behind 
and  removed  the  article  by  means  of  obstetric  forceps. 

A  remarkable  series  of  similar  cases  will  be  found  in  "Anomahes  and 
Curiosities  of  Medicine,"  by  Geo.  M.  Gould  and  Walter  M.  Pyle. 

Wounds  of  the  rectum  require  free  drainage,  antiseptic  irrigation,  and 
antiseptic  dressing.  If  the  peritoneum  is  opened,  laparotomy  must  be  per- 
formed, the  peritoneal  cavity  irrigated,  the  rectal  wound  sutured,  and  the 
abdomen  flraincd. 


Fistu! 


a  in 


Ar 


85. 


Ischiorectal  abscesses  are  situated  in  the  ischiorectal  fossa.  They 
travel  in  the  line  of  least  resistance,  which  is  upward,  and  more  often  burst 
into  the  bowel  than  externally.  They  are  caused  by  cold,  by  external  trau- 
matisms, by  perforations  of  the  rectum  by  hard  fecal  masses,  or  by  the  passage 
of  bacteria  into  the  fossa  through  a  fissure,  an  ulcer,  or  an  ulcerated  pile. 
They  may  be  either  acute  or  tuberculous.  In  many  cases  the  process  is  at 
first  tuberculous  and  mixed  infection  with  pyogenic  bacteria  takes  place. 

The  symptoms  are  the  same  as  those  of  abscess  anywhere,  the  swelling, 
however,  being  brawny  and  fluctuation  being  hard  to  detect.  Pain  in  the 
groins  is  often  complained  of,  and  there  may  be  enlarged  glands  in  these 
regions.  They  commonly  result  in  fistula,  and  a  patient  should  be  warned 
of  this  tendency  before  operation  is  performed. 

The  treatment  is  instant  incision,  the  cut  radiating  from  the  anus  hke 
the  spoke  of  a  wheel.  Incision  is  followed  by  insertion  of  a  finger,  breaking 
down  the  necrotic  septa  of  cellular  tissue,  irrigation  and  packing  with  iodo- 
form gauze  or  the  insertion  of  a  drainage-tube.  If  a  fistula  is  found  to  open 
in  the  rectum,  it  is  operated  upon  as  directed  in  the  article  upon  Fistula. 

Imperforate  Anus.— There  are  two  forms  of  this  condition.  In  one 
form  the  rectum  empties  into  the  bladder,  vagina,  or  urethra.  In  the  other 
form  there  is  no  rectal  opening  either  upon  the  surface  of  the  body  or  in  the 


Fig.  484. — Fistula  in  ano  ;  a,  Blind  external  ;  b,  blind  internal ;  c,  complete  (Esmarch  and  Kowalzig). 


urinary  organs.  The  diagnosis  is  usually  at  once  apparent,  except  in  cases 
where  the  anus  looks  normal,  when  the  diagnosis  will  often  not  be  made  until 
symptoms  of  obstruction  arise. 

Treatment. — If  the  rectum  bulges  when  the  child  cries,  open  into  it  with 
a  knife  and  keep  the  opening  patent  by  inserting  a  plug  of  iodoform  gauze. 
In  cases  in  which  the  rectum  is  more  deeply  seated  a  catheter  is  introduced 
into  the  bladder,  an  incision  is  made  from  the  anus  to  the  coccyx,  the  rectum 
is  sought  for,  and  when  found  is  sewed  to  the  anus,  and  is  incised.  In  some 
cases  Keen  and  others  have  performed  Kraske's  operation,  pulling  down  the 
rectum  to  the  anal  margin,  sewing  it  there,  and  incising  the  occluded  anus. 
If  the  rectum  cannot  be  found  or  cannot  be  pulled  down,  an  artificial  anus 
must  be  made. 

Fistula  in  ano  is  the  track  of  an  unhealed  abscess.  An  abscess  in  the 
anal  region  is  apt  to  refuse  to  heal  because  of  the  constant  movement  of  the 
parts  (produced  by  respiration,  coughing,  the  passage  of  gas,  defecation,  etc.). 
The  passage  of  feces  will  keep  a  fistula  open.  If  a  tuberculous  ulcer  perforates, 
a  tuberculous  sinus  forms,  and  a  tuberculous  sinus  is  also  apt  to  follow  a 
cold  abscess  of  the  ischiorectal  fossa.  Fistula  is  often  associated  with 
phthisis  pulmonalis,  and  is  not  unusually  linked  with  piles,  cancer,  or  stricture. 

There  are  three  varieties  of  fistula^the  blind  external  (Fig.  484,  .A.),  the 


856  Diseases   and   Injuries  of  the   Rectum   and   Anus 

blind  internal  (Fig.  4S4,  b),  and  the  complete  (Fig.  484,  c).  The  external 
opening  is  usually  near  the  anus,  but  may  be  far  away,  and  there  may  be  only 
one  pathway  or  there  may  be  several  sinuses.  In  a  healthy  individual  the 
external  orifice  is  small  and  a  mass  of  granulations  sprouts  from  it.  In  a  tu- 
berculous fistula  the  external  orifice  is  large  and  irregular,  with  thin  and  under- 
mined edges,  shows  no  granulations,  extrudes  small  quantities  of  sanious  pus, 
and  the  skin  about  it  is  purple  and  congested.  In  a  fistula  following  an  anal 
abscess  the  inlernal  opening  is  just  above  the  anus,  between  the  two  sphinc- 
ters. In  fistula  following  an  ischiorectal  abscess  the  internal  opening  is 
usuallv  near  the  anus,  but  may  in  rare  cases  be  above  the  internal 
sphincter.  A  sinus  may  run  up  under  the  mucous  membrane  from  the 
internal  opening.  In  a  horseshoe  fistula  the  internal  opening  is  usually 
upon  the  posterior  wall  of  the  bowel,  "  and  from  this  a  tract  leads  into 
the  ischiorectal  fossa,  not  on  one  side  only,  but  upon  both.  Therefore 
we  have  one  opening  into  the  bowel  and  one  through  the  skin  on  either 
side."  *  In  some  cases  of  horseshoe  fistula  there  is  no  internal  opening; 
in  other  cases  there  are  two  openings.  In  an  old  fistula  the  track  becomes 
fibrous  and  cannot  collapse.  Two  or  more  fistulae  may 
exist  in  the  same  patient.  In  dealing  with  a  fistula  always 
determine  if  the  condition  is  stationary  or  progressive. 
The  symptoms  of  a  complete  fistula  are  the  passage  of 
feces  and  gas  through  the  opening  and  the  flow  of  a  dis- 
charge which  stains  the  clothing.  In  a  complete  fistula 
a  probe  can  be  carried  from  the  external  opening  into  the 
bowel.  After  a  time  incontinence  of  feces  is  apt  to  come 
on,  repeated  attacks  of  inflammation  thickening  the  rec- 
-——  tum  and  destroymg  its  sensibility,     rrom  time  to  time 

Fig-.  485.— Opera-      ^j^g  opening  will  block,  and  new  abscesses  form.     In  ex- 

tion  for   fistula   in   ano  .J  r        ^  -r,        i  •    ,  i  •        n        i  n 

(Esmarch  and  Kowai-      amining  a  fistula  use  Brodie  s  probe,  as  its  flat  handle 
zig)-  enables    one  to    locate  the    direction    the   bent    instru- 

ment   has    taken,    and    its    slender    shaft    will    find   its 
way  through  a  very  small  channel. 

Treatment. — In  treating  a  fistula  cleanse  the  parts,  as  cleanly  work, 
though  it  will  not  prevent  pus,  will  hmit  suppuration.  The  external  parts 
are  washed  with  soap  and  water.  The  rectum,  which  must  be  empty,  is  irri- 
gated with  hot  saline  solution.  Corrosive  sublimate  should  not  be  used  in 
the  rectum,  because  it  is  irritant,  causes  a  flow  of  serum,  and  hence  lessens 
tissue  resistance,  and  is  rendered  inert  as  an  antiseptic  by  being  converted 
into  sulphid  of  mercury.  Anesthetize  the  patient.  If  operating  upon  a 
complete  fistula,  pass  a  grooved  director  into  the  external  opening,  carry  it 
through  the  sinus,  make  it  enter  the  bowel,  bring  its  point  out  externally,  and 
Hft  the  tissues  between  the  sinus  and  the  surface.  Incise  the  tissues  (JFig. 
485).  Cut  the  sphincter  at  a  right  angle  to  its  fibers,  and  do  not  cut  it  more 
than  once  at  (jne  operation.  Push  the  finger  to  the  depth  of  the  wound,  to 
determine  that  the  sinus  does  not  ascend  above  the  internal  oy)ening.  If  there 
are  two  fistukc,  cut  one  through,  and  when  one  wound  has  healed,  cut  the  other. 
In  some  straight  sinuses  the  tract  can  be  extirpated  and  the  parts  sutured,  ])ri- 
mary  union  usually  resulting.    Look  for  branching  sinuses,  and  if  any  are  found 

*  "  Disea.se.s  of  the  Rectum,  Anus,  anfl  Sigmoid  Flexure,"  by  Joseph  M.  Mathews. 


Pruritus   of   the  Anus  857 

slit  them  open.  Examine  carefuUy  to  see  if  there  is  a  sinus  beneath  the  mucous 
membrane  of  the  bowel,  and  if  such  a  sinus  is  found  slit  it  up.  Curet  all 
sinuses,  and  if  they  are  very  fibrous  clip  them  away  with  scissors.  Cut  away 
diseased  skin;  irrigate  with  salt  solution;  pack  with  iodoform  gauze;  and 
dress  with  gauze  and  a  T-bandage.  In  forty-eight  hours  remove  the  dress- 
ings, spray  with  peroxid  of  hydrogen  and  irrigate  with  salt  solution,  dust  with 
iodoform,  insert  lightly  to  the  depths  of  the  wound  a  piece  of  iodoform  gauze, 
and  reapply  the  dressings.  Dress  the  wound  thus  every  day  until  healing  is 
almost  complete.  It  is  unnecessary  to  confine  the  bowels  beyond  forty-eight 
hours,  at  which  period,  if  they  have  not  moved,  an  enema  is  given.  If  the 
dressing  at  any  time  becomes  stained  with  feces,  re-dress  at  once.  Get  the 
patient  out  of  bed  as  soon  as  possible. 

If  a  blind  external  fistula  does  not  heal,  every  sinus  must  be  incised,  and 
thickened  walls  must  be  cut  away  or  scraped  away. 

In  a  blind  internal  fistula  an  external  incision  is  made  to  convert  the  case 
into  a  complete  fistula,  which  is  then  treated  as  is  directed  above. 

In  horseshoe  fistula,  more  than  one  operation  may  be  necessary  in  order 
to  avoid  cutting  the  sphincter  muscle  twice  in  one  operation,  a  proceeding 
which  would  probably  lead  to  fecal  incontinence.  One  side  alone  is  operated 
on.  Sinuses  are  opened  and  scraped,  the  sphincter  is  divided,  the  angles  and 
edges  of  skin  are  trimmed  awa}-,  and  the  wound  is  packed.  When  the  wound 
is  healed,  or  nearly  healed,  the  other  side  should  be  operated  upon. 

If  fecal  incontinence  results  from  an  operation  for  fistula,  remove  the  scar- 
tissue  and  endeavor  to  suture  the  separated  muscular  fibers.  Should  an 
operation  be  undertaken  for  fistula  if  phthisis  exists  ?  Many  of  the  old  mastei*s 
said  no.  Mathews  sums  up  the  modern  view:  in  incipient  phthisis  operate; 
in  rapidly  progressive  fistula  operate  whether  cough  exists  or  not;  if  much 
cough  exists,  do  not  operate  unless  the  fistula  is  rapidly  progressive;  in  the 
last  stages  of  phthisis  do  not  operate. 

Pruritus  of  the  anus  is  a  symptom,  and  not  a  disease.  It  may  be 
due  to  piles,  fissure,  seat-worms,  eczema,  nerve-disturbance,  kidney  disease, 
jaundice,  constipation,  inebriety,  the  opium-habit,  torpid  liver,  dyspepsia, 
alcohol,  tea-drinking,  vesical  calculus,  tobacco-smoking,  urethral  stricture, 
uterine  disease,  diabetes,  ovarian  trouble,  and  mental  disorder.  The  itching 
is  worse  at  night,  and  is  often  of  fearful  intensity. 

Treatment. — Remove  the  cause.  Prevent  constipation.  Several  times 
a  day  wash  the  parts  with  very  hot  water,  dr\-  them,  and  apply  a  mixture  con- 
t  lining  .5j  of  camphophenique  and  oj  of  water  (Mathews).  Kelsey  directs 
th.it  the  parts  be  cleansed  twice  a  day,  and  after  each  cleansing  that  the  fol- 
lowing ointment  be  apphed:  menthol,  o]\  cerat.  simp.,  5ij;  oil  of  sweet 
almonds,  f.5j;  acid,  carbolic,  .^j;  pulvis  zinc,  oxid.,  .sij.  Mathews  commends 
the  following  mixture:  chloral,  .5j;  gum-camphor,  .5ss;  glycerin  and  water, 
each  5j.*  In  this  disease  a  "scarf-skin"  forms,  which  must  be  made  to  peel 
ofT  by  the  application  of  iodin,  pure  carbolic  acid,  corrosive  sublimate  (gr. 
iv  to  oj  of  cosmolin),  calomel  (3ij  to  .^j  of  cosmolin),  or  camphophenique. 
In  obstinate  cases  paint  the  parts,  night  and  morning,  with  a  mi.xture  of  60 
gr.  of  alum,  30  gr.  of  calomel,  and  300  gr.  of  glycerin;  or  smear  with  an  oint- 
ment composed  of  \  part  of  oleate  of  cocain,  3  parts  of  lanolin,  2  parts  of 

*  "  Diseases  of  the  Rectum." 


858  Diseases   and   Injuries   of   the   Rectum  and  Anus 

vaselin,  and  2  parts  of  olive  oil  (Morain).  In  very  severe  cases  touch  -with,  a 
solution  of  silver  nitrate  (i  ;  10),  employ  the  Paquelin  cautery,  or  resect  the 
mucous  membrane  as  in  Whitehead's  operation  for  hemorrhoids. 

Fissure  of  the  anus  is  an  irritable  ulcer  at  the  anal  orifice  producing 
spasm  of  the  sphincter.  Pain  exists  because  twigs  of  nerves  are  exposed  upon 
the  floor  of  the  ulcer.  Fissure  is  caused  by  constipation  or  traumatism.  The 
symptom  is  violent,  burning  pain,  sometimes  beginning  during  defecation, 
but  usually  at  the  end  of  the  act,  and  lasting  for  some  hours.  Constipation 
exists,  and  often  pruritus.  Examination  discloses  a  fissure,  usually  at  the 
posterior  margin,  running  up  the  bowel  one-quarter  to  one-half  an  inch. 
Piles  often  exist  with  fissure. 

Treatm.ent. — The  palliative  treatment  is  to  prevent  constipation,  to  wash 
out  the  rectum  with  cold  water,  and  apply  an  ointment  made  by  evaporating 
5ij  of  the  juice  of  conium  down  to  oij,  and  adding  it  to  3J  of  lanolin  and 
gr.  xij  of  persulphate  of  iron.  Pure  ichthyol  may  do  good.  The  operative 
treatment  is  to  stretch  the  sphincter.  In  order  to  stretch  the  sphincter  the 
patient  is  anesthetized,  the  surgeon's  thumbs  are  inserted  into  the  rectum, 
and  the  parts  are  stretched  until  the  thumbs  touch  the  ischia.  After  stretching 
the  sphincter  incise  the  floor  of  the  fissure,  scrape  it  with  a  curet,  and  touch 
it  with  nitrate  of  silver  stick. 

Hemorrhoids,  or  Piles. — There  are  three  varieties  of  varicose  tumors 
of  the  rectum,  namely:  internal,  which  take  origin  within  the  external  sphinc- 
ter; external,  which  take  origin  without  the  external  sphincter;  and  mixed 
hemorrhoids,  which  are  a  combination  of  the  two. 

External  hemorrhoids  are  covered  with  skin.  Internal  hemorrhoids  are 
covered  with  mucous  membrane.  The  term  external  hemorrhoids  is  not 
strictly  accurate,  as  hemorrhage  does  not  occur  in  external  piles,  and  all  ex- 
ternal piles  are  not  related  to  the  external  hemorrhoidal  veins.  An  external 
pile  may  involve  the  veins  or  the  skin. 

External  Hemorrhoids. — External  hemorrhoids  are  classified  as  throm- 
botic, varicose,  inflammatory,  and  connective-tissue  external  hemorrhoids 
(Tuttle). 

Thrombotic  External  Hemorrhoids. — These  are  external  hemor- 
rhoidal veins  filled  with  clot.  When  an  inferior  hemorrhoidal  vein  inflames, 
the  parts  are  itchy,  painful,  and  swollen,  and  defecation  increases  the  pain. 
The  blood  clots  in  the  inflamed  vein  and  sometimes  the  vessel  ruptures. 

Symptoms  and  Treatment. — External  piles  of  this  variety  are  usually,  but 
not  always,  multiple.  Small  oval  tumors  appear  beneath  the  skin  or  the  junc- 
tion of  the  skin  and  mucous  membrane.  They  appear  suddenly.  The 
parts  itch  and  pain,  defecation  increases  the  pain,  and  each  pile  increases 
rapidly  in  size.  When  the  vein  ruptures,  a  livid,  soft  enlargement  rapidly 
forms.  External  piles  of  this  variety  may  be  absorbed,  may  become  organ- 
ized into  a  scar,  or  may  suppurate.  These  piles  do  not  bleed.  In  treating 
external  hemorrhoids  some  surgeons  merely  use  remedies  to  combat  the 
inflammation.  An  old  plan  of  treatment  is  to  incise  the  blood-tumor,  turn 
out  the  clot,  and  pack  with  a  bit  oi  iodoform  gauze.  Mathews  freezes  the 
part  or  injects  cocain,  catches  up  the  blood-tumor  with  a  volsellum,  excises 
the  tumor  and  the  tabs  of  inflamed  skin,  dusts  the  part  with  iodoform,  and 
dresses  it  with  antiseptic  gauze.     The  bcjwels  should  not  be  allowed  to  move 


Internal   Hemorrhoids  859 

for  two  days.  Never  inject  external  piles  with  carbolic  acid;  it  causes  great 
inflammation,  excessive  pain,  and  is  not  free  from  danger.  If  the  patient 
declines  operation,  order  rest,  a  non-stimulating  diet,  avoidance  of  tobacco 
(Mathews),  the  use  of  saline  purgatives,  injections  into  the  rectum  of  cold 
water  several  times  a  day,  sponging  of  the  anus,  frequently  with  hot  water, 
and  the  application  of  hot  poultices.  As  the  acute  symptoms  begin  to  disap- 
pear use  lead-water  and  laudanum;  when  they  have  nearly  subsided  apply 
zinc  ointment.  Extract  of  hamamelis  is  a  valuable  application  to  external 
piles. 

Varicose  External  Hemorrhoids. — These  are  varicose  external  hemor- 
rhoidal veins  and  are  visible  at  the  anal  margin  when  the  patient  strains. 
They  rarely  produce  pain  or  discomfort  and  it  is  seldom  that  operation  is 
necessary.  The  bowels  should  be  moved  daily,  but  not  with  violent  purga- 
tives, and  after  each  movement  cold  should  be  applied  to  the  anus,  while  the 
patient  is  recumbent.  Tuttle  advocates  the  use  at  night  of  an  ointment 
containing  ^ij  of  suprarenal  extract  and  3vj  of  lanolin.  The  ointment  is 
spread  on  cotton-wool,  which  is  applied  to  the  anus  and  held  in  place  by  a 
T-bandage. 

Inflammatory  Piles. — By  this  term  we  mean  edematous  inflammation 
of  the  anal  folds.  The  inflammation  may  be  due  to  a  traumatism,  the  pres- 
ence of  an  ulcer  or  fissure,  etc.  There  are  burning,  itching,  and  swelling  of 
the  anus,  which  are  greatly  increased  by  defecation.  One  or  more  pear- 
shaped  swellings  can  be  seen  at  the  anal  margin. 

In  some  cases  medical  treatment  produces  cure.  This  treatment  consists, 
during  the  first  twenty-four  hours,  in  the  use  of  cold  and  of  rest  in  bed.  After 
this  period  heat  should  be  employed.  Tuttle  applies  gauze  soaked  in  a  25 
per  cent,  solution  of  boroglycerid  and  places  a  hot-water  bag  over  this.  He 
also  recommends  the  following  ointment  to  be  appHed  two  or  three  times  a 
day : 

R  .      Morphinse  sulph.,  gr.  v-x  ; 

Ichthyol,  H  iv  ; 

Ung.  belladonnas,  )_  M    rz]. 

Ung.  stramonii,       )  "^  ■' 

Sig. — Apply  two  or  three  times  a  day. 

If  these  means  fail,  ether  is  given,  the  sphincter  is  stretched,  and  the 
tumors  are  cut  away. 

Connective-tissue  External  Hemorrhoids  (Skin  Tabs). — They  are 
due  to  h^•pertrophy  of  mucocutaneous  tissue  at  the  anal  margin.  Usually 
they  result  from  acute  inflammatory  external  piles,  sometimes  they  arise 
graduallv  as  a  result  of  chronic  anal  or  rectal  inflammation  or  irritation,  and 
they  may  be  due  to  varicose  or  thrombotic  external  piles  (Tuttle).  They 
produce  no  trouble  when  not  inflamed.  The  treatment,  if  they  cause  serious 
annoyance,  is  extirpation. 

Internal  hemorrhoids  are  varicose  tumors  of  the  internal  hemorrhoidal 
plexus,  and  are  found  internal  to  the  external  sphincter,  just  within  the  anus, 
and  thev  prolapse  easily.  They  are  not  simple  varicosities,  but  new  tissue 
has  been  formed,  and  they  are  in  reahty  vascular  tumors.  They  are  covered 
with  mucous  membrane.  Capillary  piles  are  small,  sessile,  with  a  surface 
like  a  mulberry,  and  bleed  freely.     Children  are  not  very  liable  to  develop 


86o  Diseases   and   Injuries  of  the   Rectum  and  Anus 

piles,  excepting  the  capiUary  form.  Venous  piles  are  the  most  common  va- 
riety. They  extend  from  just  above  the  anal  margin  of  the  rectum  for 
an  inch  or  more.  They  are  purple  in  color,  soft,  irregular  in  outhne,  and 
are  usually  multiple.  They  bleed  when  irritated  by  hard  fecal  masses,  but 
not  so  easily  as  the  capillary  piles.  Each  pile  is  composed  of  a  varicose 
vein,  some  fibrous  tissue,  and  a  few  arterial  twigs.  Arterial  piles  are  very 
unusual.  They  are  large,  smooth,  pedunculated,  bleed  easily  and  freely, 
and  contain,  besides  a  distended  vein,  arteries  of  some  size. 

Anything  producing  venous  congestion  in  the  rectum — constipation,  dis- 
eases of  the  rectum,  enlargement  of  the  prostate,  pregnancy,  tumors  of  the 
womb,  congestion  of  the  liver,  cirrhosis  of  the  liver,  certain  diseases  of  the  heart 
and  lungs,  sedentary  occupations,  relaxing  climate,  and  stricture  of  the  urethra 
— will  cause  hemorrhoids. 

Symptoms  and  Treatment. — If  there  is  no  bleeding  and  no  protrusion,  the 
piles  give  no  trouble.  The  first  symptom  is  usually  hemorrhage,  and  rectal 
examination  by  the  speculum  will  make  clear  the  condition.  After  a  time, 
during  defecation,  the  piles  protrude,  they  may  reduce  themselves  when  the 
patient  stands  up,  or  it  may  be  necessary  to  push  them  in.  Pain  does  not 
exist  in  uncomplicated  cases,  and  pain  during  or  after  protrusion  means  "  abra- 
sion, fissure,  or  ulceration"  (Mathews). 

Palliative  Treatment. — This  will  not  cure,  but  it  will  give  great  comfort. 
Some  people  only  suffer  at  rare  times  when  the  liver  is  congested,  and  such 
subjects  will  not  submit  to  operation.  Remove,  if  possible,  the  cause  (alcohol, 
irritating  foods,  want  of  exercise,  etc.);  restrict  the  diet;  insist  on  regular  ex- 
ercise; give  a  course  of  Carlsbad  salt,  and  follow  this  by  the  stomach  use  of 
bichlorid  of  mercury  (gr.  -jj  after  each  meal).  Prevent  constipation  by  a 
nightlv  dose  of  extract  of  cascara.  After  each  bowel  movement  wash  the  parts 
and  syringe  out  the  rectum  with  cold  water,  and  dry  outwardly  with  a  soft  rag. 
If  the  hemorrhoids  prolapse,  after  restoring  them  and  injecting  cold  water,  in- 
sert a  suppository  containing  gr.  v  of  the  extract  of  hamamelis,  and  use  another 
suppository  at  bedtime.  When  the  piles  prolapse  and  inflame,  rub  Ailing- 
ham's  ointment  on  the  parts  (.^ij  each  of  ext.  of  conium  and  ext.  of  hyoscyamus, 
o]  of  ext.  of  belladonna,  and  oj  of  cosmolin).  Mathews  uses  gr.  xij  of  cocain, 
o]  of  iodoform,  .oss  of  ext.  of  opium,  and  .^j  of  cosmolin.  If  the  piles  are  pro- 
truding and  reduction  cannot  be  effected,  put  the  patient  to  bed,  give  a  hypo- 
dermatic injection  of  morphin,  and  apply  hot  poultices.  If  reduction  cannot 
soon  be  effected,  operation  must  be  resorted  to. 

Operative  Treatment. — Give  a  saline  the  morning  before,  and  an  enema 
the  evening  before  the  operation,  and  wash  out  the  rectum  well  the  morning 
of  the  operation.  In  treating  by  injection  oj  carbolic  acid  the  tumors  are  drawn 
out  or  the  patient  strains  them  out,  an  injection  is  given  by  a  hypodermatic 
syringe  into  the  center  of  the  pile,  and  as  each  pile  is  injected  it  is  pushed  into 
the  rectum.  But  one  or  two  piles  are  injected  at  each  seance  and  the  opera- 
tion is  not  repeated  ff)r  one  week  (Geo.  W.  Gay,  in  ''Boston  Med.  and  Surg. 
Jour.,"  Dec.  5,  1901).  The  dose  for  each  pile  is  n^j  or  n\^ij  of  a  10  per  cent, 
.solution  of  pure  carbolic  acid.  The  injections  relieve  the  condition,  but  are 
rarely  absolutely  curative,  and  may  produce  hemorrhage,  phlebitis,  pyemia, 
stricture,  and  even  death  (W.  T.  Bull).  The  clamp  and  cautery  may  be  used 
in   interno-external  fjiles.     The  patient  is  anesthetized  and  the  sphincter  is 


Internal    Hemorrhoids 


86 1 


4S6. — Extirpa- 
tion of  hemorrhoids 
(Esmarch  and    Kowal- 


stretched.  The  stretching  of  the  sphincter  is  very  important.  It  gives  free 
access  to  the  parts,  prevents  subsequent  spasm  and  pain,  and  lessens  the 
hkehhood  of  venous  bleeding  after  operation.  The  pile  is  caught  with  forceps 
and  drawn  outside  of  the  sphincter.  Smith's  clamp  is  applied  with  the  ivor}^ 
surface  against  the  mucous  membrane  of  the  bowel,  the 
pile  is  cut  off,  and  the  stump  is  seared  with  the  Paquelin 
cautery  at  a  dull-red  heat.  Excision  is  preferred  b}-  Al- 
lingham.  He  stretches  the  sphincter,  holds  it  open  with 
a  retractor,  catches  up  the  pile,  cuts  it  off,  and  twists  the 
bleeding  vessels.  Some  prefer  to  pass  a  silk  or  catgut 
suture,  cut  off  the  tumor,  and  tie  the  thread  (Fig.  486). 
Whitehead's  operation  is  only  to  be  performed  in  severe 
cases,  when  the  piles  are  extremely  large  and  form  a  pro- 
truding circular  mass.  Only  a  surgeon  who  can  master 
violent  hemorrhage  should  venture  to  perform  it.  Pri- 
mary union  is  rarely  secured.  When  first  introduced  the 
operation  was  viewed  with  favor,  but  e.xperience  shows 
that  stricture  not  infrequently  arises  after  its  performance; 

that  fecal  incontinence  occasionally  results,  and  that  anal  anesthesia  with 
inability  to  restrain  the  passage  of  wind  is  common.  The  entire  pile-bearing 
area  of  mucous  membrane  is  dissected  out,  and  the  cut  margin  of  mucous 
membrane  is  pulled  down  and  stitched  to  the  surface.     The  sphincter  may 

be  dilated  as  a  preliminary  measure  (Fig.  487). 
This  operation  is  sometimes  followed  by  disas- 
trous consequences,  especially  by  fecal  incon- 
tinence.* 

The  application  of  the  ligature  is  the  easiest 
and  most  generally  useful  method.  In  this  oper- 
ation, after  anesthetizing,  stretch  the  sphincter 
and  treat  each  hemorrhoid  separately.  Catch 
a  pile  with  a  pair  of  forceps  or  a  volsellum, 
pull  it  down,  and  cut  a  gutter  through  the  skin- 
margin  if  the  pile  is  of  the  mi.xed  variety,  tie 
the  small  piles  without  transfi.xing,  but  transfix 
the  large  piles;  tie  with  silk  (coarse  silk  for  the 
large  piles,  finer  silk  for  the  small  piles) ;  cut  off 
the  tumor  beyond  the  thread,  and  cut  the  liga- 
tures short.  Treat  the  other  piles  in  the  same 
manner.  Irrigate  with  hot  normal  salt  solution, 
dust  with  iodoform,  pack  a  piece  of  iodoform 
gauze  into  the  rectum,  and  apply  a  gauze  pad 
and  a  T-bandage.  Give  .'^ome  morphin  to  lock 
up  the  bowels,  and  keep  the  patient  on  a  light 
diet  for  three  days,  at  the  end  of  which  time  a 
saline  mav  be  given.  Just  before  the  bowels  act  remove  the  dressings  and 
gi\e  an  enema  of  warm  water  or  of  glycerin.  After  the  movement  wash  out 
the  rectum  first  with  peroxid  of  hydrogen  and  next  with  hot  salt  solution, 
dust  with  iodoform,  and  apply  a  gauze  pad  over  the  anus.     Irrigate  daily 

*  Andrews,  in  Mathews'  Medical  Quarterly,  Oct.,  1895. 


Fig.  4S7. — S.  .S,  The  lower  circu- 
lar incision  along  Hilton's  white 
line  ;  M.  tube  of  mucous  membrane 
dissected  from  the  spliiiicter  ;  B.  B, 
dotted  line  showing  the  i>lace  for 
the  upper  circular  incision  (Ed- 
mund .Andrews). 


862 


Diseases  and  Injuries  of  the   Rectum  and  Anus 


until  healing  is  complete.  After  the  tenth  day  examine  with  a  speculum  to 
see  that  the  ligatures  have  come  away;  if  any  are  found  in  place,  remove 
them. 

Prolapse  of  Anus  and  Rectum. — If  the  mucous  membrane  is  pro- 
lapsed, the  condition  is  called  "prolapsus  ani";  if  the  entire  thickness  of  the 
rectal  wall  is  prolapsed,  it  is  called  "prolapsus  recti."  The  commonest  form 
is  due  to  relaxation  of  the  submucous  connective  tissue  permitting  the  pro- 
trusion of  a  ring  of  mucous  membrane.  Prolapse  is  apt  to  occur  from 
excessive  straining  at  stool  and  is  commonest  in  feeble,  ill-nourished  children. 
Piles  and  worms  may  lead  to  prolapse..  Straining  from  phimosis,  stone  in 
the  bladder,   or  urethral  stricture   may  be  causative.     Its  development  is 


Fig.  488.— Joseph  D.  Bryant's  method  of  colopexy  :  A,  A,  Longitudinal  band,  with  sutures  passed 
behind  it,  including  peritoneal  and  muscular  coats  of  the  intestines,  drawn  forward  ;  B,  £,  parietal 
peritoneum  quilted  to  sides  of  the  intestine,  showing  stitches  ;   C,  old  fecal  fistula. 


favored  by  the  use  of  articles  of  food  which  cause  frequent  movements  of 
the  bowels.  If  an  individual  sits  a  long  time  on  the  seat  of  the  closet  or 
on  the  chamber,  the  development  of  prolapse  is  favored.  Prolapse  may 
be  either  large  or  small,  but  tends  to  recur  again  and  again,  and  eventually 
the  mucous  membrane  inflames,  ulcerates,  or  sloughs.  Strangulation  of  the 
prolap.sed  part  may  occur.  The  condition  is  sometimes  confused  with  hemor- 
rhoids, but  in  prolapse  the  protruding  mass  is  circular  and  has  a  depression 
in  the  center,  whereas  hemorrhoids  are  distinct  ma.sses.  Further,  hemorrhoids 
are  very  rare  in  children.     A  polypus  is  a  single  tumor  with  a  pedicle. 

Treatment. — Palliative  treatment  forbids  .straining  at  stool  and  amends 
an  improper  diet.  Phimosis  mu.st  be  corrected;  stone  in  the  bladder  must 
be  crushed  or  removed.     If  prolapse  occurs,  the  protrusion  must  be  bathed 


Ulcer  of  the  Rectum  863 

with  cold  water  and  restored.  Constipation  must  be  prevented  (enema ta 
of  water  or  glycerin  may  be  used),  and  after  each  movement  several  ounces 
of  a  solution  of  white  oak  bark  are  injected.  If  a  prolapse  is  caught 
firmly,  place  the  patient  in  the  knee-chest  position,  wash  the  mass  with 
cold  water,  grease  it  with  cosmolin,  insert  a  finger  into  the  rectum,  and 
apply  taxis  around  the  finger  (Mathews).  If  this  fails,  cover  a  finger  with 
a  handkerchief  and  insert  the  wrapped  digit  into  the  rectum ;  if  this  proves 
futile,  invert  the  patient.  Severe  cases  require  ether  before  reduction  is 
attempted.  After  reduction  apply  a  compress,  direct  it  to  be  worn  except 
when  at  stool,  and  before  each  act  of  defecation  give  an  injection  of  cold 
water  containing  an  astringent  (tannin  or  fluid  ext.  hydrastis).  A  useful 
treatment  in  many  cases  is  to  paint  the  prolapse  with  fuming  nitric  acid, 
grease  it  with  olive  oil,  and  restore  it.  Some  cases  require  excision  of  the 
mucous  membrane,  the  divided  edge  of  this  membrane  being  stitched  to  the 
skin.  In  other  cases  the  protrusion  is  stroked  with  the  cautery  and  restored. 
When  the  surgeon  comes  to  operate  for  recurring  prolapse  it  will  often  be 
found  to  have  modestly  withdrawn  and  he  may  be  obliged  to  stretch  the 
sphincter  to  bring  it  into  view.  In  persistent  cases  of  rectal  prolapse  open 
the  abdomen  and  attach  the  colon  to  the  belly-wall  (colopexy  or  sigmoi- 
dopexy.  Fig.  488). 

Ulcer  of  the  Rectum. — Ulcers  of  the  rectum  are  divided  into  the  simple 
traumatic,  the  syphihtic,  the  tuberculous,  the  dysenteric,  the  gonorrheal, 
and  the  malignant.  Simple  ulceration  is  due  to  abrasion  with  fecal  masses 
or  a  foreign  body,  the  abraded  area  ulcerating.  It  may  follow  an  operation 
for  piles  and  also  protracted  labor  (Allingham),  and  is  apt  to  be  single.  The 
base  and  edges  of  a  simple  ulcer  are  neither  prominent  nor  hard,  and  stricture 
rarely  forms.  Syphilitic  ulceration  is  a  tertiary  lesion  commonest  in  women. 
There  are  numerous  small  ulcers  of  the  mucous  coat  or  submucous  tissue, 
but  little  indurated,  with  sharp-cut  edges  which  are  not  undermined.  These 
ulcers  fuse  and  constitute  one  large  irregular  ulcer;  fibrous  tissue  forms  in 
the  wall  of  the  bowel,  induration  becomes  noticeable,  and  stricture  follows. 
There  is  profuse  discharge,  and  fistulae  are  apt  to  form.  Such  ulcers  may 
be  surrounded  by  nodules  of  a  bluish  color.  In  many  cases  the  first  con- 
dition is  stricture  due  to  the  formation  of  masses  of  fibrous  tissue  in  the 
rectal  walls,  and  ulceration  occurs  secondarily  (Fournier).  In  syphilis  there 
may  be  a  breaking  down  of  a  huge  gummy  mass  or  of  multiple  gummata. 
It  has  been  proved  by  the  microscope  that  tuberculous  ulceration  may  arise 
in  the  rectum.  Tuberculous  ulceration  presents  a  conical  ulcer  with  over- 
hanging edges  and  a  pale-red  base.  There  is  some  mucous  discharge,  some 
tenesmus,  and  a  little  pain,  but  a  stricture  rarely  forms.  Dysentery,  catarrh, 
neoplasms,  and  foreign  bodies  may  produce  ulceration  of  the  rectum. 

Symptoms.— There  may  be  merely  uneasiness  about  the  rectum,  but 
sometimes  there  is  severe  burning  pain  on  defecation.  There  may  be  con- 
stipation or  diarrhea,  the  patient  strains  at  stool,  and  the  stools  may  contain 
blood,  mucus,  or  pus.  The  history  should  be  carefully  inquired  into;  tuber- 
culosis should  be  sought  for;  the  question  of  syphilis  should  be  investi- 
gated. A  digital  examination  enables  the  surgeon  to  feel  the  ulcer,  and  an 
examination  with  an  ordinary  speculum  or  an  electric  proctoscope  brings 
it  into  view. 


864  Diseases  and   Injuries   of  the  Rectum  and  Anus 

Treatment. — In  simple  ulcer  empty  the  bowel  by  the  administration  of 
a  saline  cathartic,  wash  out  the  rectum  with  hot  water  after  the  saline  has 
acted,  introduce  a  speculum,  touch  the  ulcer  with  pure  carbohc  acid  or  silver 
nitrate  (gr.  xl  to  5]),  place  the  patient  in  bed,  restrict  him  to  a  liquid  diet, 
and  every  day  inject  iodoform  and  olive  oil  or  insufflate  iodoform  into  the 
rectum.  If  this  fails,  give  ether,  stretch  the  sphincter,  incise  the  ulcer  through 
its  entire  thickness  and  cauterize  with  fuming  nitric  acid,  caring  for  the 
case  subsequently  as  we  would  a  patient  who  had  had  piles  ligated.  In 
tuberculous  ulcer  improve  the  general  health,  send  the  patient  to  a  genial 
climate,  or  at  least  into  the  sunlight  and  fresh  air,  prevent  constipation, 
give  nutritious  food,  especially  fats,  wash  out  the  rectum  every  day  with 
hot  water,  and  insufflate  iodoform  or  inject  iodoform  emulsion.  Touch  the 
ulcer  once  a  week  with  silver  nitrate  (gr.  x  to  3J).  In  syphilitic  ulcer  give 
antisyphilitic  treatment  and  treat  the  ulcer  locally  as  is  done  in  tuberculous 
ulcer.  Dysenteric  ulcer  requires  injections  of  hot  water,  the  touching  of  the 
ulcer  with  pure  carbolic  acid,  and  insufflations  of  iodoform. 

Non=cancerous  stricture  of  the  rectum  may  be  congenital  or  ac- 
quired. There  are  two  forms  of  acquired  stricture:  first,  stricture  due  to  ex- 
ternal pressure;  second,  stricture  due  to  primary  narrowing  of  the  rectal  wall.* 
Stricture  due  to  external  pressure  is  very  rarely  complete,  and  may  be  caused 
by  bands  of  adhesions  or  a  malignant  growth.  The  second  form  may  be 
produced  by  syphilitic  tissue,  ordinary  inflammatory  tissue,  cicatrices  after 
operations,  sloughing,  tuberculous,  syphihtic,  or  dysenteric  ulceration,  rectal 
gonorrhea,  and  traumatism.  The  usual  seat  of  simple  stricture  is  from 
one  inch  to  one  and  a  half  inches  above  the  anus.  The  deposit  may  be 
limited  to  the  submucous  coat  or  all  the  coats  may  be  involved.  It  is  very 
seldom  that  stricture  arises  as  a  result  of  abrasion  from  fecal  masses  or  foreign 
bodies.  It  may  follow  an  operation  for  piles  if  considerable  tissue  is  re- 
moved, and  is  an  occasional  sequence  of  Whitehead's  operation.  Stricture 
due  to  dysentery  is  extremely  rare,  and  no  case  has  ever  been  reported  to 
the  United  States  Pension  Office  (Peterson).  The  existence  of  stricture  as 
a  result  of  rectal  gonorrhea  has  not  been  positively  proved.  A  majority 
of  sufferers  from  rectal  stricture  have  labored  under  syphilis,  but  it  is  not 
probable  that  the  lesion  is  .syphilitic  in  all  or  even  in  most  of  them.  The 
stricture  may  be  due  to  the  formation  of  fibrous  tissue,  and  ulceration  may 
or  may  not  occur.  It  may  be  caused  by  the  contraction  and  healing  of  a 
large  ulcer.  Some  maintain  that  tuberculous  stricture  does  occur.  Mathews 
dissents  from  this  view  and  points  out  that  the  disposition  of  tuberculous 
matter  is  to  break  down,  and  before  the  rectum  can  be  strictured  from  tuber- 
culosis it  breaks  down  Irom  ulceration.  Petenson  f  says  a  large  proportion 
of  the  victims  of  rectal  stricture  die  of  phthisis,  and  also  that  one-third  of 
so-called  .syphilitic  cases  are  tuberculous.  It  may  begin  as  an  ulcer  or  as 
an  infiltration  of  submucous  tissue.  Although  a  syphilitic  lesion  or  a  tuber- 
culous lesion  may  cause  rectal  stricture,  in  most  cases  such  lesions  simply 
expose  the  tissues  to  infection,  and  a  benign  rectal  stenosis  results  from 
the  infection.  Thence  tuberculosis  causes  stricture  indirectly  rather  than 
directly. 

The  symptoms  of  rectal  stricture  are  constipation,  [)ain  on  defecation, 

*  Reuben  Peterson,  in  Jour.  Amer.  Med.  A.ssoc,  Feb.  3,  1900.  f  Ibid. 


Cancer  of   the   Rectum  865 

straining  at  stool,  the  presence  of  blood  and  mucus  in  the  stools,  an  open 
anus,  and  the  passage  of  stools  flattened  out  into  ribbons.  In  some  cases 
there  is  fluid  diarrhea,  solid  fecal  matter  being  retained  above  the  stricture. 
The  stricture  is  found  by  the  finger  or  by  the  bougie.  In  syphilitic  cases, 
in  tuberculous  cases,  and  in  benign  cases  the  fibrous  thickening  is  usually  in 
the  submucous  coat,  and  in  syphihtic  and  tuberculous  cases  the  mucous 
membrane  is  apt  to  ulcerate.  It  is  said  that  complete  obstruction  may 
arise.  I  have  seen  obstructive  symptoms,  but  never  complete  obstruction 
in    rectal   stricture.     Distention   of  the  abdomen   and  colic  are  very   usual. 

The  treatment  of  non-cancerous  stricture  is  rest,  non-stimulating  diet, 
warm-water  injections,  mild  laxatives,  and  hot  hip-baths.  Cocain  supposi- 
tories may  be  needed.  Any  existing  disease  is  treated.  Bougies  are  passed 
every  other  day.  Use  a  soft-rubber  bougie,  warmed  and  oiled,  and  introduce 
it  gently.  If  only  the  method  of  gradual  dilatation  is  employed,  the  patient 
must  for  the  remainder  of  his  life  pass  a  bougie  from  time  to  time.  For 
fibrous  strictures  forcible  dilatation  (divulsion)  by  a  special  instrument  is 
employed  or  incision  is  practised.  Incision  (proctotomy)  may  be  either 
external  or  internal.  In  internal  proctotomy  one  or  more  incisions  are  made 
through  the  stricture  down  to  healthy  tissue,  the  first  cut  being  in  the  middle 
line  posteriorly.  External  proctotomy,  which  divides  the  sphincters,  is  apt 
to  leave  incontinence  as  a  legacy.  Electrolysis  finds  some  advocates,  but 
on  what  grounds  it  is  difficult  to  see.  In  some  cases  the  rectum  should 
be  removed.     In  incurable  cases  perform  inguinal  colostomy. 

Cancer  of  the  rectum  is  the  cancer  of  the  bowel  most  often  met  with. 
It  may  be  primarily  malignant  or  may  arise  from  an  adenoma.  The  com- 
monest growths  are  composed  of  cylindrical  cells,  and  may  be  soft  or  scirrhous. 
In  cases  secondary  to  epithelioma  of  the  anus  ordinary  epithelioma  arises. 

In  most  rectal  carcinomata  the  cells  present  a  tubular  arrangement  sur- 
rounded by  a  more  or  less  plentiful  stroma  of  connective  tissue.  In  soft  tumors 
the  connective  tissue  is  scanty,  in  hard  tumors  it  is  plentiful. 

It  not  unusually  occurs  before  the  thirty-fifth  year,  and  is  seen  as  early 
as  the  twenty-fourth  year.  The  retroperitoneal  and  inguinal  glands  are 
involved  late  or  not  at  all.  Extensive  ulceration  occurs.  If  a  hard  ring 
encircles  the  rectum,  the  lumen  of  the  tube  is  greatly  and  progressively 
diminished.     In  cases  of  diffuse  infiltration  the  lumen  is  not  greatly  lessened 

Symptoms. — The  symptoms  of  rectal  cancer  are  like  those  of  non- 
malignant  stricture,  except  that  the  pain  is  greater,  the  hemorrhage  more 
severe,  and  constipation  is  apt  to  alternate  with  diarrhea.  The  finger  and 
the  speculum  make  the  diagnosis.  In  rectal  cancer  metastasis  occurs  late. 
The  most  favorable  cases  for  operation  are  those  in  which  the  growth 
is  small  and  movable.  Accurately  define  the  extent  of  the  growth  and  en- 
deavor to  make  out  if  it  has  invaded  the  cellular  tissue  outside  of  the 
rectum,  the  prostate,  the  bladder,  the  sacrum,  the  uterus,  etc. 

Treatment. — In  every  case  of  cancer  of  the  rectum  the  following  question 
must  be  considered:  Shall  we  perform  a  radical  operation  in  hope  of  pro- 
ducing cure  or  at  least  greatly  prolonging  life?  In  what  cases  should  a 
radical  operation  be  attempted?  It  is  the  proper  procedure  if  there  are 
no  metastatic  deposits,  if  the  patient  is  in  fair  general  condition  and  free 
from  serious  organic  disease,  and  if  the  cancerous  bowel  is  movable  and 
55 


866 


Diseases  and  Injuries  of  the   Rectum  and  Anus 


not  fixed  by  dissemination  to  adjacent  structures.  As  W.  Watson  Cheyne 
says  ("Brit.  Med.  Jour.,"  June  13,  1903),  a  slight  adhesion  to  the  vagina 
is  not  a  contraindication  because  this  portion  of  the  vagina  can  be  readily 
removed  with  the  diseased  rectum.  Some  surgeons  will  not  attempt  radical 
operation  if  they  cannot  pass  a  finger  through  the  growth.  I  do  not  regard 
high  position  as  forbidding  operation,  although,  of  course,  it  makes  it  more 
dangerous  to  life  and  less  promising  as  to  cure.  Cheyne  is  of  the  same 
opinion. 

If  a  radical   operation   is  determined   on,   the   next   question   to  answer 


Fig.  489. — Tying  off  the  tumor  through  an 
abdominal  incision  after  separating  peritoneum 
from  sacrum  and  bladder  (Weir). 


Fig.  490. — Lower  end  of  rectum  everted 
through  the  anus  and  the  upper  end  of  bowel 
drawn  out  of  the  abdominal  cavity  (Weir). 


Fig.  491. — a,  The  upper  bowel  drawn  out 
through  the  everted  lower  end  of  rectum  ;  b, 
the  ends  of  the  two  portions  of  the  rectum  sewn 
together  (Weir). 


Fig.  492. — The  united  bowel  replaced  with 
posterior  drainage  and  the  divided  peritoneum 
so  sewn  together  as  to  shut  off  the  general 
peritoneal  cavity  from  the  pelvis  (Weir). 


is,  Shall  we,  or  shall  we  not,  do  a  preliminary  colostomy  ?  If  the  cancer 
is  very  low  down  and  is  to  be  removed  from  the  perineum,  preliminary  colos- 
tomy should  not  be  done.  If  the  cancer  is  high  up  and  we  propose  to  attack 
it  by  Weir's  method,  prehminary  colostomy  should  not  be  done.  If  Kraske's 
operation  is  to  be  performed,  we  believe  prehminary  colostomy  is  indicated. 
It  enables  us  to  cleanse  the  area  upon  which  operation  is  to  be  performed, 
and  to  keep  the  wound  clean,  and  it  gives  us  a  much  better  chance  of  obtaining 
primary  union.  In  ca.ses  in  which  the  sphincter  is  retained  and  it  is  possible 
to  anastomose  the  divided   ends  of  the   rectum   together,   colostomy  is  not 


Cancer  of  the   Rectum 


867 


necessary;  and  if  an  artificial  anus  has  be',n  made  in  such  a  case,  anocher 
operation  will  be  required  to  close  it.  As  a  matter  of  fact,  I  have  found 
it  always  difi&cult  and  usually  impossible  tc  suture  the  divided  ends  of  the 
gut  together  after  Kraske's  operation,  and  I  now  follow  the  advice  of  Keen, 
and  always  precede  it  by  a  colostoma  j.f  radical  operation  is  rejected  (and 
at  least  three-fifths  of  the  cases,  when  tirst  seen  by  the  surgeon,  are  beyond 
such  aid),  palliative  treatment  is  desirable.  One  plan  is  to  every  day  intro- 
duce a  tube  through  the  stricture,  wash  out  the  rectum  with  warm  water, 
and. after  washing  inject  emulsion  of  iodoform  (gr.  x  to  5J  of  sweet  oil).  In- 
jections of  chlorid  of  zinc  (gr.  j  to  5J  of  water)  lessen  the  foulness  of  the 
discharge.  The  bowels  are  opened  regularly  by  laxatives,  and  if  the  growth 
causes  obstructive  symptoms  it  is  scraped  away  with  a  sharp  spoon.  Opium 
is  given  to  reheve  pain.  The  advantage  of  this  plan  is  that  the  patient  does 
not  suffer  from  the  unpleasantness  of  an  artificial  anus.  Sooner  or  later,  how- 
ever, the  growth  gets  outside  of  the  bowel,  and  terrible  pain  will  arise  from 
involvement  of  the  sacral 
plexus.  W.Watson  Cheyne 
("Brit.  Med.  Jour.,"  June 
13,  1903)  would  restrict 
palliative  treatment  of  this 
character  to  cases  in  which 
f  ungating  masses  grow 
from  one  side  of  the  bowel. 
If  a  growth  encircles 
the  bowel  and  produces 
symptoms  of  obstruction, 
colostomy  must  be  per- 
formed. This  operation 
gives  great  comfort  to  the 
patient,  and  allays  pain  by 
intercepting  the  feces  be- 
fore they  reach  the  cancer. 
I  am  not  convinced  that 
it    distinctly    retards    the 

growth  of  the  cancer  or  notably  prolongs  life.  Unfortunately,  colostomy  does 
not  do  away  with  pain  if  the  sacral  plexus  is  involved.  Operative  treatmeut  in- 
cludes one  of  several  procedures.  Excision  of  the  rectum  from  below  (Cripp's 
operation)  is  practised  if  not  more  than  three  inches  require  removal,  if  the  peri- 
toneum is  not  invaded,  and  if  the  adjacent  organs  are  free  from  disease.  The 
peritoneum  must  not  be  opened  in  Cripp's  operation.  After  the  growth  is  re- 
moved the  divided  rectum  is  pulled  down  and  sutured  to  the  skin.  Excision 
of  the  rectum  after  excising  a  portion  of  the  sacrum  (Kraske's  operation, 
Fig.  493)  is  a  procedure  which  permits  removal  of  the  entire  tube,  portions 
of  the  colon,  and  even  of  adjacent  parts.  The  peritoneum  is  opened  de- 
liberately in  this  operation,  and  is  subsequently  closed  with  sutures  before 
the  gut  is  opened.  The  glands  from  the  mesocolon  are  always  removed. 
The  lower  end  of  the  upper  segment  of  bowel  is  fastened  in  the  wound,  or, 
if  colostomy  has  been  previously  performed,  may  be  closed.  In  some  few 
cases  in  which  it  is  not  necessary  to  remove  the  lower  end  of  the  rectum, 


Fig.  493.— Different  levels  of  resection  of  the  sacrum  : 
A',  O.  Kochers  line;  B.  V.  Kraske's;  B.  H,  Hochenegg's  ; 
B,  D,  Bardenheuer's ;  R,  S,  Rose's  (Mass). 


868  Diseases  and  Injuries  of   the   Rectum  and  Anus 

the  two  portions  may  be  anastomosed  after  resection  of  a  part  of  the  tube. 
Kraske's  operation  may  be  done  by  an  osteoplastic  method,  the  bone  not 
being  removed.  It  is  well  to  precede  a  Kraske  operation  two  weeks  by  an 
inguinal  colostomy,  which  permits  of  cleansing  the  lower  bowel  of  feces  and 
lessens  the  chance  of  severe  wound-infection  and  delayed  healing  after  the 
removal  of  the  rectum.  A  preliminary  colostomy  may  make  the  operation 
of  extirpation  more  difficult  by  fixing  the  intestine,  and  thus  interfering 
with  the  necessary  drawing  down  of  the  gut  (E.  H.  Taylor).  If  the  growth 
is  extensive  and  the  mesocolon  short,  it  may  be  best  to  perform  a  right  inguinal 
colostomy;  but  in  most  cases  left  inguinal  colostomy  is  preferred  (Gerster). 
The  colostomy  remains  open  during  the  patient's  life,  except  in  those  rare 
cases  of  Kraske's  operation  in  which  the  continuity  of  the  rectum  can  be 
re-established  after  excision  of  the  growth.  In  such  cases  the  artificial  anus 
is  closed  some  time  after  the  resection  of  the  rectum. 

Robt.  F.  Weir  ("Med.  News,"  July  27,  1901)  has  been  so  much  impressed 
with  the  difficulties  and  dangers  of  Kraske's  operation  in  a  case  of  high 
carcinoma  that  he  now  employs  it  solely  in  cases  in  which  there  is  freedom 
from  disease  for  two  inches  immediately  above  the  anus  and  in  which  the 
cancer  does  not  extend  more  than  five  inches  above  the  anus.  In  other 
cases  he  does  the  following  operation:  Open  the  abdomen  above  the 
pubes,  separate  the  peritoneum  so  that  the  bowel  and  "contents  of  the 
sacral  curve"  are  liberated  behind  nearly  "to  the  tip  of  the  coccyx  and 
in  front  of  the  edge  of  the  prostate. "  The  tumor  is  then  tied  oft'  with 
tapes  (Fig.  489).  The  portion  of  the  rectum  bearing  the  tumor  is  removed, 
the  lower  end  of  the  bowel  is  everted  through  the  anus,  and  the  upper  end 
is  drawn  out  of  the  abdominal  incision  (Fig.  490).  The  upper  end  is  then 
caught  with  forceps  and  drawn  through  the  everted  lower  end  of  the  rectum 
(Fig.  491,  a).  The  ends  of  the  two  everted  portions  (Fig.  491,  b)  are  sewn 
together,  the  everted  bowel  is  replaced,  the  divided  peritoneum  is  sutured 
to  shut  off  the  peritoneal  cavity,  and  posterior  drainage  is  inserted  (Fig.  492). 
The  mortality  of  Kraske's  operation  is  from  12  to  15  per  cent.  Twenty-eight 
per  cent,  of  Kocher's  cases  of  extirpation  of  cancer  of  rectum  remain  well  from 
3  to  16  years  after  operation  (W.  W.  Cheyne,  "Brit.  Med.  Jour.,"  June  13, 

1903)- 


XXIX.  ANESTHESIA  AND  ANESTHETICS. 

Anesthesia  is  a  condition  of  insensibility  or  loss  of  feeling  artificially 
produced.  An  anesthetic  is  an  agent  which  produces  insensibility  or  loss 
of  feeling.  Anesthetics  are  divided  into — (i)  genera!  anesthetics,  as  amylene, 
chloroform,  ethylene  chlorid,  ether,  bromid  of  ethyl,  nitrous  oxid,  and  bichlorid 
of  methylene;  (2)  local  anesthetics,  as  alcohol,  bisulphid  of  carbon,  chlorid 
of  ethyl,  carbolic  acid,  ether  spray,  cocain,  eucain,  ice  and  salt,  rhigolene 
spray,  and  ethyl  chlorid  spray. 

Ane.sthesia  may  be  induced  by  a  general  anesthetic  to  abolish  the  usual 
[jain  of  labor  and  of  surgical  procedures;  to  produce  muscular  relaxation 
in  tetanus,  hernite,  dislocations,  and  fractures;  and  to  aid  in  diagnosticating 
abdominal  tumors,  joint-diseases,  fractures,  and  malingering. 


Preparation   of   the   Patient  869 

Death=rate  from  Anesthetic  Agents. — Hewitt  combines  the  statistics 

of   Julhard  and  Ormshy,  with  the  following  result  ("Anesthetics  and  their 
Administration  ")  : 

A,.-c-<=-ru,r-T-.^  Total  Number  of        Total  Number  of  ^^^ 

Anesthetic.  |    administrations.     :  Deaths.  Death-rate. 


Chloroform 
Ether      .    . 


676,767 
407,553 


214  I  in  3162 

25  I  in  16,302 


Hewitt  finds  that  during  the  last  forty  years  only  thirty  fatalities  are 
recorded  as  produced  by  nitrous  oxid,  and  he  thinks  several  of  these  should 
be  excluded.  It  is  practically  certain,  however,  that  many  deaths,  or  at 
least  some  deaths,  have  not  been  recorded. 

Ware  ("Jour.  Amer.  Med.  Assoc,"  Nov.  8,  1902)  collected  12,436  in- 
stances of  anesthesia  by  chloric!  of  ethyl,  with  one  death. 

Preparation  of  the  Patient.— Whenever  possible,  prepare  a  patient 
before  administering  a  general  anesthetic,  and  prepare  him,  if  the  case  admits 
of  it,  during  two  or  more  days.  Heart  disease  is  not  a  positive  contraindica- 
tion to  surgical  anesthesia.  It  is  quite  true  that  anesthetics  are  dangerous 
to  people  with  fatty  hearts,  but  shock  is  also  dangerous,  and  the  surgeon 
stands  between  the  Scylla  of  anesthesia  and  the  Charybdis  of  shock.  Gallant 
truly  says  that  not  enough  attention  is  paid  to  the  "character  of  the  pulse 
and  action  of  the  heart  before  operation,  by  which  to  compare  its  work  during 
anesthesia,  and  after  the  operation  is  over,  and  this  neglect  leads  to  unneces- 
sary stimulation  and  overdriving  a  heart  which  is  doing  its  average  best."* 
Always  examine  the  urine  if  the  nature  of  the  case  allows  time.  If  albumin, 
is  found,  operation  is  not  contraindicated ;  but  the  peril  of  anesthesia  is 
greater,  and  certain  dangers  are  to  be  watched  for  and  guarded  against. 
If  much  albumin  is  present,  postpone  operation  except  in  emergencv  cases. 
If  sugar  is  found,  the  danger  is  considerable,  as  diabetic  coma  occasionally 
develops.  The  percentage  of  sugar  does  not  determine  the  amount  of  danger. 
Coma  may  arise  when  only  a  little  sugar  is  present,  and  may  not  arise  when 
there  is  a  considerable  amount.  The  presence  of  aceto-acetic  acid  is  ominous. 
Empty  the  intestinal  canal  by  purgation  a  number  of  hours  before  anesthe- 
tization. It  is  well  to  give  the  bowel  six  to  twelve  hours'  rest  before  operation. 
The  usual  custom  is  to  give  a  saline  cathartic  the  evening  before  operation 
and  an  enema  early  on  the  morning  of  the  operation.  Of  course,  frequently 
the  nature  of  the  case  or  the  necessity  for  haste  does  not  permit  of  preliminarv 
emptying  of  the  intestine  by  the  administration  of  cathartics.  During  the 
twenty-four  hours  preceding  operation  food  should  be  taken  in  small  amounts 
and  in  forms  easily  digestible.  During  the  day  or  so  before  operation  there 
is  usually  impaired  digestion,  and  no  undue  strain  should  be  put  upon  the 
stomach.  In  the  morning  allow  no  breakfast  if  the  operation  is  to  be  per- 
formed at  an  early  hour;  but  if  the  patient  is  very  weak,  order  a  little  brand v 
and  beef-tea.  If  the  operation  is  to  be  about  noon,  give  a  breakfast  of  beef- 
tea  and  toast  or  a  little  consomme;  never  give  any  food  within  three  hours 
of  the  operation,  but  brandy  is  admissible  if  it  is  required.     If  the  stomach 

*  Medical  Record,  February'  2,  1899. 


870  Anesthesia  and  Anesthetics 

is  not  ,mpty  at  the  time  of  operation,  vomiting  is  almost  inevitable,  and 
porti ,  IS  of  food  may  enter  the  windpipe ;  if  the  stomach  contains  no  food, 
vorr/ting  is  far  less  hkely  to  happen;  and  even  if  it  occurs  and  vomited  matter 
sh  :ald  enter  the  windpipe,  it  may  do  little  harm,  as  it  consists  chiefly  of 
liquid  mucus.  In  cases  of  intestinal  obstruction  in  which  there  has  been 
.tercoraceous  vomiting  there  is  much  danger  that  vomiting  will  occur  during 
anesthetization.  In  some  cases  of  intestinal  obstruction,  during  the  adminis- 
tration of  the  anesthetic,  and  during  the  anesthetic  state,  a  stream  of  stinking 
brown  fluid  may  flow  without  effort  from  the  mouth.  Vomiting  or  regurgi- 
tation of  stercoraceous  material  is  profuse,  sudden,  and  dangerous.  It  may 
flood  the  bronchial  tubes  during  inspiration  and  cause  death  by  sufifocation. 
In  a  case  in  which  stercoraceous  vomiting  has  occurred  wash  out  the  stomach 
before  administering  the  anesthetic.  If  a  patient  with  intestinal  obstruction 
is  too  weak  to  permit  lavage,  a  local  anesthetic  should  be  used  instead  of 
a  general  anesthetic.  Vomiting  while  the  patient  is  under  the  influence  of 
an  anesthetic  is  dangerous  in  any  case,  because  of  the  great  cardiac  weakness 
which  precedes  and  follows  it.  If  a  patient  sleeps  well  the  night  before 
an  operation,  he  will  probably  take  the  anesthetic  better  than  if  he  sleeps 
poorly.  Effort  should  be  made  to  obtain  a  night's  sleep.  An  excellent 
expedient  is  a  hot  ammonia  bath,  followed  by  a  rub-down  with  weak  alcohol.* 
It  may  be  necessary  to  administer  trional  or  bromid.  Before  giving  the 
anesthetic  see  that  artificial  teeth  are  removed  and  that  the  patient  does 
not  have  a  piece  of  candy  or  a  chew  of  tobacco  in  the  mouth.  Always  have 
a  third  party  present  as  a  witness,  because  in  an  anesthetic  sleep  vivid  dreams 
often  occur,  and  erotic  dreams  in  women  may  lead  to  damaging  accusations 
against  the  surgeon.  Place  the  patient  recumbent.  The  effort  should  be 
to  place  him  in  as  comfortable  a  position  as  possible  if  this  position  is  consistent 
with  operative  necessities.  See  that  the  clothing  is  loose,  particularly  that 
there  is  no  constriction  about  the  neck  and  abdomen.  Do  not  have  the 
head  high  unless  this  position  is  demanded  by  the  exigencies  of  the  operation. 
The  anesthetist  must  have  a  mouth-gag  and  a  pair  of  tongue  forceps.  It  is 
very  wrong  to  say  that  a  mouth-gag  and  tongue  forceps  are  never  neces- 
sary. It  is  quite  true  they  are  often  used  when  not  needed,  but  this  does 
not  justify  us  in  being  without  them  when  they  are  needed,  and  they  may  be 
needed  very  badly.  The  anesthetist  should  also  have  a  pair  of  artery  forceps 
and  some  small  gauze  sponges  to  swab  out  the  mouth  and  throat.  A  hypoder- 
matic needle  in  working  order,  and  solutions  of  strychnin,  atropin,  digitalis, 
and  brandy  are  to  be  in  a  readily  accessible  place,  and  it  is  well  to  have 
an  electric  battery  and  a  can  of  oxygen  at  hand.  Accidents,  it  is  true,  are 
rare,  but  they  may  happen  at  any  time,  and  hence  the  surgeon  should 
always  be  prepared  for  them.  Any  danger  which  arises  must  be  met  with 
promptness  and  decision,  or  action  will  be  of  no  avail.  Many  surgeons 
give  a  hypodermatic  injection  of  morphin  a  short  time  before  operation,  to 
steady  the  heart,  prevent  vomiting  during  anesthetization,  to  shorten  the  stage 
of  excitement,  and  aid  the  bringing  about  of  in.sensibility  with  very  little  of 
the  anesthetic.  There  are,  however,  objections  to  morphin  before  anes- 
thesia, and  its  use  should  be  the  exception  and  not  the  rule.  It  depres.ses 
the   respiration,   lowers    temperature,   and   thus    increases  operative    shock, 

*  A.  Ernest  Gallant,  Med.  Record,  Dec.  30,  1899. 


Ether  and  Chloroform  871 

interferes  with  the  pupillary  phenomena  of  anesthesia,  delays  awakening 
from  the  anesthetic  sleep,  and  actually  favors  post-anesthetic  vomiting.  In 
some  cases  we  may  anticipate  trouble  from  the  anesthetic.  Cyanosis  may 
occur  in  drunkards;  in  fat,  thick-necked  individuals  of  the  Major  Bagstock 
type,  who  are  short  of  breath  and  congested  in  appearance;  in  individuals 
with  some  disease  of  the  lungs,  bronchi,  pharynx,  larynx,  or  trachea 
(empyema,  emphysema,  chronic  bronchitis,  croup,  cancer  of  the  larynx,  etc.); 
in  individuals  suffering  from  fatty  heart  or  valvular  incompetence.  Buxton 
points  out  that  an  individual  without  teeth  and  with  stenosis  of  the  nares 
is  apt  to  become  cyanotic  under  an  anesthetic,  because  the  lips  and  pillars 
of  the  fauces  are  drawn  in  like  valves  during  inspiration. 

Ether  and  Chloroform.— The  two  favorite  anesthetics  are  ether  and 
chloroform.  Only  the  very  best  ether  or  chloroform  should  be  used.  It 
is  a  good  plan,  in  order  to  lessen  bronchitis,  to  mix  with  ether  turpentine 
of  Pinus  pumilio  in  the  proportion  of  20  drops  to  6^  oz.  (Becker,  in  "  Cen- 
tralbl.  f.  Chir.,"  June  i,  1901).  Chloroform  is  more  dangerous  than  ether 
in  general  cases,  though  it  is  more  agreeable,  less  irritant  to  the  lungs  and 
kidneys,  and  quicker  in  its  action.  Chloroform  is  a  safer  anesthetic  in  warm 
than  in  cold  countries.  In  fact,  in  the  tropics  it  is  difficult  or  impossible 
to  use  ether  because  of  its  great  volatility.  Chloroform  is  preferred  in  cam- 
paigns, because  less  is  required  and  transportation  is  easier.  Recovery  from 
chloroform  is  quicker  and  quieter  than  that  from  ether,  but  chloroform- 
vomiting  lasts  longer  than  ether-vomiting.  Chloroform  may  induce  sudden 
and  even  fatal  syncope.  Hare's  experiments  on  animals  indicate  that  chloro- 
form may  kill  by  respiratory  failure  occurring  secondarily  to  failure  of  the 
vaso-motor  center;  but  certain  it  is  that  chnically  the  danger  of  chloroform 
is  paralysis  of  the  heart,  and  this  condition  may  come  on  so  rapidly  that 
death  may  occur  almost  before  an  attempt  can  be  made  to  save  life.  Leonard 
Hill  has  proved  that  most  chloroform-deaths  that  take  place  after  considerable 
of  the  anesthetic  has  been  taken  arise  from  paralytic  distention  of  the  heart. 
Sudden  death,  when  inhalations  of  chloroform  have  ju.st  commenced,  may 
be  due  to  the  irritant  vapor  acting  on  the  nasal  mucous  membrane,  exciting  a 
nasal  reflex  and  powerfully  stimulating  cardiac  inhibition.  If  ether  produces 
danger  it  does  so  usually  through  the  respiration,  and  not  the  heart,  and  there 
is  generally  time  to  undertake  means  of  resuscitation,  which  means  are  apt 
to  be  successful.  Chloroform  is  to  be  preferred  to  ether  in  the  following 
cases:  for  children  under  ten  3'ears  of  age,  in  whom  ether  causes  a  great 
outflow  of  bronchial  mucus,  which  may  asphyxiate;  for  people  over  sixty, 
free  from  advanced  cardiac  disease,  at  which  age  most  persons  have  some 
bronchitis,  and  ether  chokes  them  up  with  mucus.  Ether  also  irritates  the 
kidneys,  which  at  the  latter  age  are  apt  to  be  weak  or  diseased.  Chloroform 
is  given  if  the  actual  cautery  is  to  be  used  about  the  face,  neck,  or  mouth, 
because  ether  vapor  may  take  fire  and  chloroform  vapor  will  not.  Chloroform 
is  preferred  for  labor  cases,  when  moderate  anesthesia  only  is  required,  and 
for  operations  on  the  mouth  and  nose.  In  cleft-palate  operations  chloro- 
form is  usually  preferred,  because  it  causes  but  little  cough  and  salivary  flow. 
In  ligation  of  a  large  artery  which  is  overlaid  by  a  vein,  ether  exercises  the 
unfortunate  influence  of  greatly  enlarging  the  vein.  Hence  in  such  a  case 
chloroform  makes  the  operation  easier.     In  goiter  operations  ether  should 


872  Anesthesia  and  Anesthetics 

not  be  used,  as  it  enlarges  enormously  the  veins.  In  fact,  a  goiter  should 
be  removed  with  the  aid  of  local  anesthesia.  Chloroform  is  particularly- 
dangerous  when  there  is  myocardial  disease,  and  is  apt  to  produce  cyanosis 
and  embarrassed  respiration.  In  valvular  heart  disease  chloroform  is  more 
dangerous  than  ether,  and  even  in  functional  heart  trouble  it  is  an  undesirable 
anesthetic.  Chloroform  is  preferred  for  patients  with  difficult  respiration 
from  any  cause  other  than  heart  disease,  for  patients  with  kidney  disease, 
and  for  patients  with  diabetes.  Some  surgeons  do  not  use  ether  in  abdominal 
operations,  because  they  believe  it  may  cause  persistent  oozing  of  blood, 
but  this  view  is  not  in  accord  with  the  author's  experience.  Ether  is  the 
best  and  safest  anesthetic  for  general  use.  It  is  much  safer  than  chloroform 
in  valvular  disease  and  functional  heart  trouble.  It  is  dangerous  in  myo- 
cardial disease,  but  not  nearly  so  dangerous  as  chloroform.  In  valvular 
disease  without  heightened  arterial  tension  it  is  reasonably  safe,  but  in  valvular 
disease  with  heightened  arterial  tension  it  is  dangerous.  Ether  is  dangerous 
when  atheroma  exists.  Both  ether  and  chloroform  may  induce  changes 
in  the  blood.*  In  practically  all  cases  they  produce  a  diminution  of  hemo- 
globin and  leukocytosis.  In  some  cases  they  produce  alteration  in  the  shape 
of  the  corpuscles.  These  changes  are  especially  marked  in  anemic  blood. 
Ether  produces  distinct  leukocytosis,  probably  toxic  in  origin.  These  blood- 
changes  indicate  that  prolonged  anesthesia  may  militate  against  recovery 
from  a  severe  operation.  If  a  patient's  hemoglobin  is  below  30  per  cent., 
a  general  anesthetic  should  not  be  given.  During  the  state  of  anesthesia 
the  temperature  drops  from  one  to  three  degrees,  hence  the  patient  should 
be  carefully  covered  during  the  operation.  The  question  as 'to  the  effect 
of  ether  on  the  kidneys  is  much  disputed.  Most  surgeons  believe  that  it 
tends  to  cause  albuminuria  or  increase  existing  albuminuria.  Nitrous  oxid 
is  very  dangerous  when  there  is  vascular  degeneration,  and  it  may  induce 
apoplexy.  In  giving  ether  or  chloroform  the  administrator  must  devote  his 
undivided  attention  to  the  task.  He  must  note  every  symptom,  must  order  or 
carry  out  proper  treatment  for  comphcations,  and  must  keep  the  operator  in- 
formed as  to  the  necessity  for  haste.  The  anesthetist  must  be  a  man  who  has 
a  wholesome  respect  for  ether  and  chloroform,  although  not  afraid  of  them. 

Can  an  anesthetic  be  administered  to  a  sleeping  person  without  waking 
him?  I  know  that  chloroform  can  be  so  given,  for  I  have  succeeded  in 
giving  it  to  a  child  without  breaking  the  slumber.  Probably,  in  most  cases, 
an  attempt  will  fail,  but  in  some  it  will  succeed.  Stone  ("Cleveland  Med. 
Jour.,"  Jan.,  1902)  reports  successful  administration  to  sleeping  children 
and  also  the  chloroforming  of  a  resident  physician  while  asleep.  Paugh 
("Jour.  Amer.  Med.  Assoc,"  May  18,  1901)  reports  three  successes  with 
children.  Ether,  because  of  the  irritant  nature  of  its  vapor,  would  be  more 
apt  to  arouse  a  sleeper  than  would  chloroform. 

Administration  of  Chloroform.— Chk)roform  should  be  given  only 
by  a  trained  man.  In  fact,  safety  in  giving  chloroform  is  dependent  upon 
skill  and  experience  more  than  in  giving  ether.  The  most  dangerous  period 
is  when  the  patient  is  incompletely  anesthetized,  but  is  going  under.  Most 
deaths   happen    at   this   time.     In    administering   chloroform    have   at   hand 

*  See  the  Author  on  the  "Blood-alterations  of  Ether-anesthesia,"  Medical  News, 
March  2,   1895,  and  also  The  Proceedings  of  the  American  Surgical  Assoc,  for  1901. 


Administration   of    Chloroform 


873 


a  mouth-gag,  tongue  forceps,  artery  forceps,  small  gauze  sponges,  a  clean 
towel,  a  hypodermatic  syringe,  solutions  of  strychnin,  atropin,  and  brandy, 
an  electric  battery,  and  a  can  of  oxygen.  Use  only  pure  chloroform  (Squibb's). 
The  patient  must  be  recumbent.  No  special  inhaler  is  required,  but  the 
drug  may  be  given  upon  a  thin  towel,  a  napkin,  or  a  piece  of  lint.  The 
mask  of  Skinner  is  very  useful  (Fig.  493,  B).  Junker's  inhaler  is  used  by  many 
anesthetists  (Fig.  493,  A).  In  operations  about  the  face  Souchon's  instrument 
is  serviceable.  Souchon's  apparatus  is  so  arranged  that  chloroform  may 
be  given  through  a  tube  which  is  introduced  through  the  nose,  the  instru- 
ment being  well  out  of  the  way  of  the  operator.  Some  surgeons  cocainize 
the  nares  before  giving  chloroform,  so  as  to  prevent  supposedly  dangerous 
nasal  reflex  (Rosenberg).  It  is  a  good  plan  to  smear  the  lips  with  cosmolin 
to  prevent  blistering.  The  chloroform-vapor  must  be  well  mi.xed  with  air. 
The  chloroform  is  sprinkled  on  the  fabric  with  a  drop-bottle.  Raise  the 
napkin  well  above  the  mouth,  add  five  drops  of  chloroform,  and  tell  the 
patient  to  take  deep  and  regular  breaths,  but  do  not  tell  him  to  breathe 
forcibly.     Forcible  respiration  may  lead  to  cessation  of  respiration.     Add  a 


Fig.  493,  A. — Junker's  inhaler. 


Fig.  493,  B. — Skinner's  mask. 


few  more  drops  of  chloroform,  and  when  the  patient  grows  so  accustomed  to 
it  that  it  does  not  choke,  turn  the  wet  part  of  the  fabric  toward  the  face  and 
place  it  near  the  mouth;  do  not  touch  the  mouth  with  the  wet  lint,  because 
it  will  blister.  If  the  drug  is  given  gradually,  struggling  is  not  usually  violent 
or  prolonged.  Never  pour  on  a  large  amount  at  one  time.  Keep  the  lower 
jaw  pushed  forward  during  the  time  the  chloroform  is  being  given.  Cough 
and  vomiting  at  this  time  mean  that  the  vapor  is  too  strong.  During  the 
stage  of  excitement  do  not  suspend  the  administration  of  chloroform  unless 
respiration  becomes  difficult,  in  which  case  suspend  it  until  the  patient  takes 
one  or  two  respirations.  If  the  patient  struggles,  do  not  hold  him  and  push 
the  administration  of  the  drug.  He  holds  his  breath  while  struggling,  and 
as  struggling  ceases  takes  full,  deep  breaths.  If  the  inhaler  is  saturated 
with  chloroform,  he  may  inhale  a  dangerous  amount  during  the  deep  respira- 
tion after  struggling.  Chloroform  given  in  considerable  amount  when  the 
patient  is  breathing  deeply  from  the  effects  of  ether  is  unsafe.  If  chloroform 
is  given  subsequent  to  anesthetization  by  ether,  it  should  be  given  gradually 
and  well  mixed  with  air.  When  the  patient  becomes  anesthetized,  give 
just  enough  of  the  drug  to  keep  him  so.     After  the  patient  has  been  anes- 


874 


Anesthesia  and  Anesthetics 


thetized,  hiccough  usually  means  that  vomiting  is  going  to  occur.  If  vomiting 
occurs  at  this  time,  more  chloroform  must  be  given  to  abolish  the  reflexes. 
Deep  and  sighing  respiration  and  repeated  swallowing  indicate  that  more 
of  the  anesthetic  is  required.  Stop  the  administration  or  give  very  little 
when  shock  becomes  evident  or  when  there  is  profuse  hemorrhage.  Chloro- 
form-vapor is  not  inflammable,  hence  it  is  safer  than  ether  when  a  hot  iron 
is  to  be  used  about  the  face  and  when  there  is  a  lighted  lamp  or  a  stove  in 
a  small  room;  but  the  presence  of  flame  decomposes  chloroform  into  irritant 
products  of  chlorin,  which  sometimes  cause  the  patient  and  the  surgeon 
to  cough  (C,  HCl,  and  CCl,). 

Chloroform  and  Oxygen. —The  use  of  this  mixture  was  suggested 
by  Neudorfer.  Some  anesthetists  advocate  the  use  of  chloroform  and  oxygen, 
asserting  that  it  does  not  produce  spasm  of  the  glottis  or  muscles  of  respiration, 
that  it  does  not  produce  cyanosis  or  weakness  of  circulation,  that  it  does 
not  irritate  the  kidneys,  is  safer  to  life  than  pure  chloroform,  and  is  less 
often  productive  of  severe  and  prolonged  vomiting.  These  alleged  advan- 
tages are  probably  stated  with  rather  undue  em- 
phasis, although  I  do  believe  the  mixture  has  less 
tendency  to  produce  cyanosis  than  has  the  pure 
drug,  is  not  so  often  followed  by  vomiting,  and 
is  somewhat  safer.  Hewitt  does  not  think  that 
the  method  offers  any  "special  advantages" 
("Anesthetics  and  their  Administration,"  by 
Fred.  W.  Hewitt).  If  this  method  is  used,  a  bag 
containing  oxygen  is  attached  to  the  hand- 
bellows  attachment  of  a  Junker  inhaler,  and 
oxygen  is  forced  through  the  chloroform  and  is 
taken  to  the  face-piece. 

Administration  of  Ether. — The  adminis- 
tration should  not  be  intrusted  to  a  novice.  The 
anesthetist  should  be  one  of  your  best  men. 
Ether  is  best  given  by  a  partially  open  inhaler. 
The  most  satisfactory  appliance  is  AUis's  inhaler  (Fig.  494).  This  inhaler 
secures  a  plentiful  supply  of  air.  Before  being  used,  the  metal  frame  is  scalded, 
dried,  and  threaded  with  a  clean  gauze  bandage.  The  end  of  the  frame  which 
is  to  be  toward  the  mouth  is  covered  with  one  layer  of  gauze.  The  frame  is 
then  inserted  in  a  clean  metal  case  and  the  case  is  wrapped  in  a  clean  towel. 
Many  surgeons  prefer  closed  inhalers.  The  Clover  inhaler  is  popular  in 
England  (Fig.  495).  F  is  the  face-piece;  C,  a  reservoir  of  ether  through  which 
the  air-current  passes;  B  is  an  India-rubber  bag.  In  this  apparatus  there  is 
no  provision  for  the  entrance  of  fresh  air.  By  turning  the  reservoir  C  on  the 
tube  t  the  amount  of  current  passing  over  the  ether  can  be  regulated. 
When  this  apparatus  is  used,  the  ether- vapor  breathed  into  the  lungs 
is  expired  into  the  bag  and  is  rebreathed.  This  inhaler,  if  used  by  a 
skilful  man,  is  very  useful;  but  any  lack  of  watchfulness  or  skill  will  permit 
of  cyanosis,  and  the  very  young,  the  senile,  the  anemic  and  feeble,  are  best 
anesthetized  by  the  Allis  inhaler. 

An  admirable  detailed  account  of  anesthetization  by  the  closed  method 
will  be  found  in  Mr.  Frederic  W.  Hewitt's  treatise  on  "Anesthetics  and  their 


Fig.  494. — Allis's  ether-inhaler. 


Ether  and   Oxygen 


875 


Administration"  (page  272)  and  in  Mr.  Dudley  W.  Buxton's  treatise  on 
"  Anesthetics,  their  Uses  and  Administration  "  (page  109).  When  giving  ether, 
have  at  hand  the  same  drugs  and  apphances  as  when  chloroform  is  given, 
and  keep  the  lower  jaw  pushed  forward  during  the  administration.  When 
anesthetizing  by  x^llis's  inhaler,  place  the  dry  inhaler  over  the  mouth  and 
nose,  let  the  patient  take  several  breaths  to  gain  confidence,  pour  a  few 
drops  of  ether  into  .  the  cone,  let  the  patient  take  several  more  breaths, 
and  so  on,  gradually  increasing  the  amount  of  ether.  If  he  tends  to 
struggle,  diminish  the  amount  of  ether  for  a  time,  but  do  not  hold  him. 
Do  not  tell  him  to  breathe  forcibly.  Forcible  breathing  is  liable  to  cause 
cessation  of  respiration.  Never  suddenly  add  a  large  amount  of  the  an- 
esthetic: it  causes  coughing  and  often  vomiting.  When  the  patient  becomes 
thoroughly  anesthetized,  diminish  the  amount  of  ether.  When  bleeding  is 
profuse  or  shock  is  marked,   suspend  the  administration  of  ether  or   give 


Fig.  495. — Clover's  portable  regulating  ether-inhaler. 


very  little  of  it.  If  a  hot  iron  is  to  be  used  about  the  face,  remove  the  cone 
and  fan  away  the  ether  before  bringing  the  iron  near.  Ha\'e  anv  light  set 
high  up,  as  ether-vapor  is  heavier  than  air,  and  no  explosion  is  possible 
until  it  reaches  the  level  of  the  flame.  If  the  vapor  takes  fire,  cover  the 
patient's  mouth  and  nose  with  a  towel.  If  he  rolls  his  eyes  from  side  to 
side,  if  the  respirations  are  deep  and  sighing,  if  there  are  repeated  move- 
ments of  swallowing,  more  anesthetic  should  be  given  (Tarnowsky).  Hic- 
cough is  often  preliminary  to  vomiting,  and  always  means  that  the  refle.xes 
are  returning. 

Ether  and  O.xygen. — This  mixture  is  useful  in  certain  cases  in  which 
respiratory  difficulty  exists,  particularly  in  empyema.  If  during  the  adminis- 
tration of  ether  cyanosis  tends  to  occur,  it  is  often  advantageous  to  give 
o.xygen  with  the  ether.  The  process  of  anesthetization  by  ether  and  o.xygen 
is  somewhat  slower  than  by  ether-vapor  mixed  with  air.  It  can  be  given 
by  inserting  beneath  the  Allis  inhaler  or  pushing  deep  down   into   it  from 


8^6  Anesthesia  and  Anesthetics 

above,  a  tube  attached  to  a  reservoir  of  oxygen  and  from  which  a  stream 
of  oxygen  emerges. 

Rectal  Etherization. — Roux  suggested  this  method  in  1847.  A  bottle 
of  ether  is  set  in  water  at  a  temperature  of  122°  and  a  rubber  tube  con- 
nected with  the  bottle  is  inserted  in  the  rectum  (Molliere,  in  "  Lyon  Medical,  " 
April  28,  1884).  The  method  has  never  come  into  general  use.  It  irritates 
the  large  intestine,  and  sometimes  is  said  to  lead  to  protracted  stupor  ("Anes- 
thetics and  their  Administration,"  by  Fred.  T.  Hewitt).  Dudley  W.  Buxton, 
however,  has  employed  it  in  many  operations  about  the  face,  mouth,  and 
larvnx,  and  in  some  operations  for  empyema,  and  commends  it. 

Anesthetic  State  from  Ether  or  Chloroform. — The  inhalation  of 

an  anesthetic  produces  irritation  of  the  fauces,  often  some  cough,  a  profuse 
secretion  of  mucus,  acts  of  swallowing,  dilatation  of  the  pupils,  flushed  face, 
and  sometimes  struggling  (especially  in  children  and  in  drunkards).  If  the 
vapor  is  given  at  once  in  concentrated  form,  cough  will  be  violent  and  will 
cause  cyanosis.  If  the  anesthetic  is  given  carefully,  the  cough  soon  ceases, 
the  respirations  become  rapid  and  often  convulsive,  the  pulse  becomes  fre- 
quent, and  the  patient  passes  into  a  condition  of  active  intoxication  with 
preservation  of  sight  and  touch,  loss  of  hearing  and  smell,  diminution  of 
pain  and  sensibility,  and  often  with  illusions  or  hallucinations.  In  this 
stage  the  patient  may  struggle,  and  while  efforts  are  being  made  to  hold 
him  cyanosis  may  occur.  From  the  stage  of  excitement  just  alluded  to, 
many  subjects  (strong  men  and  drunkards)  pass  into  a  stage  of  rigidity 
in  which  the  muscles  become  firmly  fixed,  the  breathing  impeded,  the  respira- 
tions stertorous,  and  the  face  bluish  and  congested.  Too  rapid  forcing  of 
the  anesthetic  tends  to  cause  rigidity,  and  a  skilled  anesthetist  endeavors 
to  avoid  its  production,  because  it  is  dangerous.  The  next  stage  is  one 
of  insensibility;  the  pupils  are  contracted,  but  react  to  light.  If  anesthesia 
is  deep,  the  contracted  pupils  will  not  react  to  light;  if  anesthesia  is  pro- 
found, the  pupils  dilate,  but  will  not  react  to  hght.  The  conjunctival  reflex 
is  gone;  the  lids  are  closed;  if  the  arm  is  lifted  and  allowed  to  fall,  it  drops 
as  a  dead  weight;  the  skin  is  cool  and  moist,  and  often  wet  with  sweat;  the 
respirations  are  easy  and  shallow;  the  pulse  is  slow;  and  there  is  complete 
unconsciousness  to  pain.  The  loss  of  conjunctival  reflex  is  the  usually 
accepted  sign  that  the  patient  is  unconscious.  In  a  young  child  this  reflex 
is  soon  exhausted  by  touching  the  eye,  and  the  sign  is  unreliable.  If  a  baby 
is  to  be  anesthetized,  the  administrator  places  his  finger  in  the  infant's  hand. 
The  child  grasps  the  finger,  and  relaxes  its  grasp  when  unconscious. 

Always  bear  in  mind  that  a  dilated  pupil  reacting  to  light  and  associated 
with  preserved  conjunctival  reflex  means  that  anesthesia  is  not  complete; 
that  a  contracted  pupil  reacting  to  light  and  without  conjunctival  reflex 
means  moderate  anesthesia;  that  a  contracted  pupil  not  reacting  to  light 
and  without  conjunctival  reflex  means  deep  anesthesia;  that  a  dilated  pupil 
not  reacting  to  light  and  associated  with  lost  conjunctival  reflex  means  dan- 
gerously profound  anesthesia;  that  weak  pulse  and  pallor  may  be  due  to 
nausea,  but  always  require  instant  attention;  that  vomiting  may  be  due  to 
forcing  strong  vapor  upon  the  patient,  butjhat  it  may  also  be  due  to  his 
partially  emerging  from  a  state  of  insensibility. 

Watch  the  pulse  carefully  to  see  if  it  becomes  very  weak,  irregular,  ab- 


Treatment  of  Complications  '^jj 

normally  slow,  or  abnormally  fast.  Syncope  may  be  due  to  nausea,  shock, 
hemorrhage,  or  the  giving  of  too  much  of  the  drug.  Watch  the  respiration, 
and  do  not  forget  that  the  chest-walls  and  belly  may  move  when  no  air  is 
entering  the  lungs;  hence  always  Uslen  to  the  breathing.  Cyanosis  is  a 
dusky  or  bluish  discoloration  of  the  skin.  This  condition  indicates  want 
of  oxygen  in  the  blood.  The  individual  may  have  been  cyanotic  or  pre- 
disposed to  cyanosis  to  start  with;  cyanosis  may  be  due  to  posture;  to  cough 
early  in  the  administration;  to  struggling  during  the  stage  of  excitement;  or 
to  rigid  fixation  of  the  respiratory  muscles.  It  may  also  be  due  to  obstruction 
of  the  air-passages  by  some  foreign  matter,  as  blood  or  vomit,  lodging  in 
the  bronchial  tubes,  windpipe,  larynx,  or  pharynx;  falhng  back  of  the  tongue 
(swallowing  of  the  tongue);  closure  of  the  epiglottis;  or  to  the  glottis  being 
pushed  against  the  pharyngeal  wall  by  bending  the  head  forward.  Some 
patients  with  occluded  nostrils  may  fail  to  get  enough  air  because  of  closure 
of  the  lips.  A  patient  ma)  appear  to  "forget  to  breathe."  Shock  is  mani- 
fested by  deadly  pallor,  weak  and  irregular  pulse,  slow  respiration,  cold 
extremities,  and  a  drenching  sweat.  In  rare  cases  edema  of  the  lungs  occurs. 
Treatment  of  Complications. — Vomiting  due  to  too  much  anes- 
thetic is  corrected  by  giving  a  few  breaths  of  air;  vomiting  due  to  incomplete 
anesthesia  is  amended  by  giving  more  of  the  vapor.  When  the  patient 
vomits,  hang  the  head  over  the  edge  of  the  bed,  separate  the  jaws  with  the 
gag,  and  wipe  out  the  vomited  matter,  mucus,  and  saliva.  Shock  is  treated 
by  diminishing  the  amount  of  the  anesthetic  given,  by  the  hypodermatic 
injection  of  adrenalin  chlorid,  from  lo  to  20  minims  of  a  i  :  1000  solu- 
tion, or  atropin  (the  last-named  drug  is  very  useful  when  there  is  a 
profuse  sweat),  by  the  administration  of  hot  sahne  fluid  by  the  rectum, 
by  surrounding  the  patient  with  hot- water  bottles,  or  by  wrapping  him 
in  hot  blankets,  and  by  lowering  the  head  of  the  bed.  A  tendency 
to  syncope  requires  lowering  of  the  head  of  the  bed,  suspension  of  the 
anesthetic,  and  hypodermatic  injection  of  strychnin.  In  extreme  syncope, 
which  is  most  apt  to  occur  from  chloroform,  do  not  wait  for  breathing  to 
cease,  but  suspend  the  anesthetic,  lower  the  head  of  the  bed,  open  the 
mouth  with  the  gag,  catch  the  tongue  and  make  rhythmical  traction  while 
an  assistant  is  making  slow  artificial  respiration.  If  the  patient  does  not 
at  once  improve,  invert  him  completely,  holding  him  by  the  legs  and  con- 
tinuing artificial  respiration  by  compressing  the  sternum  (Nelaton).  By  con- 
tinuing artificial  respiration  the  blood  is  urged  on  through  the  heart.  Leonard 
Hill  holds  that  in  the  failure  which  arises  soon  after  administration  of  chloro- 
form is  begun  the  trouble  is  due  to  vaso-motor  paralysis  with  starvation  of 
the  nerve-centers.  In  such  a  case  he  applies  abdominal  compression  and 
in\eris  the  patient,  making  artificial  respiration  at  the  same  time.  In  the 
failure  which  occurs  after  considerable  chloroform  has  been  taken  there 
are  paralytic  distention  of  the  heart,  fulness  of  the  venous  system,  and  loss 
of  the  compensations  for  the  hydrostatic  effects  of  gravity.  In  such  a  con- 
dition empty  the  distended  heart  of  venous  blood  by  raising  the  patient 
into  an  erect  position;  and  after  a  moment  place  him  recumbent  and  make 
artificial  respiration.  Give  hypodermatic  injections  of  adrenalin  chlorid,  atro- 
pin, ether,  or  even  of  ammonia.  Put  mustard  over  the  heart  and  spine. 
Employ    faradism  to  the  phrenic  nerve  (one  pole  to  the   epigastric    region. 


878  Anesthesia  and  Anesthetics 

the  other  to  the  right  side  of  the  root  of  the  neck).  Let  fresh  air  into  the 
room,  put  hot-water  bottles  around  the  legs,  apply  friction  to  the  extremi- 
ties, wrap  the  patient  in  hot  blankets,  give  an  enema  of  brandy,  and  hold 
ammonia  to  the  nose. 

'"  Forgetting  to  breathe'''  is  met  by  removing  the  inhaler  and  waiting 
a  moment;  a  breath  will  usually  be  taken  soon;  but  if  it  is  not  taken,  open 
the  mouth  and  pull  forward  the  tongue;  this  causes  a  refle.x  inspiration. 
C3-anosis  is  practically  not  encountered  when  oxygen  is  given  with  ether 
or  chloroform.  Cyanosis,  if  slight,  and  due  to  cough  or  strugghng,  is  met 
by  removing  the  inhaler  while  the  patient  takes  a  breath  or  two  of  air.  If 
position  is  responsible  for  cyanosis,  correct  it.  In  empyema,  lying  upon 
the  sound  side  may  produce  it,  and  obstruction  to  breathing  may  be  due 
to  bending  down  the  head.  If  due  to  stenosis  of  the  nares  in  a  person  without 
teeth,  hold  the  lips  apart  with  a  finger. 

Dudley  W.  Buxton  points  out  that  duskiness  will  often  pass  away  if 
ether  is  removed,  one  or  two  inhalations  of  chloroform  given,  and  ether 
then  continued.  If  in  any  case  cyanosis  is  severe  or  grows  worse,  suspend 
the  drug,  dash  cold  water  in  the  face,  force  open  the  jaws,  pull  forward  the 
tongue,  make  artificial  respiration  until  a  breath  is  taken,  and  then  give 
oxygen  for  a  time.  If  these  means  fail,  stretch  the  sphincter  ani  and  bleed 
from  the  external  jugular  vein.  If  a  breath  is  not  now  taken,  do  trache- 
otomy. In  respiratory  or  heart  failure  forced  artificial  respiration  by  Fell's 
method  is  of  great  value.  In  Fell's  method  a  tracheal  tube  is  inserted,  and 
by  means  of  a  foot-bellows  air  is  forced  into  the  lungs,  after  first  passing 
through  a  warming  chamber.  Instead  of  a  tracheal  tube,  we  may  use  a 
face-mask  and  an  intubation-tube.  ^'Swallowing  the  tongue''^  is  corrected 
by  pulling  the  tongue  forward.  If  it  tends  to  recur,  lay  the  head  upon  its 
side  or  keep  the  tongue  anchored  with  forceps.  Closure  oj  the  epiglottis 
is  corrected  by  pulling  the  patient's  head  over  the  edge  of  the  table  and 
pushing  strongly  back  upon  his  forehead.  This  maneuver  lifts  the  hyoid 
bone,  and  with  it  the  epiglottis.  The  epiglottis  can  be  lifted  by  passing  a  spoon- 
handle  or  the  index-finger  over  the  dorsum  to  the  base  of  the  tongue  and  press- 
ing forward.  If,  in  obstruction  to  respiration,  the  above  means  fail,  make 
artificial  respiration  at  once;  if  obstruction  continues,  perform  tracheotomy. 

Edema  of  the  lungs  is  treated  by  instant  venesection,  the  inhalation  of 
nitrite  of  amyl,  and  the  administration  of  stimulants  and  nitroglycerin  hypo- 
dermatically.  Sometimes,  during  the  anesthetic  state,  the  muscles  of  the  belly 
become  very  rigid,  a  condition  which  greatly  interferes  with  an  abdominal 
operation.  It  may  arise  during  cyanosis,  and  if  so  caused  is  amended,  as 
cyanosis  abates  under  proper  treatment.  In  some  cases  it  is  due  to  the 
fact  that  sufficient  anesthetic  has  not  been  given.  If  the  air-passages  are 
obstructed,  abdominal  rigidity  is  apt  to  arise.  In  some  cases  it  seems 
impossible  to  overcome  it  with  ether.  In  such  a  case,  if  the  anesthetist  is 
a  trusted  man,  anesthetize  the  patient  with  gas  and  ether  and  then  give 
chloroform  (Blumfield,  in  "Lancet,"  May  31,  1902). 

Artificial  Respiration.  Laborde's  Method.— Place  the  patient  on 
his  back  with  the  head  lower  than  the  body,  all  the  clothing  loo.sened,  and 
the  jaws  wedged  apart,  and  wipe  the  mucus  from  the  throat  and  mouth. 
Gra.sp  the  tongue  with  forceps,  and  f)nce  in  every  four  seconds  pull  it  (juickly 


The   Reaction  from  Anesthesia 


879 


and  strongly  forward  and  then  permit  it  to  go  back.  It  may  be  necessary 
to  keep  up  this  proceeding  for  thirty  minutes  or  even  more. 

Laborde's  method  should  be  associated  with  "concentric  thoracic  and 
upward  abdominal  pressure  apphed  in  a  rhythmic  manner  by  two  assistants 
at  the  time  of  relaxation  of  the  tongue. "  *  Laborde  believes  that  tongue- 
traction  causes  contractions  of  the  diaphragm. 

Sylvester's  Method  (Figs.  496,  497). — The  patient  is  placed  recumbent 
with  the  foot  of  the  bed  raised.  The  surgeon  grasps  the  arms  just  above 
the  elbows,  and  draws  them  outward  and  upward  until  they  are  nearly  per- 


Fig.  496. — Artificial  respiration,  first  movement. 

pendicular;  they  are  held  perpendicular  for  two  seconds  while  air  is  entering 
the  lungs;  the  arms  are  then  lowered  and  pressed  against  the  sides  of  the 
chest  for  two  seconds,  during  which  time  the  chest  is  emptied  as  in  expiration. 
These  movements  of  elevation  and  depression  are  made  twelve  or  fifteen 
times  a  minute. 

The  Reaction  from  Anesthesia. — After  the  administration  of  the 
anesthetic  has  been  suspended  and  the  operation  has  been  completed  the 
temperature  is  usually  subnormal.  The  patient  must  be  watched  until  con- 
sciousness returns.     If  he  is  left  alone,  a  change  of  posture  may  lead  to 


Fig.  497. — Artificial  respiration,  second  movement. 

arrest  of  feeble  respiration,  the  assumption  of  the  erect  position  may  cause 
fatal  syncope,  or  mucus  or  vomited  matter  may  block  the  air-passages  and 
cause  suffocation.  The  best  position  to  place  him  in  is  the  recumbent, 
the  head  being  level  with  the  body  or  somewhat  lower,  and  the  side  of  the 
face  resting  on  the  pillow.  Shock  is  treated  by  ordinary  methods.  The 
inhalation  of  oxygen  is  of  great  value  in  rousing  a  patient  from  the  state 
of  anesthesia,  and  will  often  prevent  vomiting.  If  vomiting  occurs,  the  head 
should  be  upon  its  side  or  should  be  hung  over  the  edge  of  the  bed,  and  after 
the  spell  of  vomiting  the  mouth   must  be  wiped  clear.     The  face  should 

*  Joseph  D.  Erv'ant's  "Operative  Stirgery." 


88o  Anesthesia  and  Anesthetics 

be  washed  with  cold  water  and  be  fanned  rather  actively.  It  is  routine 
practice  in  the  Jefferson  Medical  College  Hospital  to  administer  vinegar 
by  inhalation  during  the  reaction  from  an  anesthetic.  This  proceeding  often 
prevents  vomiting.  Some  patients  awake  from  anesthesia  as  from  a  quiet 
sleep;  others  are  noisy,  turbulent,  and  violent.  The  duration  of  the  period 
of  reaction  varies  with  the  anesthetic  used,  the  amount  given,  and  the  per- 
sonal tendencies  of  the  patient.  The  patient  must  not  be  allowed  to  sit  up 
for  several  hours  at  least.     No  food  is  to  be  aUowed  for  at  least  four  hours. 

After=effects  of  Anesthetics. — Vomiting. — Vomiting  may  persist 
for  hours,  greatly  exhausting  the  patient  and  doing  infinite  harm,  it  may 
be,  if  the  operation  were  upon  the  brain  or  an  intra-abdominal  structure. 
If  vomiting  continues,  forbid  food.  Very  hot  water  in  doses  of  a  teaspoonful 
should  be  given  at  frequent  intervals.  A  draught  of  hot  water  may  relieve 
the  condition  by  washing  out  the  mucus  from  the  stomach.  Other  remedies 
which  may  succeed  are:  hot  black  coffee,  a  mustard  plaster  over  the  stomach, 
fresh  air  in  the  room,  small  pieces  of  ice  placed  in  the  mouth  and  sucked, 
small  doses  of  iced  champagne,  and  drop  doses  of  a  3  per  cent,  solution 
of  cocain  or  3-drop  doses  of  a  5  per  cent,  solution  of  eucain.  The  best  reme- 
dies for  persistent  vomiting  are  inhalation  of  vinegar  and  lavage  of  the  stomach. 
Some  persons,  as  Dudley  W.  Buxton  points  out,  suffer  greatly  from  nausea 
although  there  is  little  or  no  vomiting.  In  such  cases  Buxton  uses  rtij  of 
tincture  of  nux  vomica  in  a  teaspoonful  of  hot  water  every  ten  minutes  until 
six  doses  are  taken.  If  this  plan  fails,  he  gives  drop  doses  of  wine  of  ipecac 
or  minim  doses  of  dilute  hydrocyanic  acid.* 

Vomiting  from  chloroform  is  usually  more  difficult  to  check  than  vomit- 
ing from  ether. 

Respiratory  disorders  are  more  often  noted  after  ether  than  after  chlo- 
roform. Bronchitis  may  follow  or  bronchopneumonia  (ether-pneumonia). 
Respiratory  difficulties  may  be  due  to  chilling  the  patient  by  bringing  him 
from  a  warm  operating-room  through  a  cold  hall  and  into  a  cool  bedroom. 
Bronchopneumonia  is  especially  common  in  septic  patients,  and  may  be 
due  in  some  cases  to  aspiration  of  septic  material  into  the  bronchi  (cases 
of  cancer  of  tongue  and  pharynx,  and  cases  with  stercoraceous  vomiting). 
Bronchitis  and  bronchopneumonia  are  much  more  common  after  ether  than 
after  chloroform.  They  are  treated  by  ordinary  methods.  If  chloroform 
is  given  when  a  gas-light  is  in  the  room,  the  vapor  is  decomposed  and  certain 
highly  irritant  products  are  inhaled,  which  produce  laryngeal  spasm  and 
possibly  bronchitis.  The  treatment  is  to  freely  admit  fresh  air  into  the 
room,  and  to  have  the  patient  inhale  oxygen  or  vinegar.  Ether-pneumonia 
mu.st  not  be  confounded  with  post-operative  pneumonia,  described  by  Wm. 
H.  Bennett. f  This  latter  condition  may  arise  from  seven  to  fourteen  days 
after  operation  in  robust,  gouty  people,  and  is  usually  unilateral. 

Renal  Complications. — After  the  administration  of  an  anesthetic, 
blood,  albumin,  or  sugar  may  appear  in  the  urine,  and  the  secretion  may 
become  scanty  or  even  be  suppressed.  It  is  usually  maintained  that  chloro- 
form is  less  apt  to  irritate  the  kidneys  than  is  ether,  but  there  has  been  much 
dispute  on  this  pjoint.  If  albumin  is  present  before  anesthetization,  the 
condition  may  be  rendered  worse  when  ether  or  chloroform  is  given.     The 

"^'"Anesthetics,"  by  Dudley  W.  Buxton.  f  Practitioner,  Dec,  1896. 


A.   C.   E.   Mixture  88 1 

truth  of  the  matter  probably  is  that  if  the  kidneys  are  healthy  a  small  or 
moderate  amount  of  either  drug  is  not  particularly  irritant;  but  if  the  kidneys 
are  diseased,  a  small  amount,  and  even  if  they  are  healthy,  a  large  amount, 
of  either  drug  produces  decided  renal  irritation.  Chloroform  is  less  irritant 
because  less  chloroform  than  ether  is  given  to  secure  and  maintain  anesthesia. 
Scantiness  or  suppression  of  urine  may  be  due  to  operative  shock  rather 
than  to  ether  or  chloroform.  If  the  urine  becomes  somewhat  scanty  or 
if  albumin  appears  in  it,  give  non-irritant  diuretics,  diaphoretics,  and  cathar- 
tics, and  employ  enteroclysis.  If  the  urine  becomes  very  scanty,  use  hypo- 
derhioclysis.  If  post-operative  suppression  arises,  give  intravenous  infusion 
of  hot  saline  fluid. 

Post-anesthetic  Paralysis. — Paralysis  may  arise  during  anesthesia  as 
a  result  of  cerebral  hemorrhage  or  embolism. 

It  sometimes  happens  that  when  a  person  has  come  out  of  anesthesia 
a  palsy  of  some  part  is  found  to  exist,  the  condition  being  peripheral  and 
not  central  in  origin.  Such  palsies  may  be  due  to  pressure  of  an  extremity 
upon  a  table-edge  or  to  pressure  upon  nerves  by  placing  the  patient  in  certain 
positions.*  Garrigues  points  out  that  when  the  arm  is  elevated  to  the  side 
of  the  head  or  when  it  is  drawn  out  strongly  from  the  body  the  brachial 
plexus  may  be  compressed  by  the  head  of  the  humerus  (Braun).  \A'hen 
the  arm  is  in  external  rotation  and  is  drawn  backward  and  outward  the 
median  nerve  is  stretched,  and  when  the  forearm  is  flexed  and  supinated 
the  ulnar  nerve  is  stretched  (Braun,  quoted  by  Garrigues).  Garrigues  insists 
that  in  most  cases  the  brachial  plexus  is  squeezed  between  the  collar-bone 
and  the  first  rib,  and  it  is  particularly  apt  to  be  squeezed  when  it  is  stretched 
by  the  head  being  drawn  to  the  opposite  side  or  being  allowed  to  fall  back.t 

Post-anesthetic  paralysis  is  most  common  in  the  arm,  but  may  occur 
in  the  leg  or  face.  The  prognosis  is  good  as  a  rule.  The  treatment  is  that 
of  any  pressure-palsy. 

Primary  Anesthesia. — Instruct  the  patient  to  count  aloud  and  hold 
one  arm  above  his  head.  Give  the  ether  rapidly.  In  a  short  time  he  be- 
comes mixed  in  his  count  and  his  arm  sways  or  drops  to  the  side.  There 
is  now  a  period  of  insensibility  to  pain  lasting  only  about  half  a  minute, 
and  during  this  period  a  minor  operation  can  be  performed.  The  patient 
quickly  reacts  from  primary  anesthesia  without  vomiting  (Packard). 

Mixtures. — Mixture  of  Ether  and  Chloroform. — This  may  be  used 
in  varying  proportions.  Hewitt  employs  2  parts  of  chloroform  to  3  parts 
of  ether. 

Mixture  of  Alcohol  and  Chloroform. —  All  the  chloroform  mixtures 
produce  the  effects  of  chloroform,  but  we  are  giving  the  drug  in  an  unknown 
amount.  It  was  believed  by  Sansom,  who  devised  this  mixture,  that  the 
alcohol  prevents  concentration  of  chloroform-vapor  by  retarding  evaporation. 
When  used,  i  part  of  alcohol  is  added  to  4  parts  of  chloroform. 

Nitrous   Oxid  and  Oxygen. — (See  page  883.) 

A.  C.  E.  Mixture. — This  mixture  is  often  valuable  in  cases  in  which 
ether  cannot  be  given.  It  is  composed  of  i  part  of  alcohol,  2  parts  of  chloro- 
form, and  3  parts  of  ether.     Its  action  is  supposed  to  ])e  between  that  of 

*H.  J.  Garrigues,  in  Amer.  Jour.  Med.  Sciences,  Jan.,  1S97. 
fAmer.  Jour.  Med.  Sciences,  Jan.,  1897. 

56 


882  Anesthesia  and  Anesthetics   . 

chloroform  and  ether.  The  objection  to  the  A.  C.  E.  mixture,  as  to  any 
mixture,  is  that  the  materials  do  not  evaporate  in  the  ratio  in  which 
they  are  mixed,  hence  an  uncertain  amount  of  chloroform-vapor  is  being 
inhaled  (Buxton).  This  mixture  can  be  given  in  a  Junker  or  an  open  inhaler. 
Plenty  of  air  must  be  given  with  it.  The  anesthetic  acts  similarly  to 
chloroform. 

Schleich's  Mixture  for  General  Anesthesia. — Schleich  has  recently 
introduced  a  nen'  anesthetic  agent  which  he  claims  is  safer  than  chloroform. 
This  surgeon  maintains  that  a  material  is  safe  as  an  anesthetic  only  when 
almost  all  of  the  amount  taken  in  at  an  inspiration  is  expelled  on  expira- 
tion. The  anesthetic  is  unsafe  in  direct  proportion  to  the  amount  absorbed; 
and  the  lower  the  boiling-point  of  an  anesthetic,  the  less  is  absorbed;  hence 
an  anesthetic  agent,  to  be  safe,  should  have  a  low  boiling-point.  Schleich 
makes  three  solutions.  The  first  contains  (by  volume)  i^  oz.  of  chloroform, 
^  oz.  of  petroleum  ether,  and  6  oz.  of  sulphuric  ether.  The  second  contains 
i^  oz.  of  chloroform,  ^  oz.  of  petroleum  ether,  and  5  oz.  of  sulphuric  ether. 
The  third  contains  i  oz.  of  chloroform,  h  oz.  of  petroleum  ether,  and  2f  oz. 
of  sulphuric  ether.  The  anesthetic  can  be  given  on  an  open  inhaler  or  a 
towel.  The  anesthetic  state  is  quiet,  reaction  is  rapid,  and  vomiting  occurs 
in  but  half  the  cases.  The  superiority  of  this  new  anesthetic  has  not  been 
proved.  It  sometimes  causes  dangerous  symptoms,  and  has  produced  death. 
Garrigues,  who  formerly  approved  of  it,  has  abandoned  it.  It  will  certainly 
not  displace  ether  or  chloroform. 

Ethyl  bromid  is  sometimes  used  for  short  operations.  It  is  thought 
to  be  safer  than  ethyl  chlorid.  It  is  given  while  the  patient  is  recumbent. 
The  unconsciousness  is  obtained  in  from  one  to  three  minutes  and  is  rapidly 
recovered  from,  and  there  is  no  after-sickness.  The  unconsciousness  lasts 
about  three  minutes.  Three  drams  are  given  to  a  child,  and  six  drams 
to  an  adult.  A  towel  is  put  over  the  face,  and  the  entire  amount  to  be  given 
is  poured  on  at  once,  and  as  soon  as  the  patient  is  unconscious  the  towel 
is  taken  away  and  no  more  of  the  drug  is  given  (Cumston).  Cases  have 
been  reported  in  which  sudden  death  has  followed  the  administration  of 
this  drug,  and  it  should  not  be  given  if  there  is  disease  of  the  heart,  lungs, 
or  kidneys.*  If  it  kills,  it  acts  like  chloroform.  It  may  be  given  before 
ether  to  prevent  unpleasant  effects,  but  it  is  usually  not  considered  proper 
to  giv^e  it  before  chloroform.  Zematski,  however,  has  u.sed  it  before  chloro- 
form in  2000  cases  ("Vratch,"  August  25,  1901). 

Chlorid  of  ethyl  is  a  rapid  anesthetic  and  appears  to  be  a  safe  one. 
It  should  be  given  upon  a  mask  so  that  it  does  not  evaporate  into  the  air. 
The  odor  of  the  drug  is  agreeable.  The  anesthetic  state  is  induced  in 
from  thirty  seconds  to  three  minutes,  and  the  anesthetic  condition  ]a.sts  from 
one  to  three  minutes,  and  it  is  recovered  from  rapidly,  usually  without  vomit- 
ing or  unpleasant  after-effects.  It  is  to  be  noted  that  complete  muscular 
relaxation  does  not  occur,  in  many  cases  the  conjunctival  reflex  is  not  com- 
]>Iete]y  abolished,  and  often  the  pupils  do  not  contract.  Its  superiority  over 
nitrous  oxid  is  doubtful,  and  sometimes  it  fails  to  produce  complete  uncon- 
.sciousne.ss.  Lotheis.ser,  in  a  study  of  2500  cases  of  anesthesia  by  this  agent, 
reports  i  death.  Ware,  as  previously  noted,  collected  12,436  cases  with 
*  See  Cumston,  in  Boston  Med.  and  Surg.  Jour.,  Dec.  20,  1894. 


Nitrous  Oxid  Gas 


883 


I  death.  From  8  to  10  gm.  of  ethyl  chlorid  are  given  for  a  short  opera- 
tion. The  patient  must  always  be  recumbent  when  taking  it.  The  drug 
is  only  used  for  a  brief  operation  or  examination.  When  it  kills,  it  acts 
in  a  similar  manner  to  chloroform.  It  may  be  given  before  ether  to  prevent 
unpleasant  symptoms,  fc)ut  not  before  chloroform. 

Nitrous  oxid  gas  may  be  used  to  obtain  anesthesia  for  brief  operations. 
It  is  contraindicated  when  vascular  degeneration  exists,  because  apoplexy  may 
followitsadministration.  This  gas  is 
stored  in  steel  cylinders,  in  which  it 
is  liquefied.  The  gas  is  passed  into 
a  rubber  bag  (Fig.  498),  and  is 
given  to  the  patient  by  means  of  a 
tube  and  a  mouth-mask,  a  wedge 
being  placed  between  the  patient's 
molar  teeth,  and  the  nostrils  being 
closed  by  the  anesthetist's  fingers. 
The  wedge  must  be  held  by  a  string, 
so  that  it  cannot  be  swallowed. 
The  patient  becomes  unconscious  in 
about  one  minute,  and  we  know  the 
patient  is  anesthetized  by  the  stertor 
and  cyanosis  and  the  insensitiveness 
of  the  conjunctivae.  Watch  the 
pulse,  and  if  it  flags  at  once  suspend 
the  administration.  The  phenom- 
ena are  asphyxial,  stertorous  res- 
piration, cyanosis,  and  even  con- 
vulsions, dilatation  of  the  pupils, 
rapidity  of  the  heart,  and  swelling 
of  the  tongue.*  It  is  sometimes 
useful  to  give  nitrous  oxid  first  and 
follow  this  with  ether  (page  885). 
By  this  method  the  patient  is  anes- 
thetized rapidly  and  pleasantly  with 
the  nitrous  oxid,  and  the  anesthesia 
is  maintained  by  the  ether. 

It  used  to  be  thought  that  nitrous 
oxid  necessarily  produces  cyanosis, 
because  the  gas  can  only  cause  anes- 
thesia by  partially  asphyxiating  the 
patient.     We  know  this  is  untrue, 

because  if  nitrous  oxid  is  mixed  with  oxygen  or  atmospheric  air  anesthesia  is 
obtained  without  cyanosis.  Nitrous  oxid  is  a  genuine  anesthetic  agent.  If  a 
prolonged  administration  of  nitrous  oxid  is  desired,  pure  nitrous  oxid  can  be 
given,  a  breath  of  fresh  air  being  allowed  from  time  to  time.  By  this  method 
Preston  has  anesthetized  many  patients,  the  duration  of  the  anesthesia  being 
from,  ten  to  fifty  minutes.  A  better  plan  is  to  give  nitrous  oxid  and  oxygen. 
Hewitt  formulates  the  following  views  as  to  the  use  of  oxygen  and  nitrousoxidif 

*See  Hewitt,  Brit.  Med.  Jour.,  Feb.  18,  1899.  f  Brit.  Med.  Jour.,  Feb.  18,  1899. 


Fig.  49S. — Hewitt's  nitrous  oxid  apparatus. 


884 


Anesthesia  and   Anesthetics 


"  In  order  to  obtain  the  best  form  of  anesthesia  oxygen  should  be  admin- 
istered with  nitrous  oxid  by  means  of  a  regulating  apparatus  (Fig.  499), 
the  percentage  of  the  former  gas  being  progressively  increased  from  2  or 
3  per  cent,  at  the  commencement  of  the  administration  to  7,  8,  9,  or  10  per 
cent.,  according  to  the  circumstances  of  the  case.  The  longer  the  adminis- 
tration lasts,  the  greater  may  be  the  percentage  of  oxygen  admitted. 

"The  next  best  results  to  those  obtainable  by  means  of  a  regulating 


Fig.  499. — Hewitt's  nitrous  oxid  and  oxygen  apparatus. 


apparatus  for  nitrous  oxid  and  o.xygen  are  to  be  secured  by  administering 
certain  con.stant  mixtures  of  these  two  gases.  Mixtures  containing  5,  6,  or 
7  per  cent,  of  oxygen  are  be.st  for  adult  males;  and  mixtures  containing 
7,  8,  or  9  per  cent,  are  best  for  females  and  children.  The  next  best  results 
to  those  last  mentioned  are  to  be  obtained  by  means  of  mixtures  of  nitrous 
oxid  and  air,  from  14  to  18  per  cent,  of  the  latter  being  advisable  in  ane.s- 
thetizing  men,  and  from  iS  to  22  per  cent,  in  anesthetizing  women  and  chil- 
dren. " 


Nitrous   Oxid  Gas  Followed  by   Ether  885 

Bichlorid  of  Methylene. — The  composition  of  the  so-called  bichlorid 
of  methylene  is  a  matter  of  dispute.  Some  high  authorities  believe  it  to  be 
a  mixture  of  methyl  alcohol  and  chloroform.  It  rapidly  produces  uncon- 
sciousness, and  the  patient  returns  quickly  to  consciousness  when  the  ad- 
ministration is  suspended.  Some  surgeons  have  thought  highly  of  it,  and 
claim  that  it  is  pleasant,  safe,  and  is  not  followed  by  vomiting  as  often  as 
is  chloroform.  The  weight  of  opinion  is  that  it  is  dangerous,  death  being 
similar  to  death  from  chloroform.     It  is  given  with  a  Junker  apparatus. 

Anesthetic  Successions. — Bromid  of  Ethyl  Followed  by  Chloro- 
form or  Ether. — (See  page  882.) 

Chlorid  of  Ethyl  Followed  by  Chloroform  or  Ether. — (See  page  882.) 

Chloroform  Followed  by  Ether. — Chloroform  is  sometimes  given  until 
the  sensation  becomes  more  or  less  obtunded,  when  ether  is  substituted. 
This  is  done  to  save  the  patient  from  the  unpleasant  sensations  of  etheri- 
zation. It  is  a  practice  not  to  be  commended,  because  it  is  precisely  in  the 
beginning  that  chloroformization  is  most  dangerous. 

Ether  Followed  by  Chloroform. — When  the  patient  cannot  be  relaxed 
or  rendered  unconscious  by  ether,  or  when  some  other  complication  develops, 
it  is  common  practice  to  suspend  ether  and  substitute  chloroform.  If  the 
change  is  made,  chloroform  should  be  given  cautiou.sly.  A  large  quantity 
should  never  be  poured  upon  the  inhaler  at  one  time.  The  change  should 
never  be  made  when  the  patient  is  struggling,  because  the  deep  respirations 
which  attend  or  follow  struggling  may  lead  to  the  rapid  inhalation  of  a  dan- 
gerous dose  of  chloroform-vapor.  Further,  as  Hewitt  points  out,  the  change 
should  not  be  made  unless  it  is  imperatively  necessary,  when  the  patient 
is  deeply  under  the  influence  of  ether. 

Nitrous  Oxid  Gas  Followed  by  Ether  (Gas  and  Ether). — This  very 
valuable  method  was  suggested  by  Clover.  The  patient  is  made  unconscious 
by  nitrous  oxid  and  is  kept  unconscious  by  ether.  Thus  are  avoided  excite- 
ment, struggling,  and  the  very  unpleasant  sensations  induced  by  ether.  More 
important  even  than  this,  the  method  is  safe.  It  is  more  satisfactory  in 
women  and  children  than  in  men.  In  very  muscular  men  and  in  very  stout 
elderly  men  it  should  not  be  used.  Many  operators  first  anesthetize  with 
nitrous  oxid,  using  an  ordinary  dental  apparatus,  and  then  give  ether  on  an 
ordinary  inhaler.  The  anesthetist  must  bear  in  mind  that  ether  must  be 
given  gradually,  not  suddenly  poured  on  in  large  amount.  Others  prefer 
to  use  a  combined  gas-and-ether  inhaler.  Hewitt  thus  describes  the  admin- 
istration by  means  of  Clover's  portable  ether-inhaler  fitted  with  a  stop-cock 
and  a  detachable  gas-bag  ("Anesthetics  and  their  Administration"): 

"  If  the  patient  be  lying  upon  his  back,  his  head  should  be  turned  to 
one  side.  The  face-piece  with  the  charged  ether  chamber  is  then  applied 
during  an  expiration.  Air  will  be  breathed  backwards  and  forwards.  When 
the  respiration  is  seen  to  be  proceeding  freely,  and  the  face-piece  fits  well, 
the  charged  gas-bag  is  attached  to  the  ether  chamber.  Air  will  still  be 
breathed,  but  not  through  the  valves  of  the  special  stop-cock.  When  the 
valves  are  heard  to  be  working  properly,  'gas'  is  turned  on,  and  is  likewise 
breathed  through  the  valves.  Three  or  four  respirations  (or  about  one-half 
of  the  contents  of  the  bag)  are  allowed  to  escape.  The  valve  action  is  now 
stopped  by  turning  the  tap  at  the  upper  part  of  the  sto])-cock.     At  the  same 


886 


Anesthesia  and  Anesthetics 


moment  at  which  the  patient  begins  to  breathe  'gas'  backwards  and  for- 
wards, the  rotation  of  the  ether  chamber,  for  the  addition  of  ether- vapor, 
should  be  commenced.  The  administrator  will,  in  fact,  find  that  he  can, 
in  a  few  seconds  from  the  commencement  of  the  administration,  rotate 
the  ether  chamber  as  far  as  'i'  or  'ij'.  Should  swallowing  or  cough- 
ing arise,  he  must  rotate  more  slowly.  Respiration 
soon  becomes  deep  and  regular,  and  more  and  more 
ether  may  be  admitted.  At  about  this  juncture,  if 
the  apparatus  has  been  fitting  the  face  well,  signs  of 
nitrous  oxid  narcosis  may  appear,  especially  in  those 
who  are  quickly  affected  by  this  gas.  Should  jerky 
breathing  or  'jactitation'  arise,  one  full  inspiration 
of  air  may  be  admitted  at  the  air-tap.  It  should  be 
remembered,  however,  that  in  giving  'gas  and  ether' 
by  this  method,  the  object  is  to  just  steer  clear  of  the 
clonus  and  'stertor'  of  nitrous  oxid  narcosis,  and  to 
gradually  but  increasingly  mix  ether  with  the  gas. 

"  In  muscular  and  vigorous  subjects,  the  quantity 
of  gas  above  mentioned  will  be  found  to  be,  as  a 
general  rule,  insufficient  to  lead  to  the  usual  signs  of 
deep  nitrous  oxid  anesthesia.  The  rotation  of  the 
ether  chamber  should  be  continued  till  the  indicator 
points  to  '  2,'  '  3,'  or  '  F.' 

"The  mistake  that  is  most  commonly  made  is 
that  of  admitting  air  too  soon.  Should  air  be  given 
during  the  first  half  or  three-quarters  of  a  minute,  the 
patient  will  partially  come  round,  hold  his  breath,  set 
his  teeth,  and  give  a  good  deal  of  trouble.  Duskiness 
of  the  features  must  be  expected.  Speaking  generally,  air  should  not  be 
allowed  until  the  patient  is  stertorous,  when  one  breath  may  be  given.  In 
this  manner  the  patient  will  continue  breathing  a  mixture  of  nitrous  oxid, 
ether,  and  air,  till  the  usual  signs  of  deep  ether  anesthesia  appear,  when  the 
gas-bag  may  be  detached,  and  the  little  bag  ordinarily  used  with  Clover's 
inhaler  substituted." 

Hewitt  prefers  to  use  a  modified  Clover's  inhaler,  which  permits  of  the 
introduction  of  ether  after  the  inhalation  of  nitrous  oxid  has  begun. 

Local  Anesthesia. — Freezing. — Ice  and  salt  may  be  used.  Take  one- 
quarter  of  a  pound  of  ice,  wrap  it  in  a  towel,  and  break  it  into  fine  bits;  add 
one-eighth  of  a  pound  of  salt;  then  place  the  mixture  in  a  gauze  bag  and 
lay  it  upon  the  part.  The  surface  becomes  pallid  and  numb,  and  in  about 
fifteen  minutes  decidedly  analgesic.  A  spray  of  rhigolene  freezes  a  part  in 
about  ten  seconds.  It  is  highly  inflammable.  Ether-spray  anesthesia  was 
suggested  by  Benjamin  Ward  Richard.son.  Chlorid  oj  ethyl  comes  in  glass 
tubes  (Fig.  500).  Remove  the  cap  from  the  tip  of  the  tube  and  hold  the  bulb 
in  the  palm:  the  warmth  of  the  hand  causes  the  fluid  to  spray  out.  Hold 
the  tube  some  little  distance  from  the  part  and  let  the  fine  spray  strike  the  sur- 
face. The  skin  blanches  and  whitens,  and  is  ready  for  the  operation  in  about 
thirty  seconds. 

Cocain  Hydrochlorate. — Always  bear  in  mind  that  cocain  is  .sometimes 


Fig.  500. — Gebauer's  ethy 
chlorid  tube. 


Cocainization   of  a   Xerve-trunk  88/ 

a  decidedly  dangerous  agent.  There  are  on  record  fourteen  deaths  from 
cocain  (Reclus).  The  urethra  is  a  particularly  dangerous  region,  and  so 
is  the  face.  Never  use  over  two-thirds  of  a  grain  upon  a  mucous  surface, 
and  never  inject  hypodermatically  more  than  one-third  of  a  grain,  and  be 
sure  never  to  inject  the  drug  into  a  vein.  Mild  cases  of  cocain-poisoning 
are  characterized  by  great  tremor,  restlessness,  pallor,  dry  mouth,  talkative- 
ness, and  weak  pulse.  In  severe  cases  there  is  syncope  or  delirium.  Death 
may  arise  from  paralysis  or  from  fixation  of  the  respiratory  muscles  (Mosso). 
Cases  with  a  tendency  to  respiratory  failure  require  the  hypodermatic  injection 
of  strychnin.  In  cases  with  tetanic  rigidity  of  muscles  give  enemata  of 
chloral,  hypodermatic  injections  of  nitroglycerin,  or  inhalations  of  the  nitrite 
of  amyl.  In  cases  marked  by  delirium,  if  the  circulation  is  good,  give  chloral 
or  hyoscin.  In  any  case  give  stimulants,  employ  a  catheter,  and  favor 
diuresis.  Cocain-poisoning  is  always  followed  by  a  wakeful  night.  Cocain 
should  not  be  used  if  the  kidneys  are  inefficient.  In  using  cocain  try  to 
prevent  poisoning.  Because  of  the  dangers  inherent  in  cocain,  have  the 
patient  recumbent.  One  minute  before  giving  the  cocain  administer  one 
drop  of  a  i  per  cent,  alcoholic  solution  of  trinitrin,  repeating  the  dose  once 
or  twice  during  the  operation.  In  operating  on  a  finger,  after  making  the 
part  anemic,  tie  a  tube  around  the  root  of  the  digit  before  injecting  cocain, 
and  after  the  operation  gradually  loosen  the  tube.  A  hot  solution  of  cocain 
is  more  efficient  than  a  cold  solution  (T.  Costa) ;  hence  hot  solutions  can 
be  used  in  much  less  strength  and  are  safer.  The  method  of  injection  is 
as  follows:  A  sharp  needle  is  held  at  an  angle  of  forty-five  degrees  to  the 
surface,  and  is  pushed  into  the  Malpighian  layer.  One  or  two  minims  of 
a  2  per  cent,  solution  are  forced  into  the  Malpighian  layer,  and  a  whitened 
elevation  forms.  The  needle  is  withdrawn,  at  the  margin  of  the  wheal  is 
reinserted,  and  more  fluid  is  introduced,  and  so  on  until  the  region  to  be 
operated  upon  has  been  injected.  After  waiting  five  minutes  the  operation 
is  begun.  If,  after  cutting  the  skin,  it  is  necessary  to  cut  the  subcutaneous 
tissue,  pour  a  few  drops  of  a  i  per  cent,  solution  into  the  wound  from  time 
to  time.  After  the  completion  of  the  operation,  if  a  rubber  band  were  used, 
it  is  loosened  for  a  few  seconds,  tightened  for  a  few  minutes,  again  loosened 
and  readjusted,  and  so  on  several  times  (Wyeth).  In  this  way  only  a  small 
quantity  of  cocain  is  admitted  into  the  circulation  at  one  time,  and  toxic 
symptoms  are  prevented.  For  operations  upon  the  eye  a  i  to  4  per 
cent,  solution  is  employed;  a  drop  of  fluid  is  instilled  every  ten  minutes  until 
three  drops  have  been  given.  Over  two-thirds  of  a  grain  should  not  be 
painted  upon  a  mucous  membrane.  Rarely  use  over  a  10  per  cent,  solution 
on  mucous  membranes,  although  in  laryngeal  operations  a  20  per  cent, 
.solution  may  be  required.  For  the  nasal  mucous  membrane  a  bit  of  wool 
soaked  in  a  5  per  cent,  solution  is  inserted  or  a  sprav  of  4  per  cent,  solution 
is  thrown  from  an  atomizer  into  the  nostrils.  In  the  rectum,  \ulva,  \agina, 
and  uterus  use  a  5  per  cent,  solution;  in  the  urethra  a  4  percent,  solution, 
and  in  the  bladder  a  2  per  cent,  solution. 

Cocainization  of  a  Nerve-trunk. — Krogius  has  pointed  out  that  if 
cocain  is  injected  into  the  tissue  about  a  nerve-trunk  anesthesia  will  follow 
in  the  area  supplied  by  the  nerve.  The  anesthesia  will  be  produced  in  five 
minutes,  and  will  last  fifteen  minutes.     If  cocain  is  injected  about  the  root 


888  Anesthesia  and  Anesthetics 

of  the  finger,  all  of  the  tissues  of  the  digit  will  become  insensitive.  Injection 
over  both  supra-orbital  notches  renders  the  middle  of  the  forehead  insensitive. 
Injection  over  the  ulnar  nerve  causes  complete  anesthesia  of  its  trajectory. 
This  plan  is  extensively  used  in  Helsingfors. 

It  has  been  demonstrated  by  Crile  ("Jour.  Amer.  Med.  Assoc,"  Feb. 
22,  1902)  that  the  injection  of  cocain  into  a  nerve-trunk  interposes  an  absolute 
block  to  the  transmission  of  afferent  and  efferent  impulses  and  greatly  lessens 
operative  shock.  In  5  cases  he  employed  this  method  to  secure  anesthesia 
for  amputation  of  the  leg,  and  4  of  the  patients  did  not  know  that  any  opera- 
tion was  being  performed. 

Eucain  hydrochlorate  is  far  safer  than  cocain,  and  in  most  cases  is 
to  be  preferred  to  it.  It  is  injected  in  the  strength  of  from  2  to  5  per 
cent.  It  can  be  boiled  without  destroying  its  properties,  and  hence  can  be 
readily  rendered  sterile.  It  occasionally,  though  rarely,  happens  that  the 
injection  of  eucain  causes  sloughing,  especially  at  the  extremities,  in  fatty  tis- 
sue, in  tendon-sheaths,  and  in  bursas.     It  can  be  used  on  mucous  membranes. 

Infiltration-anesthesia  was  devised  by  Schleich,  of  Leipsic,  who  was 
dissatisfied  with  cocain,  because  it  is  not  safe  and  sometimes  fails  to  produce 
complete  local  anesthesia,  owing  to  want  of  thorough  diffusion.  He  found 
that  salt  solution  (0.2  per  cent.),  if  injected  into  uninflamed  parts,  produced 
anesthesia.  To  obtain  this  anesthesia  the  part  must  be  distended  by  wide 
infiltration.  If  minute  quantities  of  cocain,  morphin,  and  carbolic  acid 
are  added  to  the  solution,  the  anesthesia  becomes  more  thorough  and  more 
prolonged,  and  can  be  obtained  even  in  inflamed  areas. 

Schleich  uses  three  solutions: 

No.  I,  a  strong  solution,  which  is  used  in  inflamed  areas:  cocain  hydro- 
chlorate,  gr.  iij;  morphin  hydrochlorate,  gr.  -|;  sodium  chlorid,  gr.  iij;  dis- 
tilled sterile  water,  Siijf ;  phenol  (5  per  cent.),  2  drops. 

No.  2,  a  medium  solution,  which  is  employed  in  most  cases:  cocain  hydro- 
chlorate, gr.  iss;  morphin  hydrochlorate,  gr.  f;  sodium  chlorid,  gr.  iij;  dis- 
tilled sterile  water,  5iij|-;  phenol  (5  per  cent.),  2  drops. 

No.  3  is  the  weak  solution  used  to  infiltrate  extensive  areas;  cocain  hydro- 
chlorate, gr.  I;  morphin  hydrochlorate,  gr.  f;  sodium  chlorid,  gr.  iij;  dis- 
tilled sterile  water,  liijf ;  phenol  (5  per  cent.),  2  drops. 

The  injections  are  begun  in  the  skin,  not  under  it  (Fig.  501),  and  are 
made  one  after  another  until  the  area  to  be  operated  upon  is  surrounded 
above,  below,  and  on  all  sides  with  Schleich's  solution.  At  each  infiltrated 
area  a  wheal  forms  in  the  skin.  This  infiltration  can  be  made  painlessly  by 
touching  with  pure  carbolic  acid  the  point  where  the  needle  is  to  be  inserted, 
or  by  freezing  this  spot  with  ethyl  chlorid.  After  infiltration  of  the  skin  an 
incision  is  made,  and  when  deeper  tissues  are  reached  they  are  infiltrated 
before  incising  them.  If  a  nerve  comes  in  sight,  touch  it  with  a  drop  of 
pure  carbolic  acid.  Van  Hook  says  that  the  anesthesia  obtained  by  this 
method  is  due  to  artificial  ischemia,  pressure  upon  the  tissues,  the  direct  action 
of  the  drugs,  and  the  lowered  temperature.*  The  method  is  very  efficient, 
and  can  be  u.sed  for  operations  of  considerable  magnitude.  Matas  uses  a 
special  apparatus  to  infiltrate  the  tissues.  The  fluid  is  driven  by  compressed 
air,  and  widespread  or  "massive"  infiltration  is  produced. 
*  Med.  News,  Nov.  16,  1895. 


Cocainization  of  the  Spinal   Cord  889 

Cocainization  of  the  Spinal  Cord. — Bier  has  produced  complete  anes- 
thesia of  the  entire  body  except  the  head  by  the  injection  of  a  small  amount 
of  cocain  into  the  subarachnoid  space  of  the  spinal  cord.  A  solution  of 
cocain  of  a  strength  of  from  0.5  per  cent,  to  i  per  cent,  is  used  by  some,  but 
cocain  cannot  be  boiled  without  impairment  of  its  anesthetic  power,  and 
carbolic  acid  must  be  added  to  it  in  small  amount.  Hence  cocain  so  pre- 
pared is  not  certainly  sterile,  and  the  carbolic  acid  added  may  induce  harmful 
symptoms.  (See  Neugebauer,  in  ''Wien.  klin.  Woch.,"  1901,  Nos.  50.  51, 
52.)  Some  surgeons  use  a  solution  of  eucain,  which  can  be  boiled,  but  it 
is  not  so  rapid  and  certain  as  cocain.  Some  use  tropacocain  (lUwicz).  A 
solution  of  this  drug  can  be  boiled,  is  less  poisonous  than  cocain,  and  some- 
what slower  in  action.  E.xperimenters  tell  us  that  gr.  ss  to  gr.  iss  may  be 
given,  but  it  is  not  wise  to  give  over  0.5  of  a  grain. 

The  best  plan  is  that  of  A.  W.  Morton.  He  takes  chemically  pure  crystal- 
line hydrochlorate  of  cocain,  places  it  for  fifteen  minutes  in  a  dry  temperature 
of  300°  F.,  and  puts  it  in  sterile  tubes  until  wanted.  The  dose  depends  upon 
the  locality  in  which  we  wish  to  induce  analgesia  and  varies  between  0.3  gr. 
and  0.5  gr.     The  required  dose  is  placed  in  the  barrel  of  the  sterile  syringe 


// 

Fig.  501. — The  syringe-point  stops  at  the  papillary  layer,  and  the  fluid  lodges  in  the  skin  itself  (\'an 

Hook). 


and  is  dissolved  in  cerebrospinal  fluid  drawn  into  the  syringe  for  that  purpose. 
The  syringe  should  be  of  glass,  so  that  it  can  be  boiled.  The  concave  portion 
of  the  needle  should  be  dull,  so  that  a  plug  of  skin  will  not  be  cut  out  and 
obstruct  the  needle  (A.  W.  Morton,  in  "Jour.  Amer.  ]Med.  Assoc,"  Nov.  8, 
1902).  The  patient  hes  upon  his  side  with  the  back  curved.  The  back 
has  been  previously  sterihzed.  The  dressings  are  removed  and  the  region 
to  be  punctured  is  resterilized.  The  spines  of  the  third  and  fourth  lumbar 
vertebrae  are  located  and  the  needle  is  entered  in  the  mid-line  beneath  the 
spine  of  the  third  or  fourth  lumbar  vertebra  and  is  pointed  upward  and  forward. 
The  surgeon  determines  that  he  has  punctured  the  subarachnoid  space  by 
lessened  resistance  and  the  appearance  of  fluid  at  the  needle-opening.  The 
syringe,  with  a  closed  piston,  contains  0.3  gr.  of  sterile  cocain.  It  is  attached 
to  the  needle;  the  piston  is  withdrawn  until  the  syringe  is  half  full  of  cere- 
brospinal fluid.  When  the  cocain  is  dissolved,  the  solution  is  slowly  injected, 
the  needle  is  withdrawn,  and  the  puncture  is  sealed  with  collodion. 

The  anal  region  becomes  anesthetic  in  from  one  to  two  minutes;  the 
lower  extremities  in  from  three  to  six  minutes,  and  the  upper  e.xtremities 
in  from  fifteen  to  thirtv  minutes.     The  anesthetic  condition  lasts  from  one 


890  Anesthesia  and  Anesthetics 

to  three  hours,  or  even  longer,  and  is  due  to  the  contact  of  cocain  with  the 
nerve-roots  (A.  W.  Morton,  "Jour.  Amer.  Med.  Assoc,"  Nov.  8,  1902). 

In  performing  the  operation  care  must  be  taken  to  prevent  the  escape  of 
cerebrospinal  fluid. 

After  cocainization  of  the  spinal  cord  surgical  operations  can  be  per- 
formed on  many  regions,  without  causing  pain.  Among  the  operations  which 
have  been  performed  are  resection  of  the  knee,  resection  of  the  ankle,  osteotomy 
(Bier),  amputation  of  the  leg  (Lower),  and  hysterectomy  (Tufifier). 

Cocainization  of  the  spinal  cord  is  not  growing  in  popularity.  It  is 
regarded  by  most  surgeons  as  rather  a  surgical  curiosity.  It  should  never 
be  used  as  a  routine  procedure,  and  it  will  not  displace  ether  or  chloroform. 
By  it  analgesia  can  usually  be  secured.  A.  W.  Morton  ("Jour.  Amer.  Med. 
Assoc,"  Nov.  8,  1902)  has  used  it  673  times  without  a  failure,  and  60  of  these 
operations  were  above  the  diaphragm.  Most  operators  have  had  failures 
above  the  diaphragm.  No  one  should  attempt  it  who  is  not  well  trained 
in  aseptic  methods,  because  infection  of  the  cord  or  its  membranes  will  prove 
fatal.  Whether  or  not  ultimate  harm  ever  comes  to  the  cord  is  n6t  certain. 
Bristow  ("Brooklyn  Med.  Jour.,"  1902,  xvi,  page  410)  reports  the  case  of  a 
man,  fifty-five  years  of  age,  on  whom  he  operated  for  hemorrhoids  after 
spinal  cocainization.  An  examination  one  month  later  indicated  degenera- 
tion of  the  posterior  and  lateral  columns  of  the  cord  (spastic  lower  e.xtremities, 
ataxic  gait,  increased  knee-jerks,  ankle  clonus,  and  inability  to  retain  urine). 
Marx  ("New  York  Med.  Record,"  Dec.  22,  1900)  states  that  one  case  in  his 
experience,  after  cocainization  of  the  spinal  cord,  developed  a  typical  loco- 
motor ataxia.  Dandois  ("Jour,  de  Chir.  Brux.,"  April-May,  1901)  reports 
a  case  upon  which  he  had  operated  for  traumatic  rupture  of  the  urethra. 
Spinal  cocainization  was  employed.  Paraplegia  developed  and  lasted  two 
months.  Dr.  Francis  D.  Patterson,  who  furnished  me  with  the  above  refer- 
ences, writes  me  that  there  are  several  cases  of  hemorrhage  into  the  sub- 
arachnoid space  on  record. 

Is  there  any  danger  of  death  from  cocainization  of  the  cord  ?  If  the 
operation  is  not  performed  with  scrupulous  aseptic  care,  it  is  very  dangerous. 
Even  when  performed  by  the  best  surgeons  death  may  occur.  Dr.  Francis 
D.  Patterson,  who  has  investigated  this  subject,  writes  me  that  Tuffier  places 
the  mortality  at  3  in  2000,  but  excludes  from  consideration  3  deaths  ("  La 
Presse  Medicale,"  vol.  Iv,  1901,  page  190).  Reclus  finds  6  deaths  in  less 
than  2000  cases  (Address  before  the  Paris  Academie  de  Medecine,  March  19, 
1901).  Hahn,  in  1708  cases  collected  from  literature,  found  8  deaths  ("Mitt, 
f.  d.  Grenzgeb.  d.  Med.  u.  Chir.,"  1900,  iii,  337).  Patterson's  investigations 
persuade  him  that  the  mortality  is  about  3  in  every  1000  cases. 

Cocain  seems  to  act  like  a  toxin  on  the  pia  and  arachnoid.  Examination 
of  fluid  withdrawn  after  the  performance  of  cocainization  shows  that  it  con- 
tains polymorphic  leukocytes  (Ravant  and  Aubourg,  in  "  Gaz.  Hebd.  de  Med. 
et  de  Chir.,"  June  27,  1901). 

Unpleasant  after-effects  are  common.  Among  these  are  nausea,  vomiting, 
sweating,  overaction  of  the  heart,  involuntary  evacuation  of  feces,  cramps  in 
the  limbs,  headache,  chills,  and  shock.  Many  of  these  symptoms  are  prob- 
ably due  to  absorption  of  cocain,  but  the  headache  must  be  due  to  tension, 
because  it  is  relieved  by  the  withdrawal  of  some  cerebrospinal  fluid  by  lumbar 


Cocainization   of   the   Spinal   Cord  89 1 

puncture   (Ravant  and  Aubourg,   in   '' Gaz.   Hebd.   de  Aled.   et  de  Chir.," 
June  27,  1901). 

In  a  case  in  which,  because  of  heart  disease,  pulmonary  disease,  kidney 
disease,  or  some  other  condition  in  which  a  general  anesthetic  is  inadmissible, 
spinal  cocainization  is  justifiable.  I  agree  with  Francis  D.  Patterson  that 
spinal  cocainization  should  be  reserved  for  cases  in  which  other  forms  of 
anesthesia  are  positively  contraindicated. 


8q2  Burns  and   Scalds 


XXX.   BURNS  AND  SCALDS. 

BuRXS  and  scalds  are  injuries  due  to  the  action  of  caloric.  Scalds  are 
due  to  heated  fluids  or  vapors.  There  is  no  true  pathological  difference 
between  burns  and  scalds.  Dupuytren  classifies  burns  into  six  degrees,  as 
follows:  (i)  characterized  by  erythema;  (2)  characterized  by  dermatitis  with 
the  formation  of  vesicles;  (3)  characterized  by  partial  destruction  of  the  skin, 
whic'..  structure  is  not,  however,  entirely  burnt  through;  (4)  characterized 
by  destruction  of  the  skin  to  the  subcutaneous  tissue;  (5)  characterized  by 
destruction  of  all  superficial  structures  and  of  part  of  the  muscular  layer; 
(6)  characterized  by  "carbonization"  of  the  whole  thickness  of  the  muscles. 

The  symptoms  of  a  severe  burn  are  local  and  constitutional.  Local 
symptoms  are  pain  and  inflammation,  which  vary  in  nature,  in  intensity, 
or  in  degree  according  to  the  extent  of  tissue-damage.  Constitutional  symp- 
toms are  very  weak  pulse,  shallow  respiration,  and  subnormal  temperature, 
— in  other  words,  the  condition  of  shock  exists.  The  patient  may  die  without 
reacting  from  shock,  but  in  most  cases  there  is  reaction,  followed  by  a  severe 
reactionary  fever,  with  a  strong  tendency  to  congestion  of  internal  parts. 
During  the  existence  of  fever  there  may  be  vomiting,  diarrhea,  hemoglobinuria, 
albuminuria,  and  enlargement  of  the  liver,  spleen,  lymph-glands,  and  tonsils. 
The  symptomatic  stages  are  often  designated  as  prostration,  reaction,  and 
suppuration.  During  the  first  forty-eight  hours  after  a  burn  there  is  conges- 
tion in  and  about  the  burned  area — severe  pain  and  possibly  internal  con- 
gestions. There  may  be  shock  and  possibly  toxic  delirium  or  convulsions. 
From  the  end  of  the  second  to  the  end  of  the  eighth  or  ninth  day  there  is 
severe  inflammation  of  the  burnt  area,  formation  of  sloughs,  and  a  strong  ten- 
dency to  inflammation  of  the  brain  in  head  burns,  of  the  lungs  in  chest  burns, 
of  the  abdominal  organs  in  abdominal  burns,  and  of  duodenal  inflammation 
in  any  burns.  Duodenal  inflammation  may  result  in  Curling's  ulcer.  Duo- 
denitis and  Curling's  ulcer  are  probably  due,  as  Wm.  Hunter  suggested,  to  the 
bile  having  become  irritant  by  the  excretion  in  it  of  toxic  matter  ("A  Manual 
of  Surgical  Treatment,"  by  W.  Watson  Cheyne  and  F.  F.  Burghard).  After 
the  eighth  or  ninth  day  the  sloughs  separate  and  healing  begins.  The  raw  sur- 
face is  slow  to  heal,  hemorrhages  may  occur,  the  granulations  are  apt  to  be 
exuberant  and  edematous,  and  the  scars  are  very  contractile  and  often  produce 
hideous  or  disabling  deformity.  If  over  one-half  of  the  body-surface  is  badly 
burnt,  death  will  almost  certainly  occur,  and  probably  within  two  days. 
The  danger  of  a  burn  depends  upon  its  extent,  its  depth,  and  its  situation. 
Burning  of  a  large  area  superficially  is  much  more  dangerous  than  burning 
a  small  area  deeply.  Burns  of  the  extremities  are  not  so  dangerous  as  are 
burns  of  the  head,  chest,  or  abdomen.  Death  after  severe  burns  is  positively 
not  due  to  loss  of  body-heat  in  the  burnt  area.  Some  think  it  is  produced 
Vjy  autointoxication  with  retained  body-secretions.  High  temperature  pro- 
duces blood-changes, — viz.,  disintegration  of  red  corpuscles.  Thrombosis 
may  occur,  and  irritation  of  the  kidneys  and  other  organs  is  produced  by 
"products  of  corpuscular  degeneration."  * 

The  blood  of  burned  animals  contains  toxins   (Kijanitzen),  and  so  does 

*  P.ardoen,  in  Johns  Hopkins  Hospital  Bulletin,  April,  1897. 


Treatment  of   Burns  893 

the  urine  (Reis).  It  seems  probable  that  the  constitutional  symptoms  and 
death,  if  it  occurs,  are  due  partly  to  corpuscular  disorganization,  and  partly 
to  the  absorption  of  toxic  matter  from  the  seat  of  injury,  this  matter  having 
been  formed  by  the  action  of  heat  on  the  body-cells  and  fluids.  Sepsis  is 
not  infrequent.  Death  may  be  directly  due  to  shock,  to  .sepsis,  to  exhaustion, 
to  embolism  or  thrombosis,  to  congestion  of  the  brain,  lungs,  or  kidneys, 
or  to  Curling's  ulcer  of  the  duodenum. 

Treatment. — The  local  treatment  of  slight  burns  (as  sunburn)  is  to 
moisten  the  parts  frequently  with  a  saturated  solution  of  bicarbonate  of 
sodium,  or  a  1:8  solution  of  phenol  sodique.  In  burns  of  moderate  degree 
a  mixture  of  zinc  ointment  with  iodoform,  though  not  antiseptic,  is  a  com- 
fortable dressing. 

If  a  large  surface  is  burnt,  remove  the  ciothing  with  great  care,  and  before 
applying  dressings,  give  a  hypodermatic  injection  of  morphin,  administer 
stimulants,  and  if  the  patient  has  a  chill  place  him  in  a  warm  bath.  Use  all 
ordinary  means  to  secure  reaction  from  shock.  If  we  desire  to  dress  a  large 
burn  aseptically,  anesthetize  the  patient,  spray  the  burnt  area  with  per- 
oxid  of  hydrogen,  irrigate  it  with  a  solution  of  boric  acid,  dry  with  sterile 
cotton,  dust  with  Senn's  powder  (three  parts  of  boric  acid  and  one  part  of 
salicylic  acid),  and  dress  with  salicylated  cotton.  Senn's  powder  is  better 
than  iodoform.  Iodoform  may  allay  pain,  but  is  apt  to  produce  dermatitis. 
Change  the  dressing  no  oftener  than  is  required,  and  at  each  change  proceed 
as  above  described,  although  it  will  not  be  necessary  to  anesthetize.  Per- 
oxid  of  hydrogen  softens  and  loosens  the  dressings,  and  they  can  be  readily 
removed.  The  custom  in  the  Jefferson  Medical  College  Hospital  is  to  give 
morphin  and  stimulants,  to  cut  away  the  clothing,  to  wrap  the  unburnt  parts 
with  blankets,  and  place  about  them  cans  or  bags  of  hot  water.  The  burnt 
region  is  sprayed  with  peroxid  of  hydrogen  contained  in  an  atomizer,  and 
irrigated  with  salt  solution.  Portions  of  epidermis  which  remain  are  re- 
tained. Any  blisters  are  opened  with  a  sterile  needle,  and  the  part  is  dressed 
with  several  layers  of  sterile  lint  or  tarlatan  soaked  in  normal  salt  solution, 
and  the  dressing  is  kept  moist.  During  the  second  or  inflammatory  stage 
use  stimulants  and  concentrated  food,  allay  pain  by  opium  or  morphin, 
favor  elimination  by  the  skin,  bowels,  and  kidneys,  and  combat  any  tendency 
to  internal  congestion  or  inflammation. 

The  picric  acid  treatment,  first  suggested  by  Thiery,  has  many  advocates. 
It  greatly  mitigates  the  pain.  It  is  used  early  only  in  limited  burns  of  the 
first  and  second  degrees,  but  it  can  be  employed  in  late  stages  of  deep  burns 
to  stimulate  the  formation  of  epidermis.  If  used  early  in  a  large  or  a  deep 
burn,  it  may  poison  the  patient  (may  produce  carboluria).  The  part  should 
be  disinfected,  gauze  saturated  with  a  i  per  cent,  watery  solution  of  picric 
acid  should  be  laid  upon  the  burnt  area,  and  be  covered  with  absorbent 
cotton  and  a  bandage.  This  dressing  is  not  changed  for  three  to  five  days, 
and  the  next  dressing  can  be  left  in  place  until  the  burn  is  healed.  D'Arcy 
Power  has  carefully  studied  the  real  status  of  picric  acid  as  a  remedy  for 
burns,  and  some  of  his  conclusions  have  been  set  forth  above. 

Perier  dresses  a  bum  with  a  tarlatan  compress,  folded  six  times  and 
soaked  in  the  following  solution:  boric  acid,  oijss;  antipyrin,  3jss;  sterile 
water,  oviij.  The  following  ointment  is  used  by  Reclus:  iodoform,  gr.  xv; 
antipyrin,  gr.  Ixxv;  boric  acid,  gr.  Ixxv;  vaselin,  ojss. 


894  Burns  and  Scalds 

Carron  oil  consists  of  equal  parts  of  linseed  oil  and  lime-water.  It  allays 
the  pain  of  a  burn,  but  it  is  a  filthy  preparation,  and  its  use  is  followed  by 
much  pus-formation.  CosmoHn  gives  comfort  as  a  dressing,  but  should 
not  be  used  on  the  face  lest  it  cause  pigmentation.  The  elder  Gross  used 
lead  paint.  A  solution  of  nitrate  of  potassium  allays  the  pain.  Where 
extensive  destruction  of  tissue  has  taken  place  use  splints  and  extension  to 
limit  contractures,  and  skin-graft  as  soon  as  possible.  If  granulation  is 
slow,  stimulate  with  copper  sulphate  or  mild  silver-nitrate  solutions.  Exu- 
berant granulations  require  burning  down.  Flabby  granulations  require 
pressure.  If  heahng  is  slow,  or  if  the  burn  is  extensive,  skin-graft.  When 
an  extremit}'  has  been  carbonized  amputation  must  be  performed.  The 
constiiutional  treatment  is  to  bring  about  reaction;  combat  pain  with  opium; 
and  keep  the  bowels  and  kidneys  active.  If  suppuration  occurs,  give  t-onics, 
stimulants,  and  concentrated  foods.  Complications  are  treated  according 
to  general  rules. 

Burns  and  Scalds  of  the  Tongue,  Pharynx,  Glottis,  and  Epi= 
glottis. — A  child  or  lunatic  may  drink  boiling  fluid  or  inhale  steam  from  a 
tea-kettle.  Firemen  occasionally  suffer  from  scalds  of  the  tongue  and  phar- 
ynx after  being  suddenly  enveloped  in  a  cloud  of  hot  steam,  and  from  burns 
by  the  inhalation  of  hot  vapor  or  flame.  Caustic  may  be  taken  into  the  mouth 
or  swallowed.  The  tongue  and  pharyngeal  mucous  membrane  swell  greatly, 
large  vesicles  form,  there  are  shock,  severe  pain,  dysphagia,  and  dyspnea. 
Edema  of  the  glottis  may  arise. 

Treatment. — Combat  shock;  give  morphin  for  pain;  puncture  vesicles, 
and  have  the  patient  almost  constantly  suck  bits  of  ice.  If  great  swelling 
occurs,  make  multiple  longitudinal  incisions  through  the  mucous  membrane 
of  the  dorsum  of  the  tongue.  If  edema  of  the  glottis  begins,  scarify  it.  If 
this  fails,  perform  intubation  or  tracheotomy. 

Burns  of  the  Esophagus.— The  esophagus  is  seldom  scalded,  as  a 
boiling  fluid  rarely  gets  below  the  pharynx.  The  swallowing  of  an  acid  or 
alkali  produces  severe  burns  at  the  constricted  portions  of  the  gullet  (page 
687).  Such  an  accident  produces  shock,  dyspnea,  violent  pain,  vomiting 
of  blood,  and  thirst.  Death  may  occur  from  shock  or  perforation  of  the 
stomach.  In  many  cases  severe  gastritis  follows  a  burn  of  the  esophagus. 
As  the  acute  symptoms  of  a  burn  of  the  gullet  gradually  abate,  sloughs  are 
cast  off,  ulcers  form,  cicatrization  begins,  and  the  signs  of  stricture  develop 
(page  687). 

Treatment. — Give  a  remedy  to  neutralize  the  caustic.  Administer 
several  large  draughts  of  water  and  wash  out  the  stomach.  Combat 
shock.  Give  morphin  for  pain.  Feed  by  the  rectum  as  long  as  the  patient's 
strength  does  not  begin  to  fail.  On  beginning  mouth-feeding,  use  at  first 
milk  and  then  beef-juice,  jelly,  and  ice-cream.  In  from  two  to  four  weeks 
after  the  infliction  of  the  burn  begin  the  use  of  bougies  to  limit  con- 
traction. 

Effects  of  Cold. — Local  Effects. — Cold  produces  numbness,  pricking, 
a  feeling  of  weight,  redness  of  the  surface  followed  by  stiffness,  local  insensi- 
bility, and  mottling  or  pallor.  .Sudden  intense  cold  causes  the  formation 
of  blebs,  the  coagulation  of  blood  in  the  superficial  veins,  and  violent  pain 
in  the  limb.     Cold  locally  produces  frost-bite  (page  149). 


Chilblain   or  Pernio  895 

The  constitutional  efjeds  of  cold  are  at  first  stimulating,  then  depressing, 
and  are  exhibited  by  uneasiness,  pain,  and  an  intense  drowsiness  which,  if 
yielded  to,  is  the  road  to  death  by  way  of  internal  congestion.  Death  from 
prolonged  cold  resembles  in  appearance  death  from  apoplexy.  Death  from 
sudden  and  overwhelming  cold  is  caused  by  anemia  of  the  brain  from  weak 
circulation  and  capillary  embolism.  To  bring  a  partly  frozen  person  into 
a  warm  room  may  cause  death  by  embolism. 

Treatment. — Frost-bite  is  treated  as  outlined  on  page  149.  When  a 
person  is  nearly  frozen  to  death  place  him  in  a  cool  room,  but  under  no  cir- 
cumstance in  a  cold  bath;  make  artificial  respiration,  rub  him  briskly  with 
flannel  soaked  in  alcohol  or  in  whiskey,  and  follow  this  by  rubbing  with 
dry  hands.  After  a  time  wrap  the  patient  in  warm  blankets  and  give  an 
enema  of  brandy.  Mustard  plasters  are  to  be  applied  over  the  heart  and 
spine.  As  soon  as  swallowing  is  possible  brandy  is  administered  by  the 
mouth.  As  the  condition  improves  gradually  raise  the  temperature  of  the 
room  and  give  hot  drinks. 

Chilblain  or  pernio  is  a  secondary  effect  of  cold.  It  usually  appears 
as  a  local  congestion  upon  the  toes,  the  ears,  the  fingers,  or  the  nose, 
and  now  and  then  inflames  and  ulcerates.  A  chilblain  is  apt  to  become 
congested  on  approaching  a  fire  or  on  taking  exercise,  and  when  con- 
gested it  itches,  tingles,  and  stings.  Frequent  attacks  of  congestion  produce 
crops  of  vesicles;  these  vesicles  rupture  and  expose  an  ulcer,  which  in  rare 
instances  sloughs. 

Treatment. — If  chilblain  aft'ects  the  toes,  prevent  congestion  of  the  legs 
and  feet.  Order  large  shoes  and  woollen  stockings,  and  forbid  tight  garters. 
The  patient  with  pernio  must  take  regular  outdoor  exercise  and  must  not 
loiter  around  a  hot  fire.  Every  morning  and  evening  he  should  take  a  general 
cold  sponge-bath,  following  by  rubbing  with  alcohol  and  frictions  with  a 
coarse  towel,  and  in  winter  he  should  sleep  with  warm  stockings  on  or  with 
his  feet  upon  a  warm-water  bag.  \\'hen  a  chilblain  is  only  a  congested  spot 
it  should  be  washed  twice  a  day  in  cold  salt  water,  rubbed  dry  with  flannel, 
and  subjected  to  applications  of  tincture  of  iodin  and  soap  liniment  (i :  2), 
tincture  of  cantharides  and  soap  liniment  (i:  6),  or  equal  parts  of  turpentine 
and  olive  oil  (W.  H.  A.  Jacobson).  Jacobson  says  itching  is  relieved  by 
painting  belladonna  hniment  upon  the  part  and  allowing  it  to  dry.  Tincture 
of  iodin  may  relieve  it,  and  so  may  a  mustard  foot-bath.  A  valuable  prepara- 
tion for  itching  is  composed  of  3j  of  powdered  camphor  and  .siv  of  cosmolin, 
A  little  of  this  ointment  is  rubbed  in  twice  a  day.  The  following  prescription. 
the  source  of  which  I  do  not  remember,  is  very  valuable  for  itching:  .^j  of 
powdered  camphor;  3iss  of  ichthyol;  .5ss  of  lanolin,  and  .^iv  of  cosmolin, 
rubbed  into  the  part  and  covered  with  cotton-wool.  If  vesicles  form,  paint 
with  contractile  collodion;  if  ulcers  form,  dress  antiseptically.  If  ulcers  are 
sluggish,  use  equal  parts  of  resin  cerate  and  spirits  of  turpentine.  A  good 
antiseptic  and  protective  is  the  following:  oxid  of  zinc,  gr.  vj;  chlorid  of  zinc, 
gr.  XX ;  gelatin,  .^ij;  distilled  water,  .^j. 


896  Diseases  of  the   Skin  and  Nails 


XXXI.   DISEASES  OF  THE  SKIN  AND  NAILS. 

Dermatitis  venenata  results  from  irritants  and  from  garments  con- 
taining arsenic,  but  is  generally  due  to  rhus-poisoning.  Rhus-poisoning 
arises  from  the  poison-oak,  the  poison-ash,  the  poison-ivy,  and  other  species 
of  sumach.     Actual  touching  of  the  plants  is  not  always  necessary. 

The  symptoms  are  burning  and  itching,  redness  and  edema  of  the 
face  and  hands.  A  vesicular  eruption  begins  between  the  fingers,  and  the 
eruption  and  the  inflammation  spread  widely  over  the  body.  There  may 
be  slight  fever. 

The  treatment,  when  a  moderate  area  is  involved,  comprises  the  applica- 
tion of  cloths  wet  with  black  wash  or  lead-water  and  laudanum.  If  an 
extensive  area  is  involved,  apply  grindelia  robusta  (3iv  to  Oj  of  water)  or 
moisten  the  surface  frequently  with  sweet  spirits  of  niter.  Oxid  of  zinc 
ointment  containing  10  gr.  of  carbolic  acid  to  3J  gives  great  relief.  A  1:8 
solution  of  phenol  sodique  allays  pain  and  itching. 

Furuncle,  or  boil,  is  an  acute  and  circumscribed  inflammation  of  the 
deep  layer  of  the  true  skin  and  the  subcutaneous  cellular  tissue  following  on 
bacterial  infection  of  a  hair-follicle  or  a  sebaceous  gland.  A  boil  is  caused  by 
infection  of  a  hair-follicle  through  a  slight  wound  (by  scratching,  shaving,  etc.) 
with  the  staphylococcus  pyogenes  aureus.  Boils  are  very  common  in  indi- 
viduals with  Bright's  disease, diabetes, gout,  tuberculosis,  and  disorders  of  men- 
struation and  digestion;  and  crops  of  boils  are  apt  to  appear  during  conva- 
lescence from  typhoid  fever.  Boils  are  commonest  in  the  spring,  and  some- 
times an  epidemic  of  furunculosis  appears  in  a  hospital,  a  jail,  or  an  asylum. 

The  symptoms  of  a  boil  are  as  follows:  a  red  elevation  appears,  which 
stings  and  itches;  this  elevation  enlarges  and  becomes  dusky  in  color;  a 
pustule  forms,  that  ruptures  and  gives  exit  to  a  very  little  discharge  which 
forms  a  crust.  Inflammatory  infiltration  of  adjacent  connective  tissue 
advances  rapidly,  and  the  boil  in  about  three  days  consists  of  a  large,  red, 
tender,  and  painful  base  capped  by  a  pustule  and  a  little  crusted  discharge. 
In  rare  instances,  at  this  stage,  absorption  occurs,  but  in  most  cases  the 
swelling  increases,  the  discoloration  becomes  darker,  the  skin  becomes  edem- 
atous, the  pain  becomes  fierce  and  pulsatile,  and  the  center  of  the  boil 
becomes  raised.  About  the  seventh  day  rupture  occurs,  pus  flows  out,  and 
a  "core"  of  necrosed  tissue  is  found  in  the  center  of  a  ragged  opening.  This 
core  consists  of  the  sebaceous  gland  and  hair-follicle,  which  have  undergone 
coagulation  necrosis  (Warren).  In  a  day  or  two  more  the  core  will  be  dis- 
charged, and  healing  by  granulation  will  begin.  A  blind  boil  lasts  only  three  or 
four  days  and  has  no  core.  The  constitution  often  shows  reaction  during  the 
progress  of  a  boil.  Boils  may  be  either  single  or  multiple.  The  development 
of  one  boil  after  another,  or  the  formation  of  several  boils  at  once,  is  known 
as  "furunculosis."     Boils  are  commonest  upon  the  neck  and  the  back. 

The  treatment  consists  of  crucial  incision,  removal  of  necrotic  tissue, 
irrigation  with  peroxid  of  hydrogen  and  corrosive  sublimate,  and  the  applica- 
tion of  hot  antiseptic  fomentations. 

Aleppo  boils  (endemic  boils  of  the  tropics)  are  papules  appearing  upon 
the  exposed  parts  of  the  body.     These  papules,  which  ulcerate  and  do  not 


Carbuncle 


897 


cicatrize  for  at  least  a  year,  are  due  to  a  pathogenic  bacterium  and  leave 
ineradicable  scars. 

Carbuncle  (benign  anthrax)  is  a  circumscribed  infectious  inflammation 
of  the  deeper  layer  of  the  true  skin  and  of  the  subcutaneous  tissue,  with 
fibrinous  exudation,  muhiple  foci  of  necrosis  arising,  and  the  tissue  adjacent 
to  each  necrotic  plug  becoming  gangrenous.  The  infection  takes  place 
through  a  hair-follicle.  It  is  really  a  boil  with  extensive  infiltration  of  adjacent 
tissues.  A  boil  may  become  a  carbuncle,  and  pus  from  a  carbuncle  inoculated 
into  a  healthy  person  may  cause  either  a  boil  or  a  carbuncle.  The  causative 
organism  seems  to  be  the  staphylococcus  pyogenes  aureus.  Carbuncle  is 
most  common  in  the  upper  part  of  the  back  and  on  the  back  of  the  neck. 
In  this  region  the  skin  is  very  thick;  the  hair-follicles  hold  only  downy  hair, 
are  shallow,  and  project  but  a  short 
distance  into  the  cutis  vera.  Columns 
of  fatty  tissue  run  from  the  subcuta- 
neous tissue  in  an  oblique  direction  to 
join  the  point  and  sides  of  the  hair- 
follicle.  These  columns  are  known  as 
columnae  adiposae  and  each  one  con- 
tains a  sweat-gland  (Fig.  502).  When 
pus  runs  down  one  of  these  columns 
it  seeks  an  outlet;  it  cannot  spread 
easily  to  the  sides,  so  it  slowly  works 
its  way  to  the  deeper  tissue  and  from 
one  to  another  interspace  and  finds  its 
way  to  the  surface  through  other  fatty 
columns  (Warren's  "Surgical  Path- 
ology") (Fig.  503).  When  pus  finds 
its  way  to  the  surface,  an  opening 
forms,  hence  the  numerous  foci  of 
pointing;  finally  a  large  opening  forms 
(Fig.  504).  Carbuncles  are  most  com- 
mon in  the  spring  of  the  year.  In 
persons  with  diabetes  and  Bright's  disease  carbuncles  not  unusually  occur. 

The  local  symptoms  in  the  beginning  resemble  those  of  a  boil,  but  the 
constitution  sympathizes  from  the  very  start  (a  chill  and  a  septic  fever)  and 
the  pain  is  usually  severe.  The  inflammatory  area  begins  as  a  papule  with 
an  indurated  base,  it  enlarges  enormously,  is  boggy  to  the  touch,  is  dusky 
in  color,  is  edematous,  and  the  skin  is  not  freely  movable  over  the  deeper 
parts.  In  a  few  days  many  pustules  appear,  each  pustule  marking  the  site 
of  a  focus  of  necrosis.  Large  vesicles  filled  with  bloody  serum  \ery  frequently 
form.  In  some  cases,  about  the  tenth  day,  the  pustules  ru})ture,  the  necrotic 
plugs  are  discharged,  and  the  case  slowly  progresses  toward  cure;  but  in  many 
cases  the  carbuncle  spreads  at  the  periphery  while  pustules  are  rupturing 
near  the  center  of  inflammation,  and  pus  forms  in  the  deeper  tissues,  reaching 
the  surface  through  many  small  openings,  each  of  which  is  ]-)artly  blocked 
by  a  plug  of  dead  tissue.  A  carbuncle  in  this  stage  resembles  a  honeycomb 
(Fig.  504),  discharges  bloody  pus,  and  large  masses  of  skin  and  subcutaneous 
tissue  are  destroved.  The  entire  carbuncular  mass  nia\-  become  gangrenous, 
57 


Fig.  502. — Colunina  adiposa  (Warren). 


898 


Diseases  of  the  Skin  and  Nails 


and  a  sudden  and  almost  complete  cessation  of  pain  points  to  this  complica- 
tion. An  ordinary  carbuncle  remains  acute  for  about  three  weeks,  but  healing 
requires  a  month  more.  The  most  dangerous  situations  in  which  to  have 
a  carbuncle  are  the  face  and  neck  (tends  to  produce  septic  phlebitis,  septic 
clots  in  the  facial,  jugular,  or  ophthalmic  veins,  or  in  the  cerebral  sinuses, 
or  infective  emboli).  The  mortality  of  facial  carbuncle  is  at  least  50  per 
cent.     The  most  usual  positions  for  carbuncle  are  the  neck,  the  back,  and 


Fig.  503. — Infiltration  of  columna  adiposa  and  subcutaneous  tissue  with  pus  in  carbuncle  (Warren). 


Fig.  504  — Diagram  of  a  carbuncle  (Warren). 

the  buttocks.  The  diagnosis  of  carbuncle  is  made  by  noting  the  multiple 
foci  of  necrosis  and  the  profound  constitutional  involvement.  A  carbuncle 
may  produce  death  by  causing  septicemia,  pyemia,  or  profuse  hemorrhage. 

Treatment, — Some  have  suggested  the  treatment  of  a  carbuncle  in  an 
early  stage  by  injecting  from  five  to  thirty  drops  of  carbolic  acid  (80  per  cent.) 
into  and  around  the  inflammatory  mass.  The  best  treatment  is  thorough 
extirpation  while  the  patient  is  anesthetized.  The  entire  area  of  the  infection 
is  thus  removed,  and  the  large  wound  heals  by  granulation  and  is  subsequently 
skin-grafted.     A  useful  plan,  frequently  employed,  is  as  follows: 


On\xhia  899 

Give  ether,  make  free  crucial  incisions,  remove  dead  and  necrosing  tissue 
with  the  scissors  and  forceps,  curet  pockets,  arrest  hemorrhage  by  pressure 
and  hot  water,  cauterize  with  pure  carboHc  acid,  dust  with  iodoform,  pack 
with  iodoform  gauze,  and  dress  with  hot  antiseptic  fomentations.  Cover 
the  gauze  with  a  piece  of  some  impermeable  material  and  lay  a  hot-water 
bag  upon  the  dressing.  Every  day,  or  several  times  a  day,  remove  the  dress- 
ings, wash  with  peroxid  of  hydrogen,  irrigate  with  corrosive  sublimate  solu- 
tion, dust  with  iodoform,  and  reapply  the  iodoform  gauze  and  antiseptic 
fomentation.  Keep  up  this  treatment  until  sloughs  are  separated,  then  dress 
with  dry  antiseptic  gauze.  Secure  sleep  by  morphin,  give  quinin,  milk-punch, 
and  nourishing  diet,  and  maintain  the  action  of  the  bowels  and  kidneys. 

Erysipelas.— (See  page  166.) 

Clavus,  or  Corn. — A  com  is  a  tender,  painful,  and  circumscribed 
thickening  of  the  epidermis,  and  is  commonest  over  one  of  the  joints  of  the 
toes.  Hard  corns  are  situated  on  exposed  parts  of  the  digits;  soft  corns 
appear  between  the  digits,  where  the  parts  are  kept  constantly  moist.  Corns 
are  caused  by  pressure. 

Treatment. — The  wearing  of  well-fitting  boots  will  usually  cause  a  corn 
upon  the  toe  to  disappear.  Soak  the  feet  often  in  water  containing  bicarbonate 
of  sodium,  dry  them,  and  apply  a  circular  corn-plaster  to  the  corn  to  take  off 
the  pressure  of  the  boot.  Another  method  is  to  touch  the  corn  with  iodin 
every  night  and  pare  away  the  hard  tissue  every  morning.  An  old  and 
valuable  plan  is  to  paint  the  corn  every  night  with, a  mixture  composed  of 
salicyhc  acid,  3iss;  extract  of  cannabis  indica,  gr.  x;  and  collodion,  3j,  and 
to  scrape  this  mixture  away  every  morning.  Sojt  corns  are  treated  by  wash- 
ing the  feet  often  with  ethereal  soap,  drying,  gently  removing  the  sodden 
epithelium,  dusting  the  toes  with  borated  talc,  and  placing  absorbent  cotton 
between  the  digits.  Incurable  soft  corns  require  the  removal  of  the  skin 
from  the  adjacent  sides  of  the  two  toes  and  suturing  them  together  (thus 
converting  two  toes  into  one).  In  inflamed  corns  employ  rest  and  lead- 
water  and  laudanum,  and  let  out  pus  when  it  forms.  Remember  that  in 
old  persons  the  cutting  of  a  com  may  cause  senile  gangrene.  In  the  inflamed 
and  painful  feet  of  a  person  who  has  corns  nothing  gives  so  much  relief  as 
washing  the  feet  with  ethereal  soap,  soaking  in  hot  water,  and  wrapping 
the  feet  for  half  an  hour  in  cloths  wet  with  a  mixture  composed  of  linseed 
oil  and  lime-water,  each,  sij,  and  spirits  of  camphor,  o]. 

WartS.^(See  page  267.) 

Onychia  is  inflammation  of  the  matrix  of  the  nail.  .\  ''run-around" 
is  suppuration  of  the  matrix  at  the  root  of  the  nail,  of  traumatic  origin. 
It  requires  incision,  trimming  away  of  the  buried  edge  of  the  nail,  and  packing 
with  iodoform  gauze. 

Malignant  onychia,  which  is  inflammation  and  ulceration  of  the  entire 
matrix,  ^occurs  only  in  a  person  of  dilapidated  constitution.  This  condition 
requires  removal  of  the  entire  nail,  cauterization  of  the  matrix,  dressing  with 
iodoform  gauze,  and  the  internal  use  of  stimulants,  tonics,  and  nourishing  diet. 

Ingrowing  toe-nail  is  due  either  to  lateral  hypertrophy  of  the  edge  of  the 
nail  or  to  forcing  of  the  soft  tissues  over  the  margin  of  the  nail.  The  con- 
dition is  treated  by  splitting  the  nail,  removing  the  ingrown  piece,  the  soft 
tissue  at  the  margin,  and  the  adjacent  matrix,  and  dressing  antiseptically. 


900  Diseases  and  Injuries  of   the  Thyroid   Gland 


XXXII.     DISEASES  AND  INJURIES  OF  THE  THYROID  GLAND. 

Wounds  cause  violent  hemorrhage  which  is  difficult  to  arrest.  Ligatures 
may  cut  out  and  forceps  will  not  hold.  The  hemorrhage  is  arrested  by 
suture-ligatures,  purse-string  sutures,  the  actual  cautery,  or  removal  of  the 
bulk  of  the  gland. 

The  thyroid  gland  may  be  absent  at  birth.     Congenital  atrophy  or 

congenital  hypertrophy  may  exist. 

Acquired  atrophy  leads  to  myxedema,  a  condition  characterized  by  the 
presence  of  a  firm  subcutaneous  swelling  in  the  face,  neck,  and  limbs;  slow 
speech;  mental  dulness;  and  subnormal  temperature.  The  condition  is 
identical  with  that  produced  by  removal  of  the  entire  gland  (cachexia  strumi- 
priva). 

Cretinism  is  a  form  of  idiocy  due  to  atrophy  of  glandular  elements  in 
the  thvroid,  although  the  size  of  the  gland  is  often  increased.  The  body  is 
dwarfed;  the  face,  neck,  and  extremities  resemble  those  parts  in  myxedema, 
and  a  low  grade  of  idiocy  exists.  My.xedema  and  cretinism  are  treated  by 
the  internal  administration  of  thyroid  extract. 

Congestion  of  the  thyroid  may  be  caused  by  violent  e.xertion,  prolonged 
effort,  febrile  maladies,  and  venous  obstruction.  It  is  treated  by  removing 
the  cause  and  applying  heat  locally.     Tracheotomy  may  be  required. 

Inflammation  of  the  thyroid  (acute  or  inflammatory  goiter)  may  be 
induced  bv  a  septic  or  febrile  malady,  rheumatism,  muscular  strain  causing 
vascular  rupture,  a  wound  or  contusion  of  the  thyroid.  But  one  lobe  is  affected. 
The  ordinary  symptoms  of  inflammation  are  present.  In  addition  there  are 
dysphagia,  dyspnea,  venous  congestion  of  the  face,  epistaxis,  nausea  and 
vomiting,  and  possibly  delirium.  It  may  terminate  in  resolution,  suppura- 
tion, or  fibrous  induration. 

Goiter.— A  goiter  is  an  enlargement  of  the  thyroid  gland  not  due  to 
a  malignant  tumor  or  to  inflammation.  The  enlargement  may  affect  a 
small  portion  of  the  gland,  one  lobe,  both  lobes,  or  both  lobes  and  the  isthmus, 
and  it  may  occur  either  sporadically  or  endemically. 

There  are  a  number  of  forms  of  ordinary  goiter.  The  most  common  is 
what  is  called  parenchymatous  goiter.  In  this  condition  all  portions  of  the 
gland  enlarge,  and  the  goiter  is  consequently  bilateral.  It  does  not  appear 
first  in  one  lobe  and  at  a  considerably  later  period  in  the  other,  but  each 
lobe  is  enlarged  equally  or  nearly  equally.  Parenchymatous  goiter  is  often 
spoken  of  as  simple  goiter,  and  is  sometimes,  though  not  with  entire  accuracy, 
designated  hypertrophy  of  the  thyroid  gland. 

Adenomatous  goiter  is  a  condition  due  to  the  growth  of  encapsuled  adeno- 
mata in  the  thyroid  gland.  It  may  be  a  single  adenoma,  but  frequently 
there  are  multiple  growths.  One  or  both  lobes  may  be  involved.  The 
goiter,  however,  seems  to  begin  in  one  lobe;  and  if  both  lobes  enlarge,  one 
does  so  at  a  period  distinctly  subsequent  to  the  enlarging  of  the  other.  Ade- 
noma may  develop  in  a  healthy  thyroid  gland,  but  adenomatous  growth  is 
usually  associated  with  some  parenchymatous  growth. 

Cystic  goiter,  or  bronchocele,  is  a  condition  in  which  the  chief  ma.ss  of  the 
enlargement  is  composed  of  a  cyst  or  of  multiple  cysts.     When  cysts  form, 


Causes  of   Goiter  901 

the  thyroid  gland  is  usually  hypertrophied  or  adenomatous;  occasionally, 
however,  cysts  form  in  a  non-hypertrophied  thyroid.  The  great  majority 
of  cysts  are  due  to  cystic  degeneration  of  adenomata,  some  are  formed  by 
the  running  together  of  overdistended  thyroid  vesicles,  and  some  few  follow 
blood-extravasation  into  the  thyroid  tissue.  The  liquefaction  is  due  to  mu- 
coid or  colloid  degeneration,  and  the  fluid  of  the  cyst  is  sometimes  clear 
and  thin,  sometimes  viscid,  and  often  coffee-ground  in  appearance. 

A  fibrous  goiter  is  a  fibrous  induration.  It  is  likely  to  arise  in  old  broncho- 
celes,  and  which  may  actually  pass  into  a  calcareous  condition.  By  the  term 
malignant  goiter  is  meant  malignant  disease  of  the  thyroid  gland,  either 
carcinoma  or  sarcoma.  When  hemorrhage  takes  place  into  a  goiter,  the 
condition  is  often  spoken  of  as  a  hemorrhagic  goiter.  A  colloid  goiter  is  a 
form  of  parenchymatous  goiter  in  which  there  is  an  extremely  large  amount 
of  colloid  material.  Exophthalmic  goiter  is  discussed  on  page  904.  Occa- 
sionally an  ordinary  goiter  becomes  exophthalmic.  This  evolution  gives  rise 
to  what  the  French  call  a  Basedoivified  goiter  (see  Moreston,  in  "Rev.  de 
Chir.,"  Nov.  10,  i8gg).  A  goiter  that  develops  with  great  rapidity  is  some- 
times called  an  acute  goiter,  and  one  that  induces  marked  dyspnea  is  desig- 
nated a  suffocating  goiter.  Syphilitic,  tuberculous,  and  amyloid  enlarge- 
ments are  extremely  rare,  but  occasionally  occur.  Further,  a  goiter  may 
be  back  of  the  sternum,  or  substernal;  within  the  thorax,  or  intrathoracic; 
retrotracheal;  or  retro-esophageal.  When  a  number  of  persons  in  the  same 
region  are  attacked  with  goiter,  the  condition  is  frequently  referred  to  as 
epidemic  goiter.  When  the  condition  is  common  in  a  certain  district,  it  is 
called  endemic  goiter.  When  a  person  living  in  a  district  in  which  the  disease 
is  rare  develops  goiter  we  speak  of  the  condition  as  sporadic  goiter.  It  has 
long  been  known  that  accessory  thyroids  exist.  Median  accessory  thyroids 
are  found  about  the  hyoid  bone  and  are  formed  from  remnants  of  the  thyro- 
glossal  duct.  Lateral  accessory  thyroids  are  found  about  the  greater  cornua 
of  the  hyoid  bone.  An  accessory  thyroid  may  enlarge  with  the  thyroid, 
may  not  enlarge  even  though  the  thyroid  does,  or  may  enlarge  when  the 
thyroid  proper  remains  normal.  When  cachexia  strumipriva  does  not  develop 
after  complete  thyroidectomy,  the  patient  has  been  saved  by  enlargement 
and  functionation  of  accessory  thyroids. 

Causes  of  Goiter. — It  is  known  that  goiter  is  extremely  common  in  the 
vallevs  at  the  foot  of  certain  mountain  ranges  in  Switzerland,  southeastern 
France,  northern  Italy,  the  Austrian  Tyrol,  and  in  the  Himalayas,  and  the 
Andes.  In  a  portion  of  England  it  is  so  common  that  it  is  referred  to  as 
the  Derbyshire  neck.  It  seems  evident  that  the  disease  is  due  to  the  intro- 
duction of  some  poisonous  element  into  the  system;  but  what  this  element 
is,  is  not  positively  known.  Some  writers  maintain  that  individual  Hability 
is  developed  bv  habits  of  life;  others  think  that  susceptibility  depends  upon 
hvgienic  surroundings;  and  some  attach  great  importance  to  hereditary 
influence.  The  probability  is,  however,  that  the  disease  is  due  to  the  existence 
of  some  poisonous  substance  in  the  drinking-water.  Some  observers  have 
blamed  snow-water;  many  have  laid  the  cause  of  the  trouble  at  the  door  of 
water  impregnated  with  salts  of  lime;  but  the  real  cause  has  not  been  positively 
demonstrated. 

An  ordinary  parenchymatous  goiter  seems  to  be  a  species  of  hypertrophy. 


902  Diseases  and   Injuries  of   the  Thyroid   Gland 

A  number  of  years  ago  I  suggested  the  view  that  the  gland  has  undergone 
such  an  enlargement  and  has  become  distended  with  colloid  material  because 
the  human  body  has  demanded  more  of  the  secretion  of  the  gland  than  the 
normal  gland  has  been  able  to  supply;  as  a  consequence,  the  normal  gland 
has  enlarged  its  capacity  and  increased  its  output. 

Symptoms  of  Goiter. — One  may  determine  that  a  growth  is  in  the 
thyroid  gland  or  is  connected  with  it  by  studying  a  number  of  facts.  A 
goiter,  as  a  rule,  follows  the  movements  of  the  larynx  and  the  trachea  during 
deglutition,  and  this  sign  may  be  obtained  in  the  great  majority  of  instances. 
There  are,  however,  rare  conditions,  such  as  hyoid  cyst,  in  which  a  movement 
of  the  mass  takes  place  during  the  act  of  swallowing,  although  the  thyroid 
gland  is  not  involved.  Then,  again,  a  malignant  or  an  inflammatory  growth 
of  the  thyroid  usually  becomes  anchored  to  the  surrounding  tissues  and  does 
not  show  this  mobility.  Certainly,  however,  in  the  greater  number  of  the 
cases  the  goiter  moves  with  the  larynx  and  the  trachea  during  swallowing. 

Goiters  vary  greatly  in  size.  Cases  in  which  the  goiter  was  as  large  as 
an  adult's  head,  and  some  cases  in  which  the  goiter  liung  in  front  of  the 
breast-bone  and  reached  to  below  the  level  of  the  ensiform  cartilage,  have  been 
described.     A  very  large  goiter  may  have  a  stalk. 

When  the  entire  gland,  as  well  as  the  isthmus,  is  enlarged,  or  when  the 
isthmus  alone  is  involved,  the  swelling  may  appear  to  be  in  the  median  line 
of  the  neck.  If  the  condition  begins  in  one  lobe,  the  growth  will,  for  a  time 
at  least,  be  distinctly  one-sided;  though  when  such  a  growth  has  attained  a 
large  size,  it  may  displace  the  windpipe  and  come  itself  to  the  middle  line  of 
the  neck. 

A  goiter  of  any  considerable  size  pushes  the  sternocleidomastoid  muscle 
externally  and  anteriorly,  and  the  muscles  that  run  from  the  sternum  to  the 
hyoid  bone  and  to  the  thyroid  cartilage  overlie  the  front  of  the  growth.  The 
carotid  artery  is  displaced  externally  and  posteriorly.  The  relation  of  the 
jugular  vein  to  the  carotid  artery  is  usually  profoundly  altered.  The  artery, 
as  already  stated,  goes  externally  and  posteriorly,  while  the  vein  is  actually 
pulled  anteriorly  and  is  flattened  out  upon  the  side  or  the  anterior  surface 
of  the  goiter;  hence,  the  vein  comes  to  lie  to  the  inner  side  of  the  artery.  This 
curious  alteration  in  relationship  is  due  to  the  fact  that  the  common  carotid 
artery  has  no  branches,  and  therefore  is  pushed  externally  with  ease;  but 
the  internal  jugular  vein  receives  branches  that  lie  in  the  tumor,  pull  upon 
the  vein,  and  prevent  its  displacement  with  the  artery  (Lucke). 

Berry  alludes  to  the  fact  that  the  tumor,  unless  it  is  very  small,  usually 
reaches  the  upper  level  of  the  sternum,  and  frequently  passes  below  this 
level;  and  that  only  extremely  large  goiters  hang  in  front  of  the  sternum,  but 
that  it  is  not  at  all  unusual  for  prolongations  from  :.  goiter  to  extend  for 
quite  a  distance  into  the  mediastinum.  A  substernal  goiter  is  produc- 
tive of  very  dangerous  symptoms  and  offers  many  difficulties  in  diagnosis. 
A  goiter  will  occasionally  wander,  now  appearing  in  the  neck  and  again  dis- 
appearing Vjehind  the  sternum. 

Some  goiters  are  said  to  pulsate.  This  takes  place  in  exophthalmic 
goiter;  but  in  the  ordinary  .simple  goiter,  what  is  called  pulsation  of  the  goiter 
is  usually  the  transmitted  pulsation  from  the  carotid  artery. 

Some  of  the  most  important  symptoms  of  goiter  are  due  to  pressure  and 


Treatment  of  Goiter  903 

to  the  displacing  of  anatomical  structures.  Pressure  upon  the  veins  at  the 
root  of  the  neck  causes  great  enlargement  of  the  veins  above  the  goiter  and 
in  it.  Pressure  upon  the  recurrent  laryngeal  nerve  ma}'  induce  characteristic 
symptoms;  and  so  may  pressure  upon  the  cervical  sympathetic  or  the  cervical 
plexus.  Pressure  upon  the  larynx  and  the  trachea  may  cause  very  great 
displacement,  and  any  such  displacement  is  productive  of  marked  dyspnea. 
This  displacement  is  usually  to  the  side;  and  it  may  cause  such  a  flattening 
out  of  the  tracheal  rings  that  when  the  tumor  is  removed,  the  trachea  collapses 
and  the  patient  perishes  of  suffocation. 

A  parenchymatous  goiter  usually  begins  insidiously  and  grows  slowly. 
It  occasionally  ceases  to  grow  for  a  considerable  period  of  time,  and  may 
even  shrink.  It  frequently  enlarges  temporarily  during  menstruation  or 
pregnancy,  and  occasionally  attains  an  enormous  size  by  changing  into  the 
cvstic  form.  Alterations  in  its  consistency  and  outline  may  be  due  to  the 
developing  of  adenomatous  masses. 

In  making  a  diagnosis  between  the  different  forms  of  goiter,  one  should 
remember  that  a  fairly  symmetrical,  bilateral  growth  is  probably  parenchy- 
matous; that  sudden  enlargements  are  produced  by  hemorrhage;  that  cyst- 
formation  may  lead  to  very  great  enlargement,  and  possibly  to  i^uctuation; 
that  if  a  non-malignant  goiter  induces  dyspnea,  it  almost  invariably  does  so 
by  pressing  upon  the  larynx  and  the  trachea,  whereas  a  malignant  goiter 
may  do  so  by  interfering  with  the  nerves  of  the  part;  that  a  non-malignant 
goiter  very  rarely  produces  difficulty  in  swallowing,  but  that  a  malignant 
goiter  frequently  does  so;  and  that  cough  often  exists  if  there  is  pressure 
upon  the  larynx  or  the  trachea,  such  a  cough  being  metallic  in  nature  and 
unassociated  with  impairment  of  the  voice. 

In  any  goiter  there  may  be  cerebral  symptoms,  such  as  anemia,  syncope, 
or  even  convulsions.  Rapidly  growing  goiters  are  often  fatal,  and  slowly 
growing  goiters  are  very  rarely  so.  A  malignant  goiter  grows  with  great 
rapidity,  becomes  adherent,  infiltrates,  and  quickly  produces  metastases,  and 
both  sarcoma  and  carcinoma  produce  metastases  by  way  of  the  venous 
svstem. 

Treatment. — lodid  of  potassium  and  arsenic  internally  have  been  ad- 
vised; ointment  of  red  oxid  of  mercury  locally  is  advocated  by  some  writers. 
The  administration  of  thyroid  extract  may  do  much  good  in  a  case  of  paren- 
chymatous goiter,  but  it  is  useless  in  other  forms  of  the  disease.  It  should 
be  associated  with  the  local  use  of  tincture  of  iodin  or  ointment  of  red  iodid 
of  mercury.  In  times  past  it  was  customary  to  treat  cystic  goiters  by  aspira- 
tion and  injection  with  a  solution  of  iodin.  Electrolysis  may  benefit  a  soft 
goiter,  the  negative  pole  being  pushed  into  the  growth,  the  positive  pole 
being  applied  to  its  surface.  In  considering  the  propriety  of  operation 
remember  that  a  goiter  which  begins  at  puberty  may  pass  away.  We  should 
operate  on  every  non-malignant  goiter  which  is  increasing  rapidly  in  size, 
and  on  everv  goiter  which  causes  much  respiratory  trouble,  but  should  not 
operate  simply  for  deformity  (Bergeat).  If  enucleation  or  extirpation  is 
performed,  do  not  give  ether  or  chloroform.  These  agents  greatly  increase 
bleeding,  and  are  dangerous.  Do  the  operation  with  the  aid  of  local  anes- 
thesia (cocain,  eucain,  or  Schleich's  fluid).  It  is  a  great  advantage  to  have 
the  patient  conscious,  because  by  asking  him  to  speak  during  the  operation 


904  Diseases  and   Injuries  of  the  Thyroid   Gland 

the  surgeon  can  tell  if  the  recurrent  laryngeal  nerve  is  being  touched.  In 
many  cases  intraglandular  enucleation  is  performed,  in  other  cases  ex- 
tirpation. Occasionally  these  two  methods  are  combined  (Bergeat).  Some 
surgeons  advise  simple  division  of  the  isthmus.  Ligation  of  the  thy- 
roid arteries  has  been  recommended.  Exothyropexy  is  the  operation  of 
exposing  the  thyroid  gland,  dislocating  it  through  the  wound,  and  leaving  it 
in  this  situation.  Atrophy  of  the  gland  follows  the  operation.  Enucleation, 
if  possible,  is  the  desirable  operation.     It  may  easily  be  employed  for  the 

^^,..,™™rrrrTTTTTT  „.,  . removal  of  a  single  adenoma- 

fMi'Hrlflil'riHfrrmflrllT^^^^^  tons,  colloidal,  or  cystic  area. 

Thyroidectomy  or  extirpation 
is  employed  when  enucleation 
is  impossible.  The  entire  thy- 
Fig.  505.-Koenig's  tracheotomy  tube.  """""'  ^oid  is  not  removed  for  an  in- 
nocent growth;  a  portion  of 
the  gland  is  left  behind,  otherwise  myxedema  will  arise  (Kocher).  Unilateral 
extirpation  is  the  usual  method.  In  sarcoma  or  cancer  of  the  thyroid  complete 
extirpation  may  be  attempted.  The  operation  in  malignant  disease  will  occa- 
sionally prolong  life,  but  it  will  rarely  effect  a  cure.  In  malignant  disease  tra- 
cheotomy may  be  rendered  necessary  by  urgent  dyspnea.  The  operation  is 
often  very  difihcult  because  the  growth  may  cover  the  trachea,  the  trachea  may 
be  deviated  a  considerable  distance  from  its  proper  position,  and  the  veins  are 
very  large.  After  the  performance  of  the  operation  it  is  usually  impossible  to 
use  an  ordinary  tracheotomy  tube,  and  in  such  a  case  Koenig's  long,  flexible 
tube  is  employed  (Fig.  505). 

Exophthalmic  Goiter  (Graves's  Disease;  Basedow's  Disease;  Pulsat- 
ing Goiter). — In  a  typical  case  there  are  rapid  pulse,  protrusion  of  the  eye- 
balls, and  enlargement  of  the  thyroid  gland;  but  any  one  of  these  conditions 
may  be  absent.  The  enlargement  is  bilateral.  Supposed  unilateral  enlarge- 
ments are  instances  of  Basedowified  goiter — that  is,  are  cases  in  which  an 
ordinary  bilateral  goiter  gives  rise  to  the  symptoms  characteristic  of  Graves's 
disease.  A  sy.stohc  bruit  is  usually  audible  over  the  thyroid  region.  Von 
Graefe's  sign  may  be  present;  this  consists  of  retraction  of  the  eyelids,  and 
inability  of  the  hds  to  follow  the  eyes  in  looking  down.  The  lids  in  some 
cases  cannot  be  completely  closed,  and  when  the  eyeball  is  suddenly  turned 
up  the  lid  and  brow  may  fail  to  act  together.  In  some  cases  ocular  palsies 
exist,  in  others  there  is  photophobia  or  nystagmus.  Patients  may  suffer 
from  neuralgia,  colic,  choreic  movements,  tremor,  flushes  of  heat,  and  gastric 
crises.  Dyspnea  often  exists,  and  albuminuria  and  polyuria  are  not  un- 
common. Hemoptysis,  hematemesis,  or  mental  disturbance  is  sometimes 
noted. 

Exophthalmic  goiter  may  arise  after  emotional  excitement  or  depression, 
during  pregnancy,  or  during  the  existence  of  locomotor  ataxia,  paresis, 
epilepsy,  neurasthenia,  hysteria,  and  other  nervous  troubles.  Its  real  cause 
is  uncertain,  but  is  probably  the  action  upon  the  sympathetic  system  of  some 
poisonous  product  of  thyroid  activity. 

Treatment. — Thyroid  extract  does  harm.  Medical  treatment  in  a  se- 
vere case  should  comprise  rest  in  bed,  the  use  of  an  ice-bag  over  the  heart, 
and  the  administration  of  adrenalin.     When  the  patient  gets  about  again. 


Operations  on  the  Tliyroicl  Gland  905 

he  must  avoid  alcohol  and  all  forms  of  excitement.  Gentle  exercise  is  de- 
sirable, but  never  violent  exercise.  Diet  is  to  be  nutritious,  but  non-stimulating. 
Electricity  is  said  to  be  of  benefit.  Thymus  extract  has  been  used.  Bilateral 
extirpation  of  the  cervical  ganglion  of  the  sympathetic,  and  division  of  the 
nerve  below  the  ganglion,  have  been  employed,  and  it  is  alleged  with  benefit 
(Jaboulay).  Ligation  of  the  thyroid  arteries  may  do  good.  Partial  thyroid- 
ectomy is  the  operation  commonly  employed  in  severe  cases;  it  has  cured  80 
per  cent,  of  the  cases  operated  upon.  In  some  cases  thyroid  intoxication  fol- 
lows operation.  In  other  cases  very  rapid  growth  follows  incomplete  removal, 
and  the  operation  seems  actually  to  have  done  harm.  Sudden  death  occa- 
sionally follows  ihe  operation.  The  removal  of  an  exophthalmic  goiter 
is  difficult;  the  capsule  and  blood-vessels  rupture  from  slight  force,  and 
sudden  death  may  take  place.  All  cases  should  not  be  operated  upon;  in 
fact,  only  those  cases  should  be  operated  upon  in  which  medical  treatment 
has  proved  futile,  or  in  which  there  is  profound  toxemia  or  excessive 
dyspnea.  If  the  operation  is  performed,  neither  ether  nor  chloroform 
should  be  given,  as  either  of  these  agents  will  greatly  increase  bleeding 
and  prove  dangerous.  Operation  is  to  be  done  under  local  anesthesia 
(eucain,  cocain,  or  Schleich's  fluid).  The  younger  Kocher  reports  the 
experience  of  the  Berne  Clinic  ("  Mittheilungen  aus  den  Grenzgebieten 
der  Medicin  und  Chirurgie,"  Bd.  ix).  He  reports  74  cases  of  true  exoph- 
thalmic goiter,  59  of  which  were  operated  upon.  Every  operation  was  done 
with  the  aid  of  local  anesthesia  (i  per  cent,  cocain).  In  some  cases  partial 
thvroidectomy  was  performed;  in  some  the  thyroid  arteries  were  ligated; 
in  3  cases  not  only  were  the  arteries  tied,  but  the  sympathetic  ganglia  were 
resected.  In  these  59  cases  there  were  4  deaths  within  ten  days  from  tetany, 
and  in  39  of  the  cases  there  were  marked  disturbances  (tremor,  irregularity 
and  palpitation  of  the  heart,  vomiting,  sweating,  and  elevated  temperature). 
These  abnormalities  were  possibly  due  to  forcing  diseased  thyroid  secretion 
into  the  circulation.  Forty-five  of  the  59  cases  were  cured  and  8  were  greatly 
improved.  In  3  of  the  fatal  cases  autopsy  was  made,  but  did  not  disclose 
the  cause  of  death.  Kocher  believes  in  operation.  He  thinks,  however,  it 
removes  but  one  element  of  the  disease,  and  that  medical  treatment  may 
remove  the  others.  He  advises  strongly  against  operation  during  an  exacer- 
bation until  relief  has  been  sought,  but  not  obtained,  by  medical  means. 

Operations  on  the  Thyroid  Gland. — Intra  glandular  Enucleation  (Socin's 
Operation). — By  this  operation  an  adenoma  or  cyst  of  the  thyroid  gland 
is  removed,  the  encompassing  glandular  tissue  being  left  in  place.  The 
capsule  of  such  a  growth  is  glandular  tissue.  The  operation  of  enucleation 
is  not  suited  to  the  removal  of  multiple  tumors  and  it  cannot  be  performed 
for  parenchymatous  goiter  or  exophthalmic  goiter.  Intraglandular  enuclea- 
tion is  performed  as  follows:  The  thyroid  is  exposed  by  an  oblique  or  by  a 
horseshoe-shaped  incision.  An  irxision  is  made  through  the  capsule  of  the 
thyroid  gland  and  through  the  glandular  tissue  until  the  cyst  or  solid  tumor 
is  reached.  As  a  rule  the  tumor  can  be  recognized  from  the  fact  that  its 
color  differs  from  the  color  of  the  thyroid  tissue.  The  tumor  is  turned  out 
by  the  fingers,  a  special  .scoop,  the  knife  handle,  or  a  dry  dissector.  In 
some  cases  a  cyst  can  be  most  easily  evacuated  if,  after  e.xposure,  it  is  incised 
and  emptied  and  its  wall    is    then    grasped   with    strong  forceps.     A  solid 


9o6 


Diseases  and   Injuries  of  the  Thyroid  Gland 


tumor  should,  if  possible,  be  removed  intact.  The  wound  is  packed  tem- 
porarily with  gauze,  the  edges  of  the  cavity  are  grasped  with  forceps,  the 
gauze  is  removed,  and  every  bleeding  point  is  carefully  ligated.  The  wound 
is  closed  by  three  layers  of  sutures — "one  in  the  gland,  one  in  the  muscles, 
and  a  third  in  the  skin"  (James  Berry  on  "  Diseases  of  the  Thyroid  Gland"). 
If  the  tumor  was  large,  drain  for  twenty-four  hours;  otherwise,  do  not  drain. 


Fig.  506. — Kocher's  transverse  incision 
exposing  the  muscles  and  median  veins  of 
the  neck  (Kocher). 


Fig.   507. — Isolating   the    accessory    veins 
(Kocher). 


Enucleation  is  a  very  successful  operation  if  performed  upon  properly 
selected  cases,  and  can  be  performed  rapidly,  but  the  arrest  of  bleeding  is 
often  tedious  and  troublesome.  During  any  operation  for  goiter  sudden  death 
may  occur.  In  some  cases  a  general  anesthetic  is  responsible.  In  others, 
suffocation  arises  from  pressure  upon  or  bending  of  the  trachea  or  collapse 


Fig.  508. — Exposure  of   veins  at   lower  end        Fig.  509. — Dislocation  of   the  goiter  toward 
before  ligation  (Kocher).  the  right  (Kocher). 


of  the  trachea  as  the  goiter  is  lifted  from  its  bed.  In  rare  cases  dangerous 
dyspnea  arises  from  irritation  of  the  laryngeal  nerves  and  cardiac  inhibition 
may  be  induced  in  the  same  manner. 

When  colloid  from  the  thyroid  leaks  into  the  wound,  it  is  absorbed  and 
may  produce  serious  symptoms  or  even  death.     In  some  cases  in  which  this 


Operations  on  the  Thyroid   Gland 


907 


happens  the  patient  never  reacts  from  the  operative  shock,  but  develops  a 
very  rapid  pulse  and  intense  dyspnea,  and  dies  in  a  few  hours.  In  less  severe 
cases  there  is  a  period  of  circulatory  excitement,  dyspnea,  and  elevated  tem- 
perature (thyroid  fever). 

Extirpation. — This  term   means   removal  of  the  entire  gland   (complete 
thyroidectomy)   or  a  portion  of  the  gland  (partial  thyroidectomy)   with  the 


A.tarotis 


'  \-^'"f~  ^'  steritoclsido 
),^^dLJ.U  recurreas 

SVjjA/fVfnathureo- 


Fig.  510. — Isolation  of  the  superior  thyroid 
artery  and  vein  (Kocher). 


Fig.  511. — Ligation  of  the  inferior  thyroid 
artery  (Kocher). 


glandular  capsule,  the  operation  being  an  extracapsular  procedure.  Usually 
but  one  lobe  is  extirpated.  This  method  enables  the  operator  to  tie  the 
chief  vessels  before  he  cuts  them,  and  as  his  vision  is  not  obscured  by  bleeding, 
he  can  avoid  cutting  the  glandular  capsule,  which  would  be  sure  to  provoke 
copious  bleeding,  and  he  keeps  a  safe  distance  away  from  the  recurrent 
laryngeal  nerve. 


Fig.  512.- 


-Isolation  of  the  vena;  thyreoidese 
imas  (Kocher). 


-Isolation    and    clamping  of   the 
isthmus  (Kocher). 


If  the  patient  suffers  from  dyspnea  a  general  anesthetic  is  contraindicated. 
It  is  best  in  any  case  not  to  use  one.  Local  anesthesia  is  reasonably  .satis- 
factory and  is  far  safer.  The  patient  is  placed  recumbent,  with  the  shoulders 
a  little  raised  and  the  neck  laid  upon  a  sand-pillow  so  as  to  throw  the  head 
back  as  far  as  is  consistent  with  comfortable  respiration. 


goS  Diseases  and  Injuries  of  the  Thyroid  Gland 

An  obhque  incision,  a  horseshoe-shaped  incision,  or  a  transverse  incision 
(Fig.  506)  may  be  made.  I  usually  employ  an  incision  shaped  hke  an 
incomplete  horseshoe,  the  convexity  being  downward.  Layer  by  layer  the 
tissues  are  divided,  each  layer  being  infiltrated  with  the  local  anesthetic 
before  it  is  cut.  Vessels  are  carefully  tied  as  divided  or  before  division. 
The  muscles  which  run  from  the  sternum  to  the  hyoid  bone  may  in  some 
cases  be  separated,  but  the  extirpation  of  a  large  goiter  requires  transverse 
division  of  the  muscles  high  up.  The  capsule  of  the  lobe  is  exposed,  and 
is  separated  from  external  parts  (Figs.  507,  508,  and  509).  The  upper  por- 
tion of  the  gland  is  cleared.  The  superior  thyroid  vessels  are  found,  tied 
with  two  ligatures  each,  and  divided  between  the  hgatures  (Fig.  510). 
The  clearing  of  the  gland  is  carried  on  toward  the  median  hne  and  some 
rather  large  veins  are  encountered  and  tied  (Fig.  512).  The  lower  por- 
tion of  the  lobe  is  cleared  and  the  inferior  thyroid  vessels  are  found.  Near 
this  point  the  recurrent  laryngeal  nerve  can  be  located.  If  it  is  pressed 
upon  or  touched  with  a  blunt  instrument,  the  patient's  voice  becomes  metalhc. 
A  dehberate  attempt  is  made  to  locate  it  and  the  patient  is  engaged  in  a 
conversation  requiring  answers  while  the  surgeon  is  investigating.  The  lobe 
is  lifted  from  its  bed  and  dislocated  from  the  wound  and  the  inferior  thyroid 
vessels  are  tied  close  to  the  border  of  the  gland  in  order  to  avoid  the  recurrent 
laryngeal  nerve  (Fig.  511)  The  vessels  are  tied  and  cut  across  as  were  the 
superior  thyroid  vessels.  The  isthmus  is  next  exposed,  ligated,  and  cut 
across,  every  care  being  taken  to  prevent  colloid  from  being  squeezed  into 
the  wound  (Fig.  513).  After  dividing  the  isthmus,  any  bleeding  point  is 
ligated.  The  divided  muscles  are  sutured  with  catgut,  a  drainage-tube  is 
inserted,  and  the  superficial  wound  is  closed  with  sutures  of  silkworm-gut. 


Wounds  of  the  Thoracic   Duct 


909 


XXXIII.   DISEASES  AND  INJURIES  OF  THE  LYMPHATICS. 
Wounds,  Ruptures,  and  Occlusions  of  the  Left  Thoracic  Ducts. 

— It  was  long  believed  that  wounds  of  the  thoracic  duct  were  almost  certainly 
fatal.  It  is  now  known  that  they  are  rarely  very  dangerous  unless  the  duct 
is  divided  close  to  the  vein.  A  wound  of  the  duct  is  rarely  seen  as  the  result 
of  an  accident  because  the  adjacent  vital  structures  are  apt  to  be  injured 
at  the  same  time  and  death  rapidly  ensues.  Wounds  of  the  duct  or  of  its 
large  branches  occasionally,  but  very  rarely,  are  inflicted  during  surgical 
operations.  In  most  cases  the  injury  is  not  recognized  at  the  time,  but 
later,  when  white  fluid  escapes  from  the  wound.  The  discharge  may  con- 
tinue or  may  cease  spontaneously.  I  assisted  Dr.  Keen  in  the  case  in 
which  he  did  recognize  the  wound  at  the  time  it  was  inflicted.  A  thin 
fluid  was  observed  flowing  rhythmically  from  a  tear  in  the  duct.  It  is  to 
be  remembered  that  the  course  of  the  cervical  part  of  the  duct  is  very  variable 
and  sometimes  the  duct  lies  very  high  above  the  clavicle.  There  was  i 
death  in  17  recorded  cases  (Dudley  P.  Allen  and  C.  E.  Briggs,  in  "Amer. 
Med.,"  Sept.  21,  1901). 

When  the  discharge  from  a  cut  duct  continues  to  leak,  constitutional 
effects  will  .sooner  or  later  become  evident.  In  Schoff's  case  ("Wlen.  khn. 
W^och.,"  Nov.  28,  1901)  it  was  not  known  that  the  duct  had  been  injured 
until  the  stitches  were  removed.  The  wound  was  found  distended  with 
chyle  and  was  packed  with  iodoform  gauze.  Fifteen  days  later  the  patient 
died  from  chylothorax  and  pulmonary  compression. 

Rupture  of  the  thoracic  duct  or  of  the  receptaculum  chyli  may  occur  from 
traumatism  or  be  a  secondary  consequence  of  tuberculosis  or  carcinoma. 
Rupture  leads  to  death  by  starvation,  or  to  fatal  compression  by  the  exuded 
fluid  (Harvey  W.  Gushing,  in  "Annals  of  Surgery,"  June,  1898).  Occlusion 
of  the  main  duct  may  be  followed  by  rupture  of  the  receptaculum  chyli. 
Gradual  occlusion  by  a  tuberculous  or  inflammatory  growth  may  not  produce 
any  serious  symptoms.  Gushing  assumes  that  in  such  a  case  the  lymph- 
current  is  reversed  and  is  taken  up  by  the  right  thoracic  duct.  In  gradual 
obstruction  masses  of  dilated  lymph-vessels  may  be  found,  particularly  in 
the  thorax  and  abdomen.  If  lymph-vessels  rupture,  chyle  flows  out  and, 
according  to  the  situation,  there  arises  "  chylous  ascites,  chylothorax,  chyluria, 
or  chylous  diarrhea"  (Harvey  W.  Gushing,  "Annals  of  Surgery,"  June, 
1898).' 

Treatment  of  Wounds. — If  the  wound  does  not  completely  divide 
the  duct  and  is  discovered  at  the  time  of  operation,  suture  the  duct.  Allen 
sutured  the  duct  and  had  no  further  leakage.  If  the  duct  is  divided,  follow 
Cushing's  advice:  "It  would  seem  advisable  to  place  a  provisional  ligature 
about  the  duct  on  the  proximal  side  of  the  wound,  and  to  control  the  leakage, 
if  possible,  by  a  gauze  tampon.  This  would  act  as  a  safety-valve,  and  allow 
chyle  to  escape,  if  the  pressure  in  the  duct  became  too  great  and  there  was 
difficulty  in  establishing  a  collateral  lympliatir  circukuicn.  The  i)atient 
meanwhile  should  be  given  a  meager  diet.  If  the  leakage  should  become 
uncontrollable  and  threaten  starvation,  the  provisional  ligature  should  be 
tied,  with  the  hope  of  a  final  readjustment  of  collateral  circulation  or  trusting 


9IO  Diseases  and  Injuries  of  the  Lymphatics 

in  the  presence  of  some  anomalous  anastomotic  branch  which  might  suffice 
to  carry  the  lymph  into  the  venous  circulation"  ("Annals  of  Surgery,"  June, 
1898).  When  a  wounded  duct  is  leaking,  the  patient  should  be  fed  exclu- 
sively on  proteids. 

Lymphangitis  is  inflammation  of  lymphatic  vessels.  Reticular  lym- 
phangitis, which  is  inflammation  of  lymphatic  radicles,  is  seen  in  some  cir- 
cumscribed inflammations  of  the  skin.  It  is  apt  to  attack  the  hands,  causing 
redness  and  swelhng,  fading  at  the  point  of  initial  trouble  while  it  spreads 
at  the  periphery;  it  is  caused  by  micro-organisms  derived  from  decomposing 
animal  matter  (Rosenbach).  Erysipelas  also  causes  it  (see  Erysipelas). 
Tubular  lymphangitis,  which  is  due  to  the  entry  into  the  lymphatic  ducts 
of  virulent  micro-organisms  or  toxic  materials,  is  seen  after  the  inffiction  of 
dissecting-wounds,  septic  wounds,  snake-bites,  etc.  It  is  announced  by 
edema  and  by  minute,  hard,  red  streaks  running  from  the  wound  up  the 
extremity.     Suppuration  may  occur. 

Infective  lymphadenitis,  or  inHammation  of  the  glands,  may  follow 
lymphangitis  or  may  be  due  to  the  deposition  of  infective  material,  the  lymph- 
vessels  not  being  inflamed.  In  septic  lymphadenitis  there  are  pain,  tender- 
ness, and  swelhng;  in  severe  cases  there  is  a  chill  and  a  septic  fever.  Suppu- 
ration may  arise.  The  treatment  is  to  drain  and  asepticize  the  wound,  to 
apply  iodin,  blue  ointment,  or  ichthyol  over  the  glands  and  vessels,  and  to 
employ  rest  and  compression.  Internally,  milk  punch,  quinin,  and  nourish- 
ing diet  are  required.  If  the  glands  do  not  rapidly  diminish  in  size  after 
disinfection  of  a  wound,  and  if  they  are  in  an  accessible  region,  extirpate 
them.     If  suppuration  of  the  glands  occurs,  incise  and  drain. 

Acute  lymphadenitis,  or  acute  inflammation  of  the  lymphatic  glands, 
may  be  due  to  tubercle,  syphilis,  glanders,  cold,  or  traumatism.  Suppura- 
tion may  or  may  not  occur.  In  inflammatory  lymphadenitis  there  are  pain, 
heat,  and  nodular  swelhng.     In  severe  cases  there  is  fever. 

The  treatment  is  to  asepticize  any  area  of  infection,  place  the  glands  at 
rest,  apply  cold  and  ichthyol  ointment,  or  inject  into  the  gland  every  day  5 
minims  of  a  3  per  cent,  solution  of  carbohc  acid  to  prevent  suppuration.  If 
the  glands  do  not  rapidly  shrink,  extirpate  them.  If  pus  forms,  evacuate 
it,  drain,  and  asepticize. 

Chronic  lymphadenitis  is  almost  invariably  syphilitic  or  tuberculous. 
It  requires  constitutional  treatment  and  the  local  use  of  ichthyol,  iodin,  or 
blue  ointment.  If  these  remedies  are  not  rapidly  successful,  tuberculous 
glands  should  be  removed,  but  syphilitic  glands  wiU  rarely  require  such 
radical  treatment. 

Lymphangiectasis  (varicose  lymphatics),  or  dilatation  of  the  lymphatic 
vessels,  is  due  to  obstruction.  It  results,  as  a  rule,  from  chronic  lymphangitis 
or  the  pressure  of  a  tumor,  or  blocking  with  filarial  worms,  and  is  most 
usually  situated  in  the  pubic,  the  inguinal,  or  the  scrotal  region,  or  on  the 
inner  side  of  the  thigh.  There  are  two  forms:  the  varicose,  in  which  the 
vessels  have  a  tortuous  outline,  like  varicose  veins,  but  are  covered  only  with 
.surface  epitheh'um;  and  lymphatic  warls  (lymphangioma  circumscriptum),  in 
which  wart-h'ke  masses  spring  up,  these  masses  being  covered  with  epithelium 
and  filled  with  lymph.  In  most  ca.ses  of  lymphangiectasis  there  is  consid- 
erable hard  edema.     The  ch'seased   region  has  periodic  attacks  of  pain  and 


Lyniphadenoma  9 1 1 

redness,  and  usually  at  such  times  fever  develops.  Rupture  of  the  dilated 
vessel  causes  a  flow  of  lymph  (Jymphorrhea).  Infection  and  erysipelas  are 
apt  to  occur;   it  may  be  over  and  over  again. 

Treatment. — If  the  entire  varix  can  be  removed  it  should  be  extirpated. 
Maitland  ("Brit.  Med.  Jour.,"  Jan.  25,  1902)  shows  that  many  varices  are 
local  and  can  be  removed.  If  the  varices  are  only  partially  removed  lymphor- 
rhea  will  probably  develop. 

Lymphangioma  is  an  advanced  stage  of  lymphangiectasis  (page  260). 

The  treatment  in  mild  cases  is  to  pierce  each  vesicle  with  the  negative 
pole  of  a  galvanic  battery  and  pass  a  current.  In  severe  cases  destroy  the 
mass  with  the  Paquehn  cautery  or  excise  it  with  a  knife  or  with  scissors. 

Elephantiasis. — True  elephantiasis  (elephantiasis  Arabum)  is  chronic 
hypertrophy  of  the  skin  and  subcutaneous  tissues  following  upon  a  lym- 
phangiectasis produced  by  a  nematode  worm  (the  filaria  sanguinis  hominis). 

Spurious  elephantiasis  is  hypertrophy  of  the  skin  and  subcutaneous  tis- 
sue due  to  chronic  inflammation  (for  instance,  in  a  leg  which  possesses  an 
ancient  ulcer,  or  in  the  scrotum  of  a  man  with  urinary  fistula). 

The  treatment  is  massage  and  bandaging,  sometimes  hgation  of  the 
arterv  of  supply,  extirpation,  or  amputation. 

Tuberculous  Glands. — (See  page  183.) 

Lymphadenoma  {Malignant  Lymphoma  ;  Hodgkin's  Disease;  Pseudo- 
leukemia).— The  term  lymphoma  is  used  to  loosely  designate  any  persistent 
swelling  of  a  lymphatic  gland  or  glands.  Lymphadenoma  means  a  swelling 
of  lymph-glands  or  lymphadenoid  tissue,  which  swelling  is  progressive  in 
character,  involves  group  after  group  of  glands,  is  associated  with  anemia, 
and  often  accompanied  by  secondary  growths  in  the  abdominal  viscera. 
Fig.  514  exhibits  a  case  of  Hodgkin's  disease. 

This  disease  is  most  common  in  those  under  forty,  and  affects  males  far 
more  frequently  than  females.  In  many  cases  the  disease  arises  slowly  in 
apparently  healthy  glands  and  exists  for  some  time  before  it  takes  on  signs 
of  malignancy  and  invades  distant  glands.  A  gland  enlarged  from  irritation 
or  from  tuberculous  disease  may  become  lymphadenomatous,  and  tubercle 
bacilh  can  sometimes  be  found  in  lymphadenomatous  glands.  Lazarus  > 
asserts  that  the  disease  is  lymphosarcoma  and  the  tuberculosis  accidental. 
Musser,  Sternberg,  and  others  believe  that  tuberculosis  is  the  disease.  It 
is  probable  that  Hodgkin's  disease  is  a  form  of  tuberculosis  of  the  lymphatics. 
In  some  cases  the  disease  has  a  tendency  to  generalization  from  the  start; 
in  others  it  appears  to  remain  localized  for  many  months. 

Symptoms. — The  glands  in  the  neck  are  usually  involved  first,  but 
the  disease  mav  begin  in  the  axillary  glands,  the  thoracic  glands,  or  the  intra- 
abdominal glands. 

Two  or  more  regions  are  sometimes  involved  simultaneously  or  almost 
simultaneously. 

When  the  disease  begins  in  the  neck,  it  affects  at  first  one  side,  and  after 
manv  weeks  or  months  the  other  side  becomes  involved.  The  glands  are 
at  first  hard,  separated  from  each  other,  movable,  and  the  skin  moves  freely 
over  them.  Later  the  large  glands  weld  together  and  form  great  masses 
upon  both  sides  of  the  neck  and  in  the  axilla?  which  may  obstruct  respiration. 

After  a  time  a  verv  large  mass  may  soften,  and  in  Aery  rare  cases  the  skin 


912 


Diseases  and  Injuries  of  the  Lymphatics 


becomes  adherent  and  finally  breaks.  Intrathoracic  symptoms  point  to 
involvement  of  the  thoracic  glands.  It  may  be  possible  to  palpate  enlarged 
abdominal  glands. 

The  spleen  is  enlarged;  the  thyroid  may  be  enlarged;  anemia  is  usually 
but  not  invariably  present,  and  if  it  exists,  there  are  the  ordinary  symptoms 
which  go  with  it,  viz.,  palpation,  breathlessness,  indigestion,  vertigo,  head- 
ache, pallor,  and  sometimes  epistaxis.  Occasionally,  without  obvious  reason, 
the  glands  suddenly  increase  in  size,  or  rapidly  undergo  a  notable  but  tem- 
porary diminution. 

Slight  fever  exists  in  almost  all  cases,  and  sometimes  ague-like  paroxysms 

occur.  During  the  ex- 
istence of  fever  the  glands 
usually  increase  rapidly 
in  size. 

Diagnosis. — In  a 
widespread  case  the  diag- 
nosis is  easy;  in  a  local- 
ized case  it  is  difficult. 
True  tuberculous  glands 
are  most  apt  to  first  ap- 
pear in  the  submaxillary 
triangle;  lymphadeno- 
matous  glands,  in  the 
root  of  the  neck  or  in  the 
occipital  triangle.  Tu- 
berculous adenitis  is  most 
common  in  children.  As 
a  rule,  tuberculous  glands 
caseate,  but  they  may  re- 
main localized  for  years 
if  caseation  does  not  oc- 
cur. The  tuberculous 
glands  usually  soon  be- 
come adherent  and  im- 
movable. Lymphade- 
noma  is  most  common 
after  twenty,  rarely  re- 
mains localized  for  more  than  a  few  months,  rarely  softens  unless  very  large, 
and  the  glands  are  separated  and  movable  until  a  huge  mass  forms.  Early 
softening,  prolonged  limitation  to  one  region,  and  absence  of  pronounced 
anemia  in  a  person  under  twenty  point  to  tubercle.  In  doubtful  cases  a  gland 
.should  be  removed  for  microscopical  and  bacteriological  study. 

Prognosis. — The  di.sease  is  almost  always,  if  not  invariably,  fatal.  Most 
cases  die  within  three  years,  some  die  within  six  months,  some  few  live  four 
or  five  vears  or  more. 

Treatment. — If  the  glands  are  localized  to  one  sirle  of  the  neck,  or  even 
to  both  .sides  of  the  neck,  remove  them.  Early  removal  before  dissemination 
has  occurred  may  possibly  save  the  patient.  If  early  or  radical  removal  is 
not  possible,  do  not  operate,  but  treat  the  patient  with  nutritious  food,  tonics, 
and  courses  of  arsenic. 


Fig.  514. — Hodgkiii's  disease. 


Spiral  Reversed  Bandage  of  Upper  Extremity  913 


XXXIV.   BANDAGES. 

A  BANDAGE  IS  a  fibrous  material  which  is  rolled  up  and  is  then  employed 
to  retain  dressings,  applications,  or  appliances  to  a  part,  to  make  pressure, 
or  to  correct  deformity.  It  may  be  composed  of  flannel,  of  calico,  of  un- 
bleached muslin,  of  plain  gauze,  of  gauze  infiltrated  with  plaster-of-Paris  or 
soaked  in  silicate  of  sodium,  or  of  gauze  wet  with  corrosive  sublimate  solu- 
tion. Unbleached  muslin,  which  is  the  best  material  for  general  use,  is 
washed  to  remove  the  sizing,  is  torn  into  strips,  and  the  edges  are  stripped 
of  selvage.  One  end  is  folded  to  the  extent  of  six  inches,  this  is  folded  upon 
itself  again  and  again  until  a  firm  center  is  formed,  and  over  this  center  the 
bandage  is  rolled.  In  a  well-rolled  bandage  the  center  cannot  be  pushed  out 
of  the  roll.  A  roller  bandage  is  divided  into  the  initial  end,  which  is  within  the 
roll,  the  body  or  rolled  part,  and  the  terminal  end,  which  is  free.  In  applying 
a  bandage  the  outer  surface  of  the  terminal  end  is  first  laid  upon  the  part. 

A  cylindrical  part  of  the  body  may  be  covered  by  a  circular  bandage, 
each  turn  exactly  covering  the  previous  turns.  A  conical  part  may  be  covered 
by  a  spiral  bandage,  each  turn  ascending  a  little  higher  than  the  previous 
turn.  As  each  turn  of  a  spiral  bandage  is  tight  at  its  upper  and  loose  at 
its  lower  edge,  the  reverse  was  devised  to  correct  this  inequality;  hence  a 
conical  part  should  be  covered  by  a  spiral  reversed  bandage.  To  make  a 
reverse,  hold  the  roller  in  the  right  hand,  start  the  bandage  obliquely  upward 
(do  not  have  more  than  six  inches  of  slack),  place  the  thumb  across  the  fresh 
turn,  fold  the  bandage  down  without  traction,  and  do  not  make  traction 
until  the  turn  has  been  carried  well  around  the  limb.  A  projecting  point 
is  covered  with  figure-oj -eight  turns.  The  groin,  shoulder,  breast,  or  axilla 
can  be  covered  by  figure-of-eight  turns,  each  succeeding  turn  ascending  and 
covering  two-thirds  of  the  previous  turn  and  forming  a  figure  hke  "  the  leaves 
on  an  ear  of  corn."  Such  a  figure  is  called  a  "spica."  In  bandaging  an 
extremity  the  peripheral  turns  should  be  tighter  than  the  turns  nearer  the 
body.  Never  apply  a  tight  bandage  to  the  leg  or  the  arm  without  including 
the  foot  or  the  hand.  In  firm  dressings  of  the  forearm  and  arm  it  is  well  to 
leave  the  ends  of  the  fingers  exposed,  and  use  them  as  an  index  of  the  con- 
dition of  the  circulation  in  the  part.  In  firm  dressings  of  the  leg  and  thigh 
leave  the  toes  exposed. 

Spiral  Reversed   Bandage  of  the  Upper  Extremity. — To  apply 
this  form  of  bandage  use  a  roller  two  and  a  half  inches  wide  and  eight  yards 
long.    Take  a  circular  turn  about 
the  wrist,  and  a  second   turn  to        '»'i'"\r 
hold     the    first;     pass    obliquelv 
across  the  back  of    the  hand   to 
the    extremities    of    the    fingers; 

ascend    the    hand    to    the    root    of  Fi?- SiS-Spiral  reversed^bandage  of  the  upper  e.x- 

the  thumb  by  several  spiral  turns; 

cover  the  wrist  by  ascending  figure-of-eight  turns;  ascend  the  forearm  by 
spiral  reversed  turns;  cover  the  elbow  by  a  figure-of-eight,  and  the  arm  by 
spiral  reversed  turns;  end  the  bandage  by  two  circular  turns,  and  pin  them 
together  (Fig.  515). 
58 


914 


Bandaees 


Spiral  Bandage  of  All  the  Fingers  (Gauntlet).— The  gauntlet  bandage 
requires  a  roller  one  inch  wide  and  three  yards  long.  Take  two  circular 
turns  around  the  wrist,  pass  obliquely  across  the  wrist  to  the  root  of  the 


Fig.  516. — Gauntlet  bandage. 


F'g-  517- — Demi-gauntlet  bandage. 


Fig.  518. — Spica  of  the  thumb. 


thumb,  and  descend  to  its  tip  by  spiral  turns;  cover  in  the  thumb  by  ascending 
spiral  turns,  and  return  to  the  wrist.  Cover  successively  each  finger  in  the 
same  manner,  and  terminate  by  two  circular  turns  around  the  wrist  (Fig.  516). 
Spiral  Bandage  of  the  Palm  or  Dorsum  of  the  Hand  (Demi  gaunt- 
let).— The  demi-gauntlet  requires  a  roller  one  inch  wide  and  three  yards  long. 

This  bandage  has  only  a  limited  value; 
it  must  not  be  applied  tightly,  as  it  makes 
much  pressure  at  the  finger-roots,  but 
leaves  the  fingers  free.  If  it  is  desired  to 
cover  the  palm,  supinate  the  hand;  if  to 
cover  the  dorsum,  pronate  the  hand. 
Take  two  circular  turns  around  the  wrist,  sweep  around  the  root  of  the 
thumb,  and  return  to  the  point  of  origin.  Treat  each  finger  in  the  same 
way.     End  by  circular  turns  around  the  wrist  (Fig.  517). 

Spica  of  the  Thumb. — For  this  bandage  use  a  roller  one  inch  wide 
and  three  yards  long.  Start  at  the  wrist,  and  reach  the  tip  of  the  thumb  as 
in  applying  a  spiral  bandage  of  a  finger.  Make  a  series  of  ascending  figure- 
of-eight  turns  between  thumb  and  wrist,  each  ascending  turn  overlying  two- 
thirds  of  the  previous  turn;  terminate  with  a  circular  of  the  wrist  (Fig.  518). 

Selva'sThumb  Ban= 

dage  (Fig.  519). — Lay  the 
terminal  end  of  the  bandage 
on  the  outer  side  of  the  sec- 
ond phalanx  of  the  thumb, 
near  the  base  of  the  pha- 
lanx. Carry  it  over  the 
palmar  side  of  the  pulp  of 

the  last  phalanx  to  the  inner  side  of  the  .second  phalanx.  The  surgeon  holds  this 
turn  in  place  with  his  left  thumb  and  index  finger.  The  roller  is  returned  in  a 
recurrent  manner  to  its  placeof  origin,  overlaps  the  preceding  turn, and  is  placed 
as  much  as  pos.sible  on  the  dorsum.     The  roller  is  carried  over  the  dorsum 


Fig.  519. — Selva's  thumb-bandage  applied. 


spiral  Bandage  of  the  Foot  Covering  the  Heel 


915 


of  the  terminal  phalanx  and  is  turned  around  the  tip,  the  loop  crossing  over 
the  center  of  the  nail.  Figure-of-eight  turns  are  now  made  over  the  dorsum 
of  the  hand,  over  the  palm,  and  returning  to  the  ter- 
minal phalanx,  and  an  ascending  spica  is  made.* 

Spiral  Reversed  Bandage  of  the  Lower 
Extremity. — Take  a  roller  two  and  a  half  inches 
wide  and  seven  yards  long,  and  make  two  circular 
turns  just  above  the  malleoli,  and  an  oblique  turn 
across  the  dorsum  of  the  foot  to  the  metatarsopha- 
langeal articulation;  make  a  circular  turn,  and 
cover  the  foot  with  ascending  spiral  reversed  turns; 
return  to  the  ankle  by  a  figure-of-eight ;  ascend  the 
leg  by  spiral  reverses ;  cover  the  knee  by  a  figure- 
of-eight,  and  the  thigh  by  spiral  reverses;  termi- 
nate by  two  circular  turns  (Fig.  520). 

Bandage  of  the  Foot  Covering  the  Heel 

(American  Bandage  of  the  Foot). — Take  a  roller 
two  and  a  half  inches  wide  and  seven  yards  long. 
The  bandage  is  begun  as  is  a  spiral  reversed  ban- 
dage of  the  lower  extremity.  After  the  foot  is 
well  covered  by  ascending  spiral  reversed  turns 

carry  the  bandage  directly  around  the 
point  of  the  heel  and  return  to  the  in- 
step; from  this  point  carry  it  around 
the  back  of  the  ankle,  down  the  side 
of  the  heel,  under  the  heel,  up  to  the 
instep,  around  the  ankle  in  the  opposite 
direction,  down  the  opposite  side  of  the 
heel,  and  under  the  heel  and  up  to  the 
instep;  take  the  roller  to  above  the  mal- 
leoli, and  end  by  a  circular  turn  (Fig. 
521). 

Bandage  of  the  Foot  Not  Covering  the  Heel  (French  Method).— 
Take  a  roller  two  and  a  half  inches  wide  and  six  yards  long.  Make  a  spiral  re- 
versed bandage  of  the  foot  and  a  figure-of-eight  of  the  ankle-joint  (Fig.  522), 


Fig.   520. — Spiral    reversed 
bandage  of  the   lower  extrem- 


Fig.  521.— Method  of  covering  the  heel. 


Fig.  522. — Figure-of-eight  bandage  of  the  ankle. 


Fig.  523. — Spica  of  the  instep. 


Spiral  Bandage  of  the  Foot  Covering  the  Heel  (Ribbail's  Bandage; 
Spica  of  the  Instep). — Take  a  roller  two  and  a  half  inches  wide  and  six  yards 

*i\Iedical  News,  Sept.  28,  1895. 


gi6 


Bandages 


long.  Apply  as  a  spiral  reversed  bandage  of  the  lower  extremity  until  the 
metatarsus  is  well  covered.  Carry  the  bandage,  parallel  with  the  margin  of 
the  foot  (the  inner  or  outer  margin,  according  as  to  whether  it  is  the  left 
foot  or  the  right),  around  the  posterior  aspect  of  the  heel,  along  the  opposite 
margin  of  the  foot  to  cross  the  original  turn  at  the  median  line  of  the  dorsum. 
Make  a  number  of  these  ascending  turns,  each  turn  covering  in  three-fourths 
of  the  previous  turn;  terminate  by  circular  turns  above  the  ankle  (Fig.  523). 

Crossed  Bandage  of  Both  Eyes  (Figure-of-eight  of  Both  Eyes). — 
Take  a  roller  two  inches  wide  and  six  yards  long.  Make  a  circular  turn 
around  the  forehead  from  right  to  left,  a  second  turn  to  hold  the  first,  a  turn 
downward  over  the  left  eye,  under  the  left  ear,  around  the  back  of  the  neck, 
and  upward  under  the  right  ear  and  over  the  right  eye;  repeat  these  turns, 
and  terminate  by  a  circular  turn  of  the  forehead  (Fig.  524). 

Barton's  Bandage  (Figure-of-eight  of  the  Jaw  and  Occiput).— Take  a 
roller  two  inches  wide  and  five  yards  long.  Place  the  initial  extremity  of 
the  bandage  behind  the  inion;  pass  over  the  right  parietal  bone,  across  the 


Fig.  524. — Crossed  figure-of-eight  bandage  of 
both  eyes. 


Fig.  525. — Barton's  bandage  or  figure-of-eight 
of  tlie  jaw. 


vertex,  down  the  left  side  in  front  of  the  ear,  under  the  chin,  up  the  right 
side  in  front  of  the  ear,  across  the  vertex,  and  across  the  left  parietal  bone 
to  the  point  of  origin.  A  turn  is  now  taken  forward  along  the  right  side  of 
the  jaw  to  the  chin,  and  backward  along  the  left  side  of  the  jaw  from  the 
chin  to  the  nape  of  the  neck;  repeat  these  turns,  and  pin  the  points  of  junction 
(Fig.  525).  In  Barton's  bandage  the  ear  lies  in  an  uncovered  triangle.  The 
bandage  may  be  fini.shed  by  circular  turns  around  the  forehead.  Barton's 
h)andage  is  used  for  fracture  of  the  lower  jaw. 

Borsch's  eye=bandage  is  convenient  and  useful  (Fig.  526).  A  narrow 
bandage  is  laid  along  the  head  and  permitted  to  hang  down  the  face  in  front 
of  the  sound  eye.  A  circular  bandage  is  applied  around  both  eyes  and  over 
the  narrow  bandage  (a).  The  narrow  strip  is  lifted  and  pinned,  and  the 
.sound  eye  is  thus  uncovered.  Of  course,  the  posterior  end  of  a  should  first 
be  pinned  to  the  circular  turn. 

Gibson's  Bandage.— Take  a  roller  two  inches  wide  and  six  yards  long. 
Make  three  vertical  turns  around  the  head  and  the  jaw  in  front  of  the  ear; 


Crossed  Bandage  of  the  Angle  of  the  Jaw 


917 


reverse  the  bandage  above  the  level  of  the  ear,  and  carry  it  horizontally 
around  the  forehead  and  head  three  times;  drop  the  bandage  to  the  nape 
of  the  neck,  and  take  three  turns  around  the  neck  and  jaw;  terminate  by 
taking  from  the  nape  of  the  neck  a  half  turn  upward,  carrying  ihe  bandage 
forward  to  the  forehead,  and  pinning  it  over  the  neck  and  over  the  forehead. 


Fig.  526. — Borsch's  eye-bandage:  A,  First  step;  b,  second  step. 

Pin  each  point  of  junction  (Fig.  527).     Gibson's  bandage  is  used  for  fracture 
of  the  lower  jaw. 

Crossed  Bandage  of  the  Angle  of  the  Jaw  (Obhque  Bandage  of  the 
Jaw). — Take  a  roller  two  inches  wide  and  six  yards  long.  Make  a  circular 
turn  around  the  forehead  toward  the  affected  side,  and  a  second  turn  to 
hold  the  first;  take  the  turn  to  the  back  of  the  neck;  carry  it  forward  on  the 
sound  side,  under  the  ear  and  chin;  now  make  a  series  of  turns  around  the 
head  and  jaw,  in  front  of  the  ear  on  the  injured  side,  but  back  of  the  ear 


Fig.  527. — Gibson's  bandage. 


Fig.  528. — Oblique  or  crossed  bandage  of  the 
angle  of  the  jaw. 


on  the  sound  side:  these  turns  successively  advance  on  the  injured  side  only; 
terminate  by  going  backward  under  the  ear  of  the  sound  side  to  the  nape 
of  the  neck,  and  then  by  taking  two  circular  turns  around  the  forehead  (Fig. 
528).  This  bandage  is  used  for  fractures  of  the  ramus  of  the  jaw  and  for 
holding  dressings  upon  the  face  and  the  cranium. 


9i8 


Bandasres 


Spica  of  the  Groin  (Figure-of-eight  of  the  Thigh  and  Pelvis). — For 
one  groin  the  roller  is  three  inches  wide  and  seven  yards  long;  for  both  groins, 
three  inches  wide  and  ten  yards  long.  Take  two  circular  turns,  from  right 
to  left,  around  the  waist,  then  down  over  the  front  of  the  right  groin,  around 
the  back  of  the  thigh,  up  over  the  front  of  the  right  groin,  around  the  waist, 
down  over  the  front  of  the  left  groin,  round  the  back  of  the  thigh,  up  over 
the  left  groin,  and  around  the  waist.     The  map  being  thus  laid  out,  the 


Fig.  529. — Spica  of  the  groin. 


Fig.  530. — Spica  of  the  shoulder. 


turns  are  continued  and  ascended,  each  turn  overlying  one-third  of  the  pre- 
vious turn,  and  the  bandage  is  completed  by  a  circular  turn  around  the  waist 
(Fig.  529).     Pin  the  crossed  pieces. 

Spica  of  the   Shoulder. — Take  a  roller  two  and  a  half  inches  wide 
and  seven  yards  long.     Make  a  circular  turn  and  several  spiral  reversed 
turns  around  the  upper  arm;  then,  coming  from  behind  forward,  carry  the 
bandage  over  the  shoulder,  across  the  front 
of  the  chest,  through  the  opposite  arm-pit,  and 
return  across  the  back  to  the  shoulder.    Make  Jj(||| 

successive  and  advancing  turns  (Fig.  530). 


F'g-  531.— I'igurc-of-eight  bandage  of  the 
elbow. 


Fig.  532. — Posterior  figure-of-eight  of  both 
shoulders. 


Figure-of-eight  bandages  of  the  elbow,  both  .shoulders  (posterior  figure- 
of-eight),  the  neck  and  axilla  are  shown  in  Figs.  531,  532,  and  533.  A 
figure-of-eight  of  the  breast  is  shown  in  Fig.  538. 

Velpeau's  Bandage.— Take  a  roller  two  and  a  half  inches  wide  and 


Desault's  Apparatus 


919 


ten  yards  long.  Place  the  palm  of  the  hand  of  the  injured  side  upon  the 
shoulder  of  the  sound  side,  interposing  cotton  between  the  arm  and  the 
side.  Start  the  bandage  at  the  axilla  of  the  sound  side  posteriorly,  carry 
it  across  the  back  to  the  shoulder  of  the  injured  side,  down  the  front  of  the 
arm  and  under  the  arm  just  above  the  elbow,  returning  to  the  point  of  origin; 
repeat  this  turn,  but,  on  reaching  the  axilla  the  second  time,  cross  the  back 
and  pass  around  the  chest,  including  the  arm;  keep  on  with  these  turns. 


yA^. 


ure-of-eiarht  of  neck  and  axilla. 


Fig.  534. — Velpeau's  bandage. 


each  alternate  turn  going  over  the  injured  clavicle,  each  alternate  turn  en- 
circling the  arm  and  the  body,  the  first  turns  advancing  and  the  second  turns 
ascending  (Fig.  534).  Pin  the  crossed  pieces.  This  bandage  is  used  for 
fracture  of  the  clavicle. 

Desault's  Apparatus. — This  apparatus  consists  of  three  rollers,  a  pad, 
and  a  sling.     Each  roller  is  two  and  a  half  inches  wide  and  seven  vards  long. 


Fig.  535. — Desault's  bandage,  first  roller. 


Fig.  536.— Desault's  bandage,  second  roller. 


The  pad,  which  is  wedge-shaped,  is  inserted  into  the  axilla  with  the  base 
up.  The  first  roller  is  used  to  hold  the  pad  (Fig.  535).  The  second  roller 
binds  the  arm  to  the  side  over  the  pad.  This  pad  is  a  fulcrum,  the  shoulder 
is  the  weight,  the  arm  is  the  lever,  and  the  second  roller  of  Desault  corrects 
the  inward  deformity  of  a  fractured  clavicle  (Fig.  536).  The  third  roller 
corrects  the  downward  and  forward  displacement.  It  starts  in  the  axilla 
of  the  sound  side  anteriorlv,  crosses  the  chest  to  the  shoulder  of  the  injured 


920 


Bandaees 


side,  runs  down  the  back  of  the  arm,  around  the  elbow,  and  crosses  the  chest 
to  the  point  of  origin,  forming  the  anterior  triangle ;  it  is  now  carried  through 
the  axilla  of  the  sound  side  to  the  back,  crosses  the  back  to  the  shoulder 
of  the  injured  side,  runs  down  the  front  of  the  arm,  around  the  elbow,  and 
across  the  back  to  the  axilla  of  the  sound  side,  forming  the  posterior  triangle 
(Fig.  537).  The  formula  for  the  Desault  bandage  is:  start  in  the  axilla  of 
the  sound  side  anteriorly,  run  from  the  axilla  to  the  shoulder,  from  the 
shoulder  to  the  elbow,  from  the  elbow  to  the  axilla,  and  pass  to  the  back; 
from  the  axilla  to  the  shoulder,  from  the  shoulder  to  the  elbow,  from  the 
elbow  to  the  axilla,  and  pass  to  the  front.  Pin  the  crossed  pieces  and  hang 
the  hand  in  a  sling  (Fig.  537). 

Recurrent  Bandage  of  the  Head. — Take  a  roller  two  inches  wide 
and  six  yards  long.  Make  two  circular  turns  horizontally  around  the  fore- 
head and  head;  when  the  middle  of  the  forehead  is  reached,  catch  the  bandage, 
take  a  half  turn,  carry  the  bandage  to  the  occiput,  let  an  assistant  catch  it, 
take  a  half  turn,  bring  the  roller  forward  to  the  forehead,  covering  a  portion 
of  the  preceding  turn;  continue  this  process  until  the  scalp  is  well  covered; 


'^.    ] 


Fig-  537.— Desault's  bandage,  third  roller. 


Fig.  538. — Figure-of-eight  bandage  of  the  breast. 


terminate  with  two  circular  turns  around  the  forehead  and  head  (Fig.  539). 
It  is  often  advisable  to  take  a  turn  around  the  head  and  chin.  Pin  the  crossed 
pieces. 

Recurrent  Bandage  of  a  Stump. — Take  a  roller  two  inches  wide  and 
six  yards  long.  Make  two  light  circular  turns  around  the  root  of  the  stump ; 
make  recurrent  turns  covering  the  stump  as  is  done  in  covering  the  head; 
take  a  circular  turn  around  the  root  of  the  stump,  oblique  turns  to  the  top 
of  the  stump,  circular  turns  around  the  tip,  and  apply  an  ascending  spiral 
reversed  bandage  (Fig.  540). 

T=Bandage  of  the  Perineum. — Pass  the  transverse  part  around  the 
body  above  the  iliac  crests,  and  pin  it  in  front;  bring  one  of  the  tails  over 
the  dressing  and  up  between  the  thigh  and  the  genitals  of  one  side,  and  the 
other  tail  over  the  dressing  and  up  between  the  thigh  and  the  genitals  of 
the  opposite  side;  secure  these  tails  to  the  horizontal  band. 

Handkerchief  Bandages. — Take  unbleached  muslin  one  yard  square. 
The  mu.slin  folded  once  makes  an  ohiong  bandage;  bringing  its  diagonal 
angles  together  makes  a  triangle  bandage;  a  cravai  is  formed  by  folding  a 


Fixed   Dressing-s 


921 


triangle  bandage  from  summit  to  base;  a  cord  is  a  twisted  cravat.     The 
triangle  makes  an  admirable  sling. 

Fixed  Dressings. — Plaster-of-Paris  Bandage. — Cover  the  extremity 
with  a  cotton  or  flannel  bandage  or  with  a  woolen  stocking.  Take  a  gauze 
roller  infiltrated  with  plaster  and  place  it  endwise  in  a  basin  of  tepid  water, 
the  water  covering  the  plaster.  When  bubbles  cease  to  arise,  squeeze  the 
bandage  and  apply  it  without  much  tension,  smoothing  out  each  turn  with 
a  moistened  hand.  As  each  bandage  is  taken  from  the  basin  drop  a  fresh 
one  into  the  water.  Apply  four  thicknesses  of  bandage,  and  finish  tne  dress- 
ing by  sprinkling  dry  plaster  over  the  bandage  and  smoothing  it  with  wet 
hands.  The  ordinary  plaster  will  set  in  from  fifteen  to  thirty  minutes.  If 
it  is  desired  to  have  it  set  more  rapidly,  put  a  tablespoonful  of  salt  in  each 
pint  of  water  used ;  if  to  have  it  set  more  slowly,  pour  stale  beer  into  the  water. 
The  plaster  bandage  is  removed  by  sawing  it  down  the  front  or  by  moisten- 
ing with  dilute  hydrochloric  acid  and  then  cutting  through  the  moistened 
line  with  a  strong  knife.     Gigli  has  devised  a  mode  of  application  which 


Fig.  539. — Recurrent  bandage  of  the  head. 


Fig.  540. — Recurrent  bandage  of  a  stump. 


enables  us  to  remove  the  dressing  with  ease.  A  layer  of  cotton  is  placed 
around  the  limb.  A  piece  of  parchment  paper  which  has  been  wet  and 
shaken  out  is  placed  over  the  cotton.  A  cord  greased  with  vaselin  is  laid 
upon  the  paper  in  a  position  corresponding  to  the  line  we  will  wish  to  saw 
through  the  plaster.  Apply  the  plaster  bandage  and  see  that  the  ends  of 
the  cord  project  beyond  the  bandage.  When  desiring  to  remove  the  bandage 
take  a  steel  wire,  make  nicks  on  one  side  of  it  by  means  of  a  file,  and  attach 
the  string  to  the  wire.  Pull  the  wire  under  the  bandage.  Attach  each  end 
of  the  wire  to  a  wooden  handle  and  saw  through  the  plaster.* 

Silicate  of  Sodium  Dressing. — Protect  the  part  as  is  done  for  a  plaster 
bandage.  Bandage  the  limb  loosely  with  an  ordinary  gauze  bandage,  paint 
this  bandage  with  silicate  of  sodium,  apply  another  bandage  and  paint  it. 
and  so  on  until  six  layers  are  applied.  Gauze  bandages  are  better  than 
ordinary  bandages  to  take  up  silicate  of  sodium.  Silicate  dressings  require 
from  twelve  to  eighteen  hours  to  dry,  and  they  are  removed  by  softening 
with  warm  water  and  then  cutting. 


*  La  Semaine  Med.,  Nov.  3,  1S95. 


922 


Plastic  Surgery 


XXXV.  PLASTIC  SURGERY. 

Plastic  surgery  includes  operations  for  the  repair  of  deficiencies,  for 
the  replacement  of  lost  parts,  for  the  restoration  of  function  in  parts  tied 
down  bv  scars,  and  for  the  correction  of  disfiguring  projections.  Many 
reparative  operations  have  been  devised.  Among  them  are:  cheiloplasty, 
or  the  construction  of  a  new  lip;  the  closure  of  a  cleft  in  the  palate,  the 
lip,  or  the  penis;  the  making  of  a  new  nose;  skin-grafting;  grafting  of  muscle 
or  tendon;  nerve-grafting;  the  introduction  of  celluloid  or  metal  into  the  tissues 
to  act  as  supports;  the  injection  of  paraffin  into  the  tissues  to  amend  a  de- 


Fig.  541. — Injury  causcfl  liy  crush  and  burn.  Ilrriled  by  granulation  in  eight  months.  Showing  a 
condition  after  removal  of  scar  of  the  palm,  which  has  been  repaired  by  stitching  in  an  autoplastic 
graft  (free  flap)  from  the  thigh  (Geo.  S.  Brown). 


pression;  the  diminution  in  the  size  of  a  lip  or  a  nose;  the  amendment  of 
protuberant  ears;  the  correction  of  distortion  due  to  cicatrices;  excision  of 
scars;  clo.sure  of  congenital  sinuses  and  of  fistuhc;  removal  of  disfiguring 
growths. 

The  subject  of  plastic  surgery  is  very  extensive,  and  a  treatise  upon  it 
should  be  consulted  if  one  wishes  to  obtain  detailed  and  comprehensive 
information. 

A  plastic  operation  can  be  succe.ssful  after  lupus  only  when  the  disea.se 
has  been  cured.     It  is  useless  to  do  a  plastic  operation  during  active  syphilis. 


Skin-Gfraftincf 


923 


and  a  plastic  operation  for  a  syphilitic  loss  of  substance  is  to  be  performed 
only  after  the  patient  has  been  thoroughly  treated  and  the  disease  has  been 
apparently  cured.  The  first  step  of  a  plastic  operation  consists  in  making 
raw  the  surfaces  which  are  to  be  brought  together;  the  second  step  is  the 
complete  arrest  of  bleeding;  the  third  step  is  the  approximation  of  the  surfaces 
without  tension;  the  fourth  step  is  to  close  any  gap  from  which  tissue  may 
have  been  transplanted ; 
and  the  final  step  is  the  ap- 
plication of  the  dressings.* 
The  following  are  the 
methods  used:  | 

D  is  placement  is  the 
method  of  stretching  or  of 
sHding:  (i)  approximation 
after  freshening  the  edges 
(as  in  harelip);  (2)  shding 
into  position  after  trans- 
ferring tension  to  other  lo- 
calities (linear  incisions  to 
allow  of  stretching  of  the 
skin  over  large  wounds). 
Interpolation  is  the  method 
of  borrowing  material  from 
an  adjacent  or  a  distant  re- 
gion or  from  another  per- 
son: (i)  transferring  a  flap 
with  a  pedicle,  which  f^ap 
is  put  in  place  at  once  or 
is  gradually  gotten  into 
place  by  a  series  of  partial 

operations  (as  in  ^  rhino-  pjg.  j^^.-Claw-ha^d  from  hum.  a  tia,,  with  a  pchclc  was 
plasty,  when  a  flap  is  taken  taken  from  the  chest.     The  pedicle  was  cut  on  ninth  day. 

from    the    forehead) ;     (2) 

transplanting  without  a  pedicle,  which  is  performed  b\'  placing  in  position  and 
by  fixing  there  portions  of  tis.sue  recently  removed  from  the  part,  from  another 
part  of  the  same  individual,  or  from  a  lower  animal  (as  replacement  of  the 
button  of  bone  after  trephining,  transplanting  a  piece  of  bone  from  a  lower 
animal  to  remedy  a  bone-defect  in  a  human  being,  or  the  grafting  of  a  piece 
of  nerve  from  a  lower  animal  or  an  amputated  human  limb  to  remedy  a  loss 
of  nerve  in  a  human  being  in  nerve-grafting,  or  skin-grafting).  Retrench- 
ment is  the  removal  of  redundant  material  and  the  production  of  cicatricial 
contraction. 

Skin=grafting. — As  long  ago  as  1S47  Dr.  Frank  Hamilton  partly  covered 
an  ulcer  with  a  pediculated  flap,  and  trusted  that  the  uncovered  portion  would 
be  healed  by  new  skin  from  the  flap.  We  may  graft  small  pieces  of  epi- 
thelium taken  from  the  patient,  or  another  person,  or  one  of  the  lower  animals, 
or  we  may  graft  large  pieces  of  epithelium.  The  grafts  should,  if  possible, 
come  from  the  person  to  be  grafted.  The  epidermic  scales  may  be  scraped 
*  "American  Text-book  of  Surgery."  ■\  Ibid. 


924  Plastic  Surgery 

off  the  sound  skin  and  grafted.  Luslc  lias  blistered  the  skin  with  cantharides 
and  grafted  portions  of  the  epidermis.  The  shavings  of  a  corn  have  been 
used.     The  best  plan  is  to  cut  off  and  transplant  small  bits  of  epidermis. 

Grafts  may  come  from  another  person  or  from  a  lower  animal,  but  such 
grafts  are  not  apt  to  grow,  and  even  when  they  do  grow  fail  to  furnish  a 
secure  cicatrix.  Frog-skin  furnishes  unsatisfactory  grafts.  Some  surgeons 
have  used  bits  of  sponge;  others  the  skin  of  rabbits,  guinea-pigs,  or  pups. 
Arnot  has  employed  the  lining  membrane  of  a  hen's  egg,  cut  in  strips  and 
applied  upon  the  wound  with  the  shell-surface  uppermost.  Small  bits  of 
epidermis  taken  from  a  recently  amputated  foreskin  or  leg  may  be  used. 

Reverdin's  Method. — This  operation  was  devised  by  Reverdin  in  1869. 
Small  bits  of  epithelium  are  used  and  they  are  taken  preferably  from  the 
person  himself.  The  surface  to  be  grafted  should  possess  healthy  granula- 
tions level  with  the  skin.  Cleanse  the  skin  from  which  the  grafts  are  to 
come,  the  ulcer,  and  the  skin  about  it,  and,  if  corrosive  sublimate  is  used, 
wash  it  away  with  a  stream  of  warm  normal  salt  solution.  Thrust  a  sewing- 
needle  under  the  epidermis  to  raise  it,  cut  off  the  graft  with  a  pair  of  scissors, 
and  place  the  cut  surface  of  the  graft  upon  the  ulcer.  After  applying  a 
number  of  grafts,  place  thin  pieces  of  gutta-percha  tissue  over  them 
and  extending  on  each  side  of  the  ulcer,  and  so  placed  as  to  have  distinct 
intervals  between  them,  the  gaps  permitting  drainage.  This  tissue,  after 
being  asepticized,  is  moistened  with  warm  normal  salt  solution.  Dress 
with  a  pad  of  aseptic  gauze  moistened  with  salt  solution;  place  over 
this  gauze  a  rubber-dam,  and  over  the  latter  absorbent  cotton  and  a 
bandage.  In  the  case  of  children  apply  a  light  silicate  bandage.  Put 
the  patient  in  bed.  In  forty-eight  hours  remove  all  the  dressings  except  the 
gutta-percha  tissue,  irrigate  with  normal  salt  solution,  and  reapply  the  dress- 
ings. All  signs  of  the  grafts  will  often  have  disappeared.  In  a  da}^  or  two, 
at  the  site  of  grafting,  bluish-white  spots  should  appear,  which  are  islands 
of  epidermis.  Each  graft  is  capable  of  forming  about  half  an  inch  of  cicatrix. 
Grafting  also  stimulates  the  edges  of  the  ulcer  to  cicatrize  and  contract. 
At  the  end  of  seven  days  the  special  dressings  can  be  dispensed  with.  The 
spot  from  which  the  grafts  are  taken  is  dressed  antiseptically.  Reverdin's 
method  does  not  limit  cicatricial  contraction  to  any  great  degree,  and  the 
new  skin  is  apt  to  break  down. 

The  Ollier-Thiersch's  Method. — Oilier,  of  Lyons,  in  1872  succeeded  in 
transferring  large  pieces  of  epidermis.  In  1886  Thiersch,  of  Leipzig,  set 
forth  the  technic  practically  as  it  is  employed  to-day.  The  Ollier-Thiersch 
method  is  performed  as  follows:  Thoroughly  asepticize  the  ulcer,  the  sur- 
rounding skin,  and  the  site  from  which  the  graft  is  to  come  (the  inner  side 
of  the  arm  or  the  thigh),  and  wash  away  the  mercurial  preparation  with  nor- 
mal salt  solution.  Apply  dressings  wet  with  salt  solution.  On  bringing  the 
patient  into  the  operating-room  remove  the  dressings  from  the  ulcer,  scrape 
the  ulcer  and  its  edges,  irrigate  with  .salt  solution,  and  compress  to  arrest 
hemorrhage.  Grafts  are  then  obtained  by  putting  the  prepared  skin  upon 
the  stretch  and  cutting  strips  with  a  razor.  While  the  razor  is  being  used 
the  part  is  con.stantly  irrigated  with  salt  solution.  Mixter's  apparatus  enables 
one  to  perform  this  operation  with  great  neatness  and  speed.  This  apparatus 
consists  of  a  knife  and  an  open  square  with  sharp  points  on  the  under  surface. 


Subcutaneous  Injection  of  Paraffin  for  Prosthetic  Purposes     925 

The  square  is  forced  down  upon  the  front  of  the  thigh,  the  epidermis  mounts 
up  in  the  opening  to  above  the  level  of  the  metal  sides,  and  the  grafts  may 
be  cut  with  ease.  The  graft  contains  the  epidermis,  the  rete,  and  part  of 
the  true  skin.  In  Halsted's  clinic  the  skin  of  the  thigh  is  made  tense  by 
pressing  upon  it  with  a  piece  of  asepticized  wood,  the  wood  is  drawn  slowly 
along,  and  is  followed  closely  by  the  sharp  catlin,  with  which  the  surgeon 
cuts  long  grafts.  The  grafts  are  pressed  into  place  upon  the  raw  surface, 
and  each  graft  overlaps  a  little  the  edges  of  the  wound  and  the  adjacent 
grafts.  The  skin-wound  is  dressed  antiseptically,  and  the  grafted  area  is 
dressed  as  in  Reverdin's  method.  Recently  it  has  been  suggested  that  a 
ring  of  aseptic  gauze  be  made  to  encircle  the  limb  below  the  grafted  area, 
and  another  ring  above  the  grafted  area;  on  these  pads  little  strips  of  wood 
wrapped  in  aseptic  gauze  are  so  laid  as  to  make  a  cage,  and  around  this 
cage  the  dressings  are  applied  (moist  chamber  plan)  (Fig.  543). 

Wolfe's  Method. — It  was  pointed  out  by  Wolfe,  of  Glascow,  that  a  piece 
of  skin,  comprising  the  entire  thickness  of  that  structure,  can  be  successfully 
transplanted  without  a  pedicle.  The  ulcer  is  extirpated  and  asepticized  and 
bleeding  is  arrested.  The  flap  is  cut  one-sixth  larger  than  the  surface  to 
be  covered.     Fat  is  kept  out  of  the  graft.     The  bit  of  tissue  is  laid  upon 


Fig.  543. — Mayer's  dressing  for  Thiersch's  method  of  skin-grafting  ("American  Text-book  of 

Surgery"). 

the  wound,  the  edges  of  the  graft  being  brought  against  the  edges  of  the  raw 
area.  It  is  not  necessary  to  employ  sutures.  The  part  is  dressed  in  a  moist 
chamber.     If  the  graft  perishes,  remove  it. 

Subcutaneous  Injection  of  Paraffin  for  Prosthetic  Purposes. 

—The  principle  of  injecting  solidifying  oils  into  tissues  to  mechanically  obtain 
effects  was  first  laid  down  by  J.  Leonard  Corning  in  1891.  The  use  of 
paraffin  was  introduced  by  Gersuny  to  amend  the  deformity  of  a  saddle- 
nose.  It  has  been  used  to  hmit  incontinence  of  feces,  incontinence  of  urine 
in  women,  to  prevent  reunion  of  nerves  after  division,  to  replace  a  testicle, 
to  obliterate  smallpox  marks,  to  narrow  a  hernial  ring,  to  correct  sinking 
of  the  cheek  after  removal  of  the  upper  jaw,  and  for  other  purposes  (Mosz- 
kowicz,  in  '' Wien.  klin.  Woch.,"  June  20,  1901).  Paraffin  is  not  toxic. 
Its  injection  may  produce  some  swelling  and  redness,  but  applications  of 
cold  quickly  control  inflammation.  In  two  or  three  months  the  paraffin  be- 
comes hard  like  cartilage  and  encapsuled.  It  is  questionable  whether  or 
not  it  is  subsequently  destroyed  and  replaced  by  granulation  tissue.  Some- 
times sloughing  takes  place  in  the  skin  above  it. 

Prepare  the  paraffin  as  follows:  In  Gersuny's  clinic  solid  paraflin  is  mixed 
with  liquid  paraffin.  The  melting-point  of  the  mixture  should  be  about  104° 
F.     It  is  rendered  sterile  by  boiling,  is  injected  by  a  warm  syringe,  and  as 


926 


Plastic  Surgery 


a  semi-solid,  the  slcin  having  been  first  warmed  by  a  hot  sponge.  After  in- 
jection it  is  moulded  into  proper  shape.  It  sets  in  half  a  minute.  It  is  not 
wise  to  use  a  mixture  with  a  much  higher  melting-point,  because  it  would 
possibly  cause  thrombosis  of  veins. 

Rhinoplasty. — The  complete  operation  may  be  performed  by  trans- 
ferring a  flap  from  the  forehead.  This  is  known  as  the  Indian  operation. 
It  was  employed  for  centuries  in  India,  and  interest  in  it  was  awakened  in 
England  about  1820  by  Mr.  Carpue.  The  edges  of  the  defect  are  made 
raw.  A  model  of  the  desired  nose  is  made  out  of  gutta-percha,  and  its  out- 
Hnes  are  marked  upon  the  forehead,  and  the  cut  is  made  one-quarter  of  an 
inch  outside  of  the  outline  so  as  to  allow  room  for  retraction.  The  flap  is 
turned  down  and  sutured  in  place  (Fig.  544),  care  being  taken  not  to  cut 


Fig.  544.— Indian  method  of  rhinoplasty. 


Fig-  545- — Italian  method  of  rhinoplasty. 


off  the  blood-supply  in  the  pedicle.  Plugs  of  gauze  or  tubes  are  inserted 
to  support  the  flap. 

The  complete  operation  can  be  performed  by  the  Italian  method  (Taglia- 
cotian  method).  This  method  was  first  described  in  Tagliacozzi's  book, 
which  was  pubHshed  in  1597.  In  this  operation  the  f^ap  is  marked  out 
on  the  arm,  is  made  twice  the  size  of  the  desired  nose,  and  is  left  attached 
by  a  broad  pedicle.  The  nasal  surface  is  rendered  raw  at  proper  regions, 
and  the  flap  is  .sutured  in  place,  the  hand  being  held  upon  the  head  by  a 
special  apparatus  (Fig.  545).  The  raw  surface  upon  the  arm  is  dressed.  In 
about  three  weeks  the  flap  is  cut  loose  from  the  arm,  and  is  pared  and 
corrected  as  may  be  necessary. 

The  operations  for  harelip  and  cleft  palate,  and  plastic  operations  on 
muscles,  nerves,  tendons,  and  bones,  are  considered  in  other  portions  of  the 
work. 


Bleeding  from  the  Kidney- substance  927 


XXXVI.   DISEASES  AND   INJURIES  OF  THE  QENITO=URINARY 

ORGANS. 

Hematuria. — By  this  term  is  meant  the  voiding  of  bloody  urine  or  of 
pure  blood,  the  blood  arising  from  any  portion  of  the  urinary  apparatus, 
and  the  condition  being  a  symptom  and  not  a  disease.  Hematuria  may  be  a 
symptom  of  disease  or  of  injury  of  some  part  of  the  urinary  system,  of  blood- 
disorganizations  (purpura,  scurvy,  or  variola),  or  of  metallic  poisoning  (mer- 
cury, lead,  or  arsenic).  The  color  of  the  urine  in  hematuria  may  be  any- 
thing between  a  light  red  and  a  decided  black,  but  these  colors  may  be  pro- 
duced by  agents  other  than  blood.  Senna  and  rhubarb  make  urine  red; 
carbolic  and  salicylic  acids,  brown  or  greenish-black;  beet-root  and  sorrel, 
the  color  of  blood;  methylene-blue,  blue.  In  jaundice,  melanosis,  and  splenic 
fever  the  urine  becomes  brown.  Be  sure  that  bloody  urine  in  the  female  is 
not  due  to  admixture  with  menstrual  blood. 

Tests  for  Blood. — Spectroscope  Test. — Bloody  urine,  if  fresh  and 
diluted  with  water,  shows  the  two  absorption-bands  of  oxyhemoglobin.  The 
addition  of  ammonium  sulphid  causes  the  two  bands  to  give  place  to  the 
band  of  reduced  hemoglobin.  If  bloody  urine  stands  for  some  time,  the 
four  bands  of  methemoglobin  are  discovered  (v.  Jaksch). 

Heller's  Test. — Add  potassium  hydrate  to  the  urine,  and  boil;  a  red 
precipitate  of  earthy  phosphates  and  hematin  forms.  Throw  the  precipitate 
upon  a  filter  and  treat  it  with  acetic  acid;  a  red  solution  is  produced,  which 
soon  fades. 

Rosenthal's  Test. — Take  the  precipitate  from  caustic  potash,  dry  it, 
and  test  it  for  hematin ;  put  some  of  the  dry  sediment  on  a  sHde,  add  a  crystal 
of  common  salt,  apply  a  cover-glass,  and  cause  a  few  drops  of  glacial  acetic 
acid  to  flow  under  the  glass;  warm,  but  do  not  boil.  Teichmann's  crystals 
will  appear  on  cooling. 

Struve's  Test. — Test  the  urine  with  hydrate  of  potassium,  and  add  acetic 
acid  in  excess;  a  dark  precipitate  forms,  which  will  yield  crystals  of  hematin 
when  treated  with  sal  ammoniac  and  glacial  acetic  acid. 

Almen's  Test. — Take  10  c.c.  of  urine,  and  pour  upon  its  surface  a  mixture 
of  equal  parts  of  tincture  of  guaiac  and  old  oil  of  turpentine;  at  the  point 
of  junction  of  this  fluid  with  the  urine  there  forms  a  white  ring  which  turns 
blue. 

Microscopic  Test. — The  microscope  shows  numerous  corpuscles  except 
in  a  very  alkaline  urine,  when  but  few  corpuscles  may  be  found. 

In  hemoglobinuria — a  condition  sometimes  occurring  in  burns,  acute  mala- 
dies, and  metallic  poisoning — there  is  present  blood-coloring  matter,  which 
is  shown  by  Heller's  test  and  by  Almen's  test.  The  spectroscope  shows 
methemoglobin.  The  microscope  shows  no  corpuscles  or  only  a  few,  but 
discloses  masses  of  pigment. 

Bleeding  from  the  Kidney=substance. — Bleeding  from  the  pelvis  of 
the  kidney  and  from  the  ureter  may  be  due  to  inflammation,  congestion, 
contusion,  stone,  vicarious  menstruation,  hemorrhagic  diathesis,  powerful 
diuretics,  fevers,  purpura,  tumors,  catheterization  of  the  bladder,  etc.  Blood 
is  thorousihlv  mixed  with  the  urine,  and  no  sediment  forms  (smoky  urine). 


92< 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


The  corpuscles  are  profoundly  altered,  are  devoid  of  coloring-matter,  and 
show  pale-yellow  rings.  The  severity  of  the  hemorrhage  is  measured  by 
the  number  of  the  corpuscles.  Von  Jaksch  states  that  the  diagnosis  between 
renal  and  ureteral  hemorrhage  rests  on  the  nature  of  the  casts  and  the  epithe- 
lium present.  From  the  pelvis  of  the  kidney  and  from  the  ureter  comes 
small  epithelium,  the  cells  from  the  superficial  layers  being  polygonal  or 
elliptical,  those  from  the  deeper  layers  being  oval  or  irregular.  In  hemorrhage 
from  the  ureter  the  cells  are  few;  in  hemorrhage  from  the  pelvis  they  are 
plentiful  and  rest  upon  one  another  like  "tiles  on  a  roof"  (v.  Jaksch).  Cells 
from  the  tubules  of  the  kidney  are  small,  granular,  and  polyhedral,  have 
large  nuclei,  and  are  often  so  arranged  as  to  form  cylinders  (epithelial  casts). 
The  urine  during  and  immediately  after  a  renal  hemorrhage  is  apt  to  be 
acid  unless  alkalies  have  been  administered,  unless  the  bleeding  has  been 


Fig.  546. — Nitze's  instrument  in  use  ("  Berl.  kliti.  Wochen."). 


severe,  or  unless  pus  is  present  in  the  urine.  A  very  large  renal  hemor- 
rhage may  cause  the  passage  of  almost  pure  blood.  In  renal  hematuria 
there  are  aching  in  the  loin,  numbness  of  the  corresponding  leg,  and  often 
renal  colic.  The  use  of  the  cystoscope  enables  the  surgeon  to  determine  if 
the  hemorrhage  is  vesical  or  renal,  and  if  it  comes  from  one  or  both  kid- 
neys. If  the  bladder-fluid  is  kept  clear,  the  blood  can  be  seen  flowing  out 
of  the  ureter  of  the  damaged  organ,  or  if  both  ureters  are  catheterized  a 
sample  of  urine  can  be  obtained  from  each  kidney. 

Ureter=catheterism. — Catheterization  of  the  ureters  may  give  informa- 
tion of  the  greatest  value.  It  enables  the  surgeon  to  obtain  the  urine  from 
one  kidney  unmixed  with  urine  from  the  other  kidney  and  uncontaminated 
by  material  from  the  bladder  or  urethra.  By  this  method  we  can  determine 
if  pus,  blood,  bacilli,  etc.,  come  from  the  ureter  or  kidney,  and  from  which 


Segregation  of  Urine  929 

ureter  or  kidney.  A  stricture  or  a  calculus  of  a  ureter  can  be  located; 
hydronephrosis  and  pyonephrosis  can  be  diagnosticated;  the  presence  of  both 
kidneys,  and  if  either  kidney  is  diseased  or  if  both  are  diseased,  and  the 
secretory  capacity  of  each  kidney  in  a  given  time,  can  be  ascertained.  The 
method  is  also  employed  to  treat  various  conditions  of  the  ureter  and 
kidney. 

Kelly  impressed  upon  the  profession  that  the  ureters  in  women  can  be 
catheterized,  when  the  patient  by  the  knee-chest  posture  permits  the  atmos- 
pheric distention  of  the  bladder,  so  that  the  ureteral  orifices  can  be  inspected 
through  a  speculum.  Light  is  reflected  into  the  speculum,  a  forehead  mirror 
and  an  electric  light  being  employed.  It  may  be  necessary  to  dilate  the 
ureter  before  inserting  the  speculum.  It  is  rarely  necessary  to  give  a  general 
anesthetic.  Kelly  moistens  a  bit  of  cotton  wrapped  on  a  metal  rod  in  a 
10  per  cent,  solution  of  cocain,  introduces  it  just  within  the  external  urethral 
orifice,  and  holds  it  there  for  five  minutes  before  beginning  the  operation. 
When  the  ureteral  orifice  of  one  side  is  found  by  inspection  through  the 
speculum,  he  introduces  a  sterile  flexible  silk  catheter  lubricated  with  boro- 
glycerid  and  it  is  pushed  up  from  four  to  six  inches  in  the  ureter.  A  similar 
tube  is  introduced  into  the  other  ureter  and  the  separated  urines  are  collected 
in  test-tubes.  (See  Kelly's  ''  Operative  Gynaecology. ")  The  catheterization 
of  the  ureters  by  this  method  can  be  performed  only  by  a  dextrous  and  ex- 
perienced man;  but  such  an  individual  can  do  it  with  ease  and  celeritv;  as 
practised  by  Kelly  himself,  it  seems,  until  one  tries  it,  the  perfection  of  sim- 
plicity. 

The  ureter-cystoscope  of  Bransford  Lewis  is  an  admirable  instrument. 
It  can  be  used  upon  the  male  or  the  female,  and  it  enables  the  ordinary 
surgeon  to  catheterize  the  ureters  more  easily  than  by  Kelly's  method! 
(Fig.  548  shows  Lewis's  instrument.)  The  illumination  is  by  a  cold  elec- 
tric light,  the  bladder  is  distended  with  air,  and  the  observer  is  free  from 
the  annoyance  of  clouding  of  the  hquid  which  so  commonly  occurs  when 
the  bladder  is  distended  with  fluid. 

The  male  ureter  can  be  satisfactorily  catheterized  by  means  of  the  in- 
strument of  Nitze  (Fig.  546). 

Kelly  has  recently  catheterized  the  ureter  in  a  man  by  inserting  a  straight 
speculum,  placing  the  patient  in  the  knee-chest  position  to  inflate  the  bladder 
with  air,  and  introducing  a  metallic  catheter. 

Segregation  of  Urine. — Professor  Harris,  of  Chicago,  has  devised  an 
excellent  instrument  (Fig.  547)  which  in  many  cases  greatlv  simplifies  the 
problem  of  obtaining  unmixed  urine  from  each  ureter.  The  double  catheter 
is  passed  into  the  bladder.  The  lever  is  inserted  in  the  rectum  of  the  male 
and  the  vagina  of  the  female.  The  lever  is  fastened  to  the  perforated  frame 
from  the  double  catheter.  The  double  catheter  is  now  opened  in  the  bladder, 
and  the  blades  of  the  instrument  are  held  in  position  by  a  spring.  The 
end  of  the  lever  in  the  vagina  or  rectum  humps  up  the  floor  of  the  bladder 
between  the  separated  ends  of  the  divided  catheter,  and  forms  a  longitudinal 
septum  or  watershed  between  the  ureteral  orifices.  The  end  of  each  catheter 
lies  in  the  bottom  of  a  pocket  in  the  side  of  the  watershed.  ''  By  producing 
a  very  slight  exhaustion  of  the  air  in  the  vials  by  means  of  the  bulb,  the  urine, 
59 


930 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


as  fast  as  it  escapes  from  the  ureters,  drops  directly  into  the  ends  of  the 
catheters  and  flows  at  once  into  the  vials,  right  and  left  respectively."* 

In  using  this  instrument,  place  the  patient  flat  on  his  back  upon  a  table, 
the  thighs  and  legs  being  flexed,  and  the  feet,  hips,  and  head  being  on  the 
same  level.     Irrigate  the  bladder  thoroughly  with  sterile  water,  and  have 


Fig.  547. — Harris's  instrument  fitted  for  use. 

150  c.c.  of  fluid  in  the  bladder  when  the  blades  are  opened.  Leave  the 
instrument  in  place  for  thirty  minutes.  It  is  rarely  necessary  to  give  an 
anesthetic.  In  some  cases  cocain  must  be  used,  and  in  some  cases  of  painful 
cystitis  ether  should  be  given.  Harris  says  the  instrument  should  not  be 
used  if  there  is  a  growth  of  the  bladder  that  bleeds  easily,  if  the  bladder 
is  contracted,  or  if  there  is  a  very  large  prostate  or  a  vesical  stone. f 


Fig.  548. — Lewis's  nroter-c\stoscope. 


In  catheterization  of  the  ureters  there  is  always  .some  danger  of  carrying 
infection  upward  from  the  bladder.     The  Harris  method  of  .segregation  is 

*  M.  I.  Harris,  in   Merlicine,  April,  1898. 
fjour.  Cutan.  and  (ien.-Urin.  I)is.,  May,  1899. 


Frequency  of  Micturition  931 

free  from  this  danger.  As  a  matter  of  fact,  however,  Harris's  method 
often  possesses  elements  of  uncertainty,  because  the  septum  may  not  be 
perfect  and  the  urine  from  one  side  sometimes  contaminates  the  urine  from 
the  other.  Catheterization  of  the  ureters  is  not  so  safe,  is  far  more  difficult, 
but  gives  more  certain  results. 

Vesical  hemorrhage,  including  hemorrhage  from  the  prostate, 

may  follow  the  relief  of  retention  of  urine,  may  be  due  to  stone,  inliammation, 
tumor,  etc.,  or  may  arise  from  traumatisms,  instrumental  or  otherwise.  The 
color  of  the  urine  is  usually  bright  red,  but  if  long  retained  in  the  bladder 
it  becomes  black  and  often  tarry.  The  reaction  is  alkaline.  The  clots,  when 
floated  out,  are  large  and  without  definite  shape.  In  micturition  the  urine 
is  clear  or  only  a  Httle  colored  at  the  beginning,  but  becomes  darker  and 
darker  as  micturition  ends,  at  which  tim.e  the  flow  may  consist  of  almost 
pure  blood.  In  very  small  vesical  hemorrhages  the  urine  may  be  smoky. 
Crystals  of  triple  phosphate  indicate  bladder  disorder.  The  microscope  shows 
colorless  and  swollen  corpuscles  and  many  polygonal  cells.  Symptoms  of 
bladder  mischief  usually  exist,  but  cystoscopic  examination  or  e.xploratory 
suprapubic  cystotomy  may  be  required  for  the  diagnosis. 

Urethral  Hemorrhage. — In  urethral  bleeding  blood  appears  inde- 
pendently of  micturition,  or  blood  comes  out  first  and  is  followed  by  clear 
urine.  Urethral  hemorrhage  arises  from  acute  urethritis,  from  an  inflamed 
stricture,  from  the  passage  of  an  instrument,  or  from  some  other  traumatism. 

The  source  of  urethral  hemorrhage  can  be  ascertained  by  the  use  of  the 
endoscope. 

Pain  in  Qenito=urinary  Diseases. — Pain  as  a  symptom  of  genito- 
urinary disease  may  be  found  at  some  point  distant  from  the  seat  of  lesion. 
A  stone  in  the  bladder  causes  pain  in  the  head  of  the  penis  just  back  of  the 
meatus;  stone  in  the  kidney  induces  pain  in  the  loin,  the  groin,  the  thigh, 
and  the  testicle;  inflammation  of  the  testicle  causes  pain  in  the  fine  of  the 
cord  in  the  groin.  In  other  cases  of  genito-urinary  disease  pain  is  felt  at 
the  seat  of  lesion,  as  in  urethritis  and  prostatitis.  Pain  felt  before  micturi- 
tion, and  being  relieved  by  the  act,  is  found  in  cystitis  and  in  retention  of 
urine.  Pain  is  felt  during  micturition  in  inflammation  of  the  bladder,  pros- 
tate, and  urethra,  and  in  the  passage  of  gravel  or  stone.  Pain  which  is  acute 
at  the  end  of  micturition  is  noted  in  stone  in  the  bladder,  in  inflammation 
of  the  neck  of  the  bladder,  and  in  inflammation  of  the  prostate  gland.  The 
pain  of  stone  in  the  bladder,  it  may  be  observed,  is  ameliorated  by  rest  and 
is  aggravated  by  e.xercise.  The  pain  of  acute  prostatitis  is  intensified  by- 
defecation. 

Frequency  of  Micturition. — Frequent  micturition  arises  from  irri- 
tation of  the  sensory  nerves,  from  phimosis,  contracted  meatus,  inflammations, 
very  acid  urine,  calcuh,  urethral  stricture,  and  hyperesthesia  of  the  urethra. 
Frequency  of  micturition  may  be  due  to  spinal  irritability  from  concussion 
or  from  se.xual  excess,  from  contraction  of  the  bladder  rendering  the  \iscus 
unable  to  hold  much,  from  worry,  anxiety,  fear,  or  from  excessive  urinary 
secretion,  as  in  diabetes  or  in  the  first  stage  of  contracted  kidney.  Frequent 
micturition  exists  in  obstruction  by  enlarged  prostate  and  in  atony  of  the 
bladder-walls.     Hypersecretion  of  urine  plus  bladder  intolerance  is  known  as 

Frequency  of  micturition  increased 


932  Diseases  and  Injuries  of  the  Genito-urinaiy  Organs 

by  movement  is  observed  in  stone  and  tumor  of  the  bladder.  Nocturnal  fre- 
quency of  micturition  is  present  in  cases  of  enlarged  prostate  and  atony  of 
the  muscular  walls  of  the  bladder.  Frequency  of  micturition  with  diminution 
of  stream-caliber  suggests  a  constriction  of  the  urethral  diameter;  frequency 
of  micturition  with  diminished  force  suggests  a  posterior  stricture,  enlarged 
prostate,  or  bladder  atony.  Slowness  of  micturition  hints  at  enlarged  pros- 
tate, atony,  or  urethral  stricture. 

Sir  Henry  Thompson's  diagnostic  questions  are  as  follows: 

"i.  Have  you  any,  and,  if  so,  what,  frequency  in  passing  water?  Is  fre- 
quency more  manifest  during  the  night  or  the  day?  Is  frequency  more 
manifest  during  motion  or  rest  ?     Does  any  other  circumstance  affect  it  ? 

"  2.  Is  there  pain  on  passing  urine,  and,  if  so,  is  it  before,  during,  or 
after  the  act?  What  is  its  character — acute,  smarting,  dull,  transitory,  or 
continuous?  What  is  its  seat?  Is  it  felt  at  other  times,  and  is  it  produced 
or  intensified  by  sudden  movements? 

"3.  What  is  the  character  of  the  stream?  Is  it  small  or  large;  twisted  or 
irregular;  strong  or  weak;  continuous,  remitting,  or  intermitting?  Does  it 
come  by  the  meatus,  or  partly  or  entirely  through  fistula,'  ? 

"  4.  Is  the  character  of  the  urine  altered  ?  What  is  its  appearance,  color, 
odor,  reaction,  and  specific  gravity?  Is  it  clear  or  turbid,  and,  if  turbid, 
is  it  so  at  the  time  of  passing?  Does  it  vary  in  quantity?  Are  the  normal 
constituents  increased  or  diminished?  Does  it  contain  abnormal  elements, 
as  albumin  or  sugar?  What  inorganic  deposits  are  found?  What  organic 
materials  are  met  with? 

"5.  Has  the  urine  ever  contained  blood?  If  so,  was  the  color  brown  or 
bright  red;  were  the  blood  and  urine  thoroughly  mixed;  was  the  blood  passed 
at  the  end  or  at  the  beginning  of  micturition,  or  did  it  come  only  with  the 
last  drops  of  urine;  or  was  it  passed  independently  of  micturition  ? 

"  6.  Inquire  as  to  pain  in  the  back,  loins,  and  hips,  permanent  or  transitory, 
and  for  the  occurrence  of  severe  paroxysms  of  pain  in  these  regions." 

The  Determination  of  the  Excretory  Capacity  of  the  Kidneys 
in  Health  and  in  Disease. — The  Phloridzin  Test. — This  test  is  made 
with  comparative  ease  and  often  aids  the  surgeon  in  determining  whether  he  is 
justified  in  performing  some  operation  of  convenience.  It  enables  him  to  esti- 
mate with  a  fair  amount  of  accuracy  the  capacity  for  elimination  possessed  by 
the  kidneys.  The  test  depends  on  the  fact  that  the  healthy  epithehum  of  the 
glomeruli  and  tubes,  when  stimulated  to  activity  by  phloridzin,  forms  sugar 
from  that  drug  and  thus  produces  temporary  glycosuria.  When  the  epithelium 
is  diseased,  little  or  no  glycosuria  occurs.  The  test  is  applied  as  follows:  The 
dose  is  about  5  to  10  milligrams  of  phloridzin,  according  to  the  body-weight 
of  the  patient.  It  is  administered  hypodermatically,  the  bladder  having 
been  emptied  beforehand.  If  the  eliminating  powers  of  the  kidney  are  at 
a  healthy  level,  .sugar  should  appear  in  the  urine  within  half  an  hour  of  the 
injection.  If  at  the  end  of  this  time  only  a  small  amount  of  sugar  can  be 
detected,  one  may  assume  that  the  kidneys  are  affected;  and  if  no  sugar  can 
be  found,  a  serious  renal  disease  may  be  assumed  to  exi.st. 

The  actual  standard  that  is  to  be  considered  as  the  normal  amount  of  sugar 
which  should  be  eliminated  after  the  administration  of  phloridzin  is  a  matter 
of  some  uncertainty.     It  is  usually  estimated  at  0.3  per  cent.,  a  less  amount 


Diseases  and  Injuries  of  the  Kidney  and  Ureter  933 

of  sugar  than  this  being  taken  as  an  evidence  of  renal  difficulty  (Watson 
and  Bailey,  in  "Report  of  Boston  City  Hospital  for  1902").  The  sugar  is 
separated  from  the  phloridzin  in  the  epithelium  of  the  glomeruli  and  tubules 
of  the  cortex  of  the  kidney.     The  drug  seems  to  be  entirely  harmless. 

It  is  because  phloridzin  is  acted  upon  by  the  kidney-epithelium  that  this 
test  is  better  than  the  methylene-blue  test.  The  latter  does  not  really  measure 
the  excretory  power  of  the  kidney-epithelium ;  it  merely  shows  to  what  degree 
the  kidney  is  permeable  in  the  mechanical  sense.  Personally,  I  should  not 
be  disposed  to  set  aside  older  and  more  thorough  methods  of  urinary  analysis 
for  the  phloridzin  test,  although  I  believe  that  it  has  a  range  of  distinct  use- 
fulness. 

The  Methylene-blue  Test  (the  method  of  Achard  and  Castaign). — \\'hen 
methylene-blue  is  injected  hypodermatically  it  normally  appears  in  the  urine 
w:ithin  half  an  hour  and  disappears  in  from  thirty-six  to  forty-eight  hours. 
If  the  blue  color  is  not  manifest  in  the  urine  for  an  hour  or  more,  there  is 
impairment  of  renal  permeability.  Accuracy  in  the  test  is  not  possible  unless 
the  amount  of  the  methylene-blue  actually  passing  into  the  urine  in  a  given 
time  is  determined.  The  dose  given  hypodermatically  is  0.05  gm.  in  i  c.c. 
of  sterile  water.  The  test  is  unrehable  and  the  blue  color  may  appear  in 
the  urine  in  half  an  hour  in  some  cases  of  marked  kidney  disease. 

Cryoscopy  (Korayni's  Method). — By  cryoscopy  is  meant  a  study  of  the 
freezing-point  of  the  blood  and  of  the  urine.  This  method  is  complex  and 
difficult  of  application,  and  requires  a  considerable  amount  of  blood.  The 
examiner  determines  the  point  in  degrees  centigrade  at  which  blood  and 
urine  freeze.  The  point  at  which  each  freezes  having  been  determined,  the 
difference  between  this  and  the  freezing-point  of  distilled  water  is  the  figure 
we  seek  in  each  case.  Healthy  blood  has  a  freezing-point  of  about  0.56°  C. 
When  it  is  below  0.60°  C,  it  is  held  that  operation  is  unsafe.  Insufficiency 
of  the  kidney  is  indicated  when  the  freezing-point  of  urine  is  0.9°  C. 

Diseases  and  Injuries  of  the  Kidney  and  Ureter. 

Tumors  of  the  Kidney. — Tumors,  innocent  or  malignant,  may  arise 
in  the  kidney.  Among  the  innocent  tumors  are  fibroma,  lipoma,  angioma, 
and  adenoma.  A  malignant  tumor  may  be  either  sarcoma  or  carcinoma. 
Sarcoma  is  most  common  in  the  young,  and  may  reach  an  enormous  size. 
A  malignant  tumor  of  the  kidney  produces  hematuria,  the  urine  often 
containing  blood-casts  of  the  ureter,  kidney,  and  pelvis,  and  sometimes, 
though  rarely,  characteristic  cells.  Pain  is  often  present  in  the  loin  and 
thigh,  and  there  may  be  colic-like  attacks  when  clots  are  passing  through 
the  ureter.  Emaciation  is  rapid  and  pronounced.  A  tumor  can  usuall\'  be 
detected.  The  only  possible  treatment  for  a  malignant  growth  is  early 
nephrectomy.  In  some  few  cases  an  innocent  tumor  can  be  removed  !:>}•  a 
partial  nephrectomy.  A  malignant  tumor  requires  a  complete  nephrectomy. 
In  making  a  diagnosis  of  renal  tumor  use  the  cystoscope.  If  blood  is  coming 
from  a  ureter,  note  if  it  is  from  only  one  or  from  both.  Blood  from  Ijotli 
would  contraindicate  nephrectomy.  Before  removing  a  kidney  it  is  necessary 
to  be  sure  that  the  patient  is  possessed  of  two  kidneys.  Note  if  urine  flows 
from  each  ureter,  or,  if  uncertain,  catheterize  the  ureters. 


934  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Nephroptosis,  Prolapse  of  the  Kidney,  or  Mobile  Kidney.— 

There  are  two  forms  of  this  condition:  (i)  movable  kidney,  which  is  an  organ 
freely  moving  back  of  the  peritoneum,  either  within  the  cavity  of  its  fibro- 
fatty  capsule  or  entirely  without  its  capsule  (this  condition  is  acquired) ; 
and  (2)  floating  or  ivandering  kidney,  an  organ  having  a  mesonephron  and 
Iving  within  the  peritoneal  cavity  (this  rare  condition  is  always  congenital). 
Keen  states  that  there  may  be  drawn  a  clear  theoretical  distinction  between 
movable  and  floating  kidney,  but  practically  there  is  no  rigid  line  of  demarca- 
tion, as  a  movable  kidney  may  have  as  large  a  range  of  movement  as  a  floating 
kidnev.  The  kidney  is  normally  somewhat  mobile,  and  nephroptosis  is 
considered  to  exist  only  when  the  range  of  movement  exceeds  distinctly  what 
is  normal.  Normally,  on  inspiration  the  kidney  descends  about  half  an  inch. 
It  is  seldom  that  a  normal  kidney  can  be  palpated  in  men,  but  in  most  women 
the  right  kidney  can  be  palpated,  and  in  some  women  the  left  organ  can 
also  be  felt.  Harris  ("Jour.  Amer.  Med.  Assoc,"  June  i,  1901)  describes 
three  degrees  of  movable  kidney.  In  cases  of  the  first  degree,  one-half  of 
the  organ  can  be  distinctly  grasped  and  the  kidney  can  be  made  to  recede. 
In  cases  of  the  second  degree  both  hands  can  be  brought  together  above 
the  kidney.  In  cases  of  the  third  degree  the  kidney  has  descended  as  low 
as  the  pelvic  brim  or  has  moved  to  or  beyond  the  umbihcus.  The  organ 
may  drop  below  the  brim  of  the  pelvis,  may  cross  the  vertebral  column,  or 
may  reach  the  anterior  abdominal  w^all.  When  a  movable  kidney  becomes 
fixed  in  an  abnormal  situation,  the  organ  is  spoken  of  as  dislocated. 

Women  more  often  suffer  from  movable  kidney  than  do  men.  Kiister 
estimates  that  4.41  per  cent,  of  women  examined  in  general  surgical  practice 
have  movable  kidney.  Edebohls  finds  it  in  20  per  cent,  and  Harris  in  56 
per  cent,  of  cases  in  gynecological  practice.  In  about  one-half  of  the  cases 
it  gives  rise  to  little  or  no  trouble.  A  movable  kidney  is  found  in  the  great 
majority  of  cases  upon  the  right  side.  Floating  kidney  is  always  congenital. 
The  condition  is  occasionally,  but  rarely,  found  in  children.  Tuffier  has 
reported  3  cases  in  children  six,  nine,  and  ten  years  of  age  respectively,  and 
J.  Cromby  reported  18  cases  of  floating  kidney  in  children,  the  youngest 
patient  being  three  months  of  age  (quoted  by  Harris  in  "Jour.  Amer.  Med. 
Assoc,"  June  i,  1901).  Among  the  assigned  causes  of  the  movable  con- 
dition are  to  be  named  traumatisms;  strains;  abdominal-wall  laxity  from 
pregnancy,  removal  of  a  tumor  or  tapping  for  ascites;  absorption  of  peritoneal 
fat  from  wasting  disease  (Edebohls);  tight  lacing;  uterine  displacements;  and 
enteroptosis  leading  to  traction  on  the  transverse  mesocolon.  The  condition 
is  certainly  often  associated  with  ptosis  of  the  other  al)doniinal  viscera  (enter- 
optosis, gastroptosis,  etc.). 

Traumatism  is  rarely  the  immediate  and  essential  cause  of  a  true  mo\able, 
kidney.  In  some  cases  people  assert  that  pain  began  immediately  after  a 
blow,  an  attack  of  coughing,  violent  vomiting,  lifting,  straining  at  stool  or 
in  parturition,  or  a  fall.  In  such  cases  the  kidney  may  have  been  mobile 
before  the  accident.  Again,  pain  is  not  proof  of  the  inauguration  of  mova- 
bility.  It  is  probable,  however,  that  traumatism  may  loosen  the  kidney 
and  that  mobility  may  subsequently  develop.  Gutterbock  says  that  a  kidney 
in  normal  relations  cannot  be  rendered  mobile  by  a  simple  fall  or  a  trivial 
force.     Loosening  can  only  be  induced  by  rupturing  surrounding  tissues; 


Movable   Kidney  935 

and  if  this  happens  symptoms  of  a  distinct  nature  will  indicate  the  seat  of 
injury.  Harris  makes  out  a  strong  case  for  the  view  that  the  condition  is 
due  to  the  relation  existing  between. the  location  of  the  kidney  and  the  body 
form.  He  divides  the  body  into  three  zones.  The  upper  zone  contains  the 
lungs  and  heart.  The  middle  contains  the  liver,  stomach,  spleen,  pancreas, 
and  the  greater  part  of  each  kidney.  The  lower  contains  the  intestinal  canal 
and  the  lesser  part  of  each  kidney.  When  there  is  a  naturally  small  or  a 
diminished  capacity  of  the  middle  zone  the  kidney  is  displaced  downward. 
The  right  kidney  is  pressed  upon  by  the  heavy  liver,  which  drives  it  down; 
the  left  kidney  is  pressed  upon  by  the  comparatively  small  spleen.  Hence, 
movable  kidney  is  more  common  on  the  right  side  than  on  the  left.  The 
upper  pole  of  the  kidney  is  first  pushed  forward  and  then  the  entire  organ 
descends  (^SI.  L.  Harris,  in  ''Jour.  Amer.  Med.  Assoc,"  June  i,  1901). 
Harris  maintains  that  the  amount  of  mobility  depends  upon  the  degree  of 
contraction  of  the  middle  zone  and  upon  internal  traumata  (lifting,  strain- 
ing, coughing,  etc.). 

Symptoms  of  Both  Forms. — There  may  be  no  discomfort  whatever,  or 
the  patient  may  be  a  confirmed  invalid.  The  usual  symptoms  are  epigastric 
pain  (just  to  the  left  of  the  middle  hne),  which  disappears  when  the  kidney 
is  replaced,  dragging  pain  in  the  loin,  and  paroxysms  like  nephritic  colic. 
Sudden  attacks  of  violent  pain  in  the.  kidney  or  stomach  may  occur,  attacks 
which  are  accompanied  by  nausea,  vomiting,  great  weakness  or  collapse, 
vertigo,  chills,  and  subsequently  elevated  temperature  (Dietl's  crises). 
Dietl's  crises  are  due  to  kinking  or  twisting  of  the  ureter  or  renal  vessels 
or  to  inflammation  of  the  kidney.  They  may  be  caused  by  physical  ex- 
ertion or  indiscretion  in  diet  and  may  be  followed  by  hydronephrosis  or 
strangulation  of  the  renal  vessels.  Usually,  in  a  case  of  movable  kidney  there 
is  a  sense  of  a  moving  body  in  the  abdomen,  and  the  patient  has  aggra- 
vated indigestion,  often  accompanied  by  vomiting.  Constipation  is  the  rule, 
and  violent  attacks  of  cardiac  palpitation  are  common.  ^Most  subjects  of 
this  kidne}"-mobility  are  extremely  nervous,  many  of  them  hvsterical  or  hypo- 
chondriacal. Temporary  jaundice  is  not  uncommon.  There  is  frequentlv irri- 
tability of  the  bladder,  ^'ertigo  and  insomnia  are  present  in  many  cases.  The 
patient  cannot  sleep  when  lying  on  the  sound  side  (Goelet).  In  women  the 
sexual  organs  are  almost  invariably  deranged,  and  menstruation  aggravates 
the  pain  and  discomfort.  All  the  symptoms  are  intensified  by  exertion  and  are 
modified  by  rest.  The  urine  is  normal,  except  after  violent  exercise,  when  it 
may  contain  blood.  The  proof  of  the  existence  of  movable  kidney  is  the  find- 
ing of  a  tumor  (movable  on  respiration,  change  of  position,  and  palpation) 
shaped  like  that  organ,  pressure  upon  which  occasions  no  sensation  or  causes 
pain  or  a  sickening  feeling.  A  "lumbar  recess"  (Morris)  may  be  found,  and 
percussion  over  the  loin  gives  resonance.  In  some  cases  a  movable  kidney 
can  be  readily  detected  when  the  patient  stands  up,  but  is  difficult  to  find 
when  he  is  recumbent.  Franks's  method  of  examination  is  very  satisfactory. 
The  patient  is  placed  recumbent.  If  dealing  with  a  right  kidney,  the  surgeon 
stands  to  the  right  side  and  pushes  four  fingers  of  his  left  hand  in  the  loin 
below  the  twelfth  rib,  and  rests  the  thumb  lightly  in  front  just  below  the 
ribs.  The  patient  takes  a  full  breath  and  holds  it  a  moment,  and  just  before 
he  empties  his  lungs  the  surgeon  presses  his  thumb  up  deeply  below  the 
ribs.     During  e.xpiration  the  thumb  follows  the  liver,  and  the  fingers  pres^ 


936 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


toward  the  front.  If  with  the  right  hand  the  kidney  can  be  feU  entirely 
below  the  left  hand,  the  case  is  one  of  movable  kidney.  If  such  a  condition 
is  detected,  press  hard  with  the  right  hand,  and  gradually  loosen  the  grasp 
of  the  left  hand,  and  the  kidney  will  slip  between  the  fingers  and  ascend. 
A  normally  mobile  kidney  descends  so  that  its  lower  end  can  be  felt,  but 
it  moves  back  during  expiration.*     Goelet  uses  Kendal  Franks's  method  of 

examination,  but  has  the  patient  stand, 
with  the  weight  resting  on  the  leg  of 
the  sound  side  and  with  the  leg  of  the 
sound  side  slightly  flexed  and  resting 
on  the  toes.  The  body  leans  a  little 
forward.  A  movable  kidney  must  not 
be  mistaken  for  a  distended  gall-blad- 
der, a  tumor  of  the  mesentery,  stomach, 
or  omentum,  a  phantom  tumor,  an  ova- 
rian tumor,  or  a  cancer  of  the  pancreas. 
A  distended  gall-bladder  can  be  pushed 
upward,  but  not  backward,  and  not 
downward  unless  the  liver  is  movable; 
it  is  extremely  tender,  and  cannot  be 
pushed  out  of  reach.  A  kidney  can  be 
pushed  upward  and  backward — in  fact, 
in  all  directions.  An  enlarged  gall- 
bladder can  always  be  palpated.  A 
movable  kidney  which  is  not  enlarged 
can  be  felt  at  times  and  not  at  others 
(Henry  Morris).  A  movable  kidney  may 
pass  between  the  examiner's  fingers,  and 
if  pushed  into  the  loin  it  tends  to  remain; 
but  if  a  distended  gall-bladder  is  pushed  into  the  loin,  it  springs  out  as  soon 
as  pressure  is  relaxed  (Henry  Morris).  It  is  important  to  remember  that 
in  about  one-half  of  the  cases  of  movable  right  kidney  the  left  kidney  is 
also  movable,  but  to  a  less  degree.  Appendicitis  is  more  frequent  in  individuals 
with  movable  kidney  than  in  those  who  do  not  suffer  from  it.  Sometimes 
a  movable  kidney  endangers  life,  rupture  of  the  kidney,  twisting  or  rupture 
of  the  ureter,  or  strangulation  of  the  renal  vessels  occurring,  the  ultimate 
cause  of  death  being  albuminuria,  uremia,  or  hydronephrosis. 

Treatment. — Mobile  kidney  is  treated  as  follows:  (i)  The  rest-treatment 
o]  S.  Weir  Mitchell  may  be  tried ;  it  often  markedly  mitigates  the  symptoms, 
but  does  not  seem  to  cure.  (2)  Mechanical  support  should  always  be  tried. 
The  most  satisfactory  mode  of  applying  it  is  by  the  corset  recommended 
by  Gallant  ("Amer.  Jour.  Obstet.,"  July,  1901).  This  corset  is  long  and 
straight  in  front,  and  when  applied  fits  firmly  over  the  hips  and  lower  abdo- 
men, less  firmly  at  the  waist,  and  least  firmly  above. 

Gallant  directs  that  the  patient  lie  down,  the  head  being  on  a  pillow 
and  the  knees  drawn  up.  While  in  this  attitude  the  corset  is  put  on  and 
it  is  laced  from  below  up.  If  the  attempt  to  apply  the  corset  develops  ten- 
derness, keep  the  patient  at  rest  in  bed  until  it  can  be  applied  without  pain. 

*Brit.  Med.  Jour.,  Oct.   12,   1895. 


Fig.  549. — A.  H.  Goelet's  method  of  palpation 
for  the  detection  of  a  prolapsed  kidney. 


Injuries  of  the  Kidney 


937 


(3)  Nephrorrhaphy  or  nephropexy  is  the  operation  employed  in  man\-  in- 
stances (page  949)-  It  is  the  author's  experience  that  if  the  patient  has 
had  marked  nervous  symptoms  for  a  long  time,  nephrorrhaphy  will  rarely 
cause  them  to  permanently  pass  away,  even  though  the  kidney  remains 
firmly  anchored.  (4)  Nephrectomy  is  necessary  only  in  very  rare  cases;  it 
may  be  done  for  dislocated  kidney,  when  kidney  disease  exists,  or  when 
nephrorrhaphy  has  failed  in  a  case  of  great  severitv. 

Injuries  of  the  Kidney.— Laceration  or  rupture  is  caused  by  falls 
and  by  blows  upon  the  back  or  the  belly. 

Symptoms. — In  some  cases  the  parenchymatous  structure  is  torn,  but 
the  capsule  is  not  torn,  and  in  consequence  urine  and  blood  are  not  extrava- 
sated  into  the  perineal  connective  tissue  or  into  the  peritoneal  cavitv.  In 
other  cases  the  parenchyma  and  capsule  are  both  torn  and  urine  and  blood 
are  extravasated.  The  laceration  may  be  trivial,  may  be  considerable,  or 
may  tear  the  kidney  apart.  The  symptoms  depend  on  the  gravity  of  the 
injury.  X  slight  tear  without  involvement  of  the  capsule  may  produce  prac- 
tically no  symptoms  at  all.  A  more  severe  injury  prodljces  shock,  and,  if 
profuse  bleeding  occurs,  the 
general  symptoms  of  hemor- 
rhage. In  intraperitoneal  rup- 
ture there  is  profuse  and  usu- 
ally fatal  hemorrhage.  In 
laceration  of  the  kidney  there  is 
severe  pain  in  the  loin,  which 
shoots  into  the  testicle,  and 
lumbar  tenderness.  If  there  is 
considerable  perirenal  bleeding 
the  loin  will  be  full,  and  dull  on 
percussion,  and  if  the  hemor- 
rhage is  large  a  palpable  mass 
will  form  after  a  time  and  after 
some  days  the  skin  will  become  discolored.  There  is  frequent  and  painful 
micturition  and  sometimes  suppression  of  urine.  Hematuria  occurs  in  renal 
laceration  unless  the  rupture  was  intraperitoneal  or  the  ureter  was  torn,  in 
which  case  there  are  evidences  of  profuse  internal  hemorrhage,  abdominal 
rigidity,  etc.)  (Daniel  N.  Eisendrath,  "Jour.  Amer.  Med.  Assoc,"  Oct.  25, 
1902).  It  is  important  to  remember  that  hematuria  can  arise  from  simple 
renal  contusion,  and  that  kidney  damage  does  not  of  necessity  cause  bloody 
urine.  If  there  is  hematuria,  the  use  of  the  cystoscope  or  catheterization  of 
the  ureters,  or  the  employment  of  Harris's  segregator  will  demonstrate  from 
which  kidney  the  blood  comes.  A  kidney-laceration  may  be  followed  by 
secondary  hemorrhage,  perirenal  suppuration,  hydronephrosis,  or  pyoneph- 
rosis, and  may  cause  kidney  displacement. 

Treatment. — In  an  intraperitoneal  rupture  laparotomy  should  be  per- 
formed because  of  abdominal  hemorrhage.  As  a  rule  nephrectomy  is  neces- 
sary, but  it  may  be  possible  to  arrest  hemorrhage  by  packing.  If  the  shock 
is  pronounced  and  if  there  is  increasing  fulness  in  the  loin,  whether  hema- 
turia exists  or  not,  or  if  blood  comes  profusely  from  the  ureter,  whether  or 
not  there  is  much  shock  or  lumbar  fulness,   make  an  exploratory  lumbar 


Fig.  550. — "  Purse-string  suture  "  applied  to  a   perfora- 
tion (after  Schachner). 


938  Diseases  and  Injuries  of  the  Genito-urinar)-  Organs 

incision  and  stop  tlie  bleeding  by  packing,  or  by  a  purse-string  suture  (Figs. 
^5°'  55 1)'  o'"'  ^*  necessary,  perform  partial,  or  even  complete,  nephrectomy. 
Ordinarily,  \yhen  there  is  not  great  shock,  increasing  lumbar  swelling  or 
severe  hematuria,  treat  by  rest  in  bed  and  by  feeding  with  hquid  food  or  by 
nutritive  enemata  to  prevent  vomiting.  Opium,  tannic  acid,  or  gallic  acid 
may  be  used.  Apply  ice-bags  to  the  loin  and  the  side  of  the  abdomen,  and 
after  bleeding  ceases  strap  the  loin  and  apply  a  binder.  If  large  blood-clots 
in  the  bladder  cause  pain  or  retention  of  urine,  introduce  a  catheter  and 
inject  the  bladder  with  boric  acid,  or  use  the  tube  and  evacuator  of  a  Bige- 
low  apparatus.  If  this  procedure  fails,  open  the  bladder  by  a  suprapubic 
incision  and  drain. 

Results  oj  Operation. — Up  to  1894  there  had  never  been  a  case  of  intra- 
peritoneal rupture  operated  upon;  since  then  6  have  been  operated  upon 
and  all  recovered  (Daniel  N.  Eisendrath,  "Jour.  Amer.  Med.  Assoc,"  Oct. 
25,  1902).  Kuster  collected  47  cases  of  nephrectomy,  and  83  per  cent, 
recovered.  Keen  estimates  the  mortahty  of  primary  nephrectomy  for  rupture 
at  20  per  cent,  and  of  secondary  nephrectomy  at  38.5  per  cent.     Without 


Fig.  551.— Showing  the  appHcation  of  a  double  "  purse-string  "  suture  for  the  arrest  of  hemorrhage  in 
large  wound  (after  Schachiier). 

operation  intraperitoneal  rupture  is  inevitably  fatal.  Six  recorded  cases 
operated  upon  recovered.  Of  extraperitoneal  ruptures,  70  per  cent,  re- 
cover without  operation  (Eisendrath).  Francis  S.  Watson  ("Boston  Med. 
and  Surg.  Jour., "  July  16,  1903)  has  collected  660  cases  of  subparietal  injury  of 
the  kidney.  The  following  statistics  are  of  interest:  Treated  expectantly:  273 
cases  with  81  deaths,  a  mortality  of  29.6  per  cent.  Treated  by  operations 
other  than  nephrectomy:  99  cases  with  7  deaths,  a  mortality  of  7.7  per  cent. 
Treated  by  nephrectomy:  115  cases  with  25  deaths,  a  mortality  of  21.7  per 
cent. 

Perforating  wounds  of  the  kidney,  if  purely  posterior,  do  not  involve 
the  peritoneum;  if  anterior,  they  do.  The  symptoms  are  escape  of  blood 
and  urine  by  the  wound;  hematuria  is  usual,  but  not  invariable;  pain  as  in 
rupture;  the  patient  may  be  unable  to  micturate;  and  nausea,  vomiting,  and 
constitutional  signs  of  hemorrhage  exist.  Traumatic  peritonitis,  perine|)hric 
abscess,  or  general  sepsis  may  ensue.  Confirm  the  diagnosis  by  exploration 
with  the  finger.  Extraperitoneal  injuries  give  a  good,  and  intraperitoneal 
a  bad,  prognosis. 


Renal   Calculus  ■  939 

Treatment. — If  the  wound  in  perforated  kidney  is  extraperitoneal,  enlarge 
it  to  permit  of  drainage,  and  arrest  hemorrhage  by  packing  and  hot  water, 
or  by  a  purse-string  suture  (Figs.  550,  551).  Asepticize  the  wound,  insert 
a  drainage-tube  down  to  the  kidney,  dress  often  with  bichlorid  gauze,  keep 
the  patient  in  bed  on  a  low  diet,  and  give  gallic  acid  and  opium.  In  some 
cases  nephrectomy,  partial  or  complete,  will  be  required.  In  intraperitoneal 
wounds  perform  an  abdominal  section  and,  as  a  rule,  remove  the  damaged 
organ  (see  Nephrectomy). 

Wounds  of  the  Ureters. — Rupture  from  external  violence  is  an  ex- 
tremely rare  accident.  There  are  3  undoubted  cases  on  record  (Daniel  N. 
Eisendrath,  "Jour.  Amer.  Med.  Assoc,"  Oct.  25,  1902).  A  rupture  or 
wound  from  accidental  violence  is  almost  invariably  associated  with  other 
serious  injuries.  The  ureter  may  be  wounded  by  the  surgeon  accidentally 
during  the  performance  of  an  abdominal  operation,  or  it  may  be  wounded 
intentionally,  as  in  Morris's  cases,  in  which  a  malignant  growth  was  incor- 
porated with  the  ureter.  There  is  particular  danger  of  injuring  the  ureter 
in  operations  upon  intraligamentary  growths,  because  the  ureter  is  displaced 
and  often  resembles  an  adhesion.  The  rule  of  surgery  is,  that  when  working 
about  the  ureter  the  surgeon  neither  clamps  nor  cuts  any  structure  without 
a  careful  preliminary  examination.  Rupture  causes  severe  shock  and 
extravasation  of  urine  around  the  kidney  or  into  the  peritoneal  cavity.  In 
extraperitoneal  rupture  a  palpable  mass  forms  in  the  loin.  When  the  ureter 
is  divided  in  an  operation,  a  flow  of  urine  is  seen. 

Treatment. — The  upper  three-fourths  of  the  ureter  can  be  reached  by 
an  extraperitoneal  incision,  which  is  a  prolongation  of  the  incision  for  lumbar 
nephrectomy,  running  from  the  twelfth  rib  downward,  and  forward  to  one 
inch  anterior  to  the  anterior  superior  spine  of  the  ilium,  and  then  parallel 
to  Poupart's  ligament  until  a  point  is  reached  abo\e  its  middle  (Fenger). 
Israel's  incision  begins  at  the  anterior  edge  of  the  erector  spinas  mass  one 
finger's  length  below  the  twelfth  rib,  is  taken  forward  parallel  with  the  rib 
until  it  reaches  the  line  of  the  rib's  tip,  and  is  then  carried  toward  the  middle 
of  Poupart's  ligament  until  the  line  for  ligation  of  the  common  iliac  artery 
is  reached,  and  is  then  taken  toward  the  middle  line  as  far  as  the  outer  border 
of  the  rectus  muscle.  The  lower  one-fourth  of  the  ureter  can  be  reached 
by  abdominal  section  or  by  sacral  resection  (Cabot).  If  it  .seems  probable 
that  the  ureter  is  wounded  or  ruptured,  explore,  and  if  this  is  found  to  be 
the  case  endeavor  to  restore  the  continuity  of  the  tube  (Fenger).  A  longi- 
tudinal cut  can  be  sutured  with  line  silk.  If  the  ureter  is  cut  across  near 
the  bladder,  implant  the  proximal  end  into  the  bladder  and  ligate  the  distal 
end  (Van  Hook,  Penrose,  Kelly).  If  it  is  cut  above  the  bladder  portion, 
perform  lateral  implantation  by  \'an  Hook's  method  (page  950). 

\  longitudinal  wound  of  the  ureter  inflicted  during  an  abdominal  opera- 
tion should  be  sutured,  but  if  the  duct  cannot  be  readily  reached,  simply 
make  a  posterior  incision  and  drain,  as  the  longitudinal  wound  will  heal 
by  granulation  if  no  sutures  are  inserted  (\'an  Hook).  In  a  case  of  transverse 
division  perform  uretero-ureterostomy  or  vesical  implantation;  or,  if  neither 
of  these  methods  is  feasible,  make  a  urinary  tistula,  or  perform  nephrectomy. 

Renal  Calculus. — A  stone  in  the  kidney  is  formed  by  the  jirecipitation 
of  urinary  salts  into  the  renal  epithelial  cells  and  the  gluing  together  of  these 


940  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

salts  and  cells  by  material  from  mucus  or  blood-clot,  this  mass  serving  as  a 
nucleus  on  which  accretion  takes  place.  Most  calculi  escape  when  small 
as  gravel.  The  cause  is  a  highly  acid  urine,  which  induces  catarrh  of  the 
renal  tubes.  Such  high  concentration  of  urine  is  favored  by  a  sedentary 
life,  by  the  ingestion  of  much  alcohol  or  nitrogenous  food,  by  constipation, 
by  an  inactive  skin,  and  by  a  torpid  liver.  The  children  of  poverty  are  liable 
to  calculi  because  of  the  use  of  unsuitable  foods  and  the  formation  of  great 
amounts  of  nitrogenous  waste.  Males  more  often  suffer  than  do  females; 
certain  locations  favor  the  development  of  the  malady,  and  a  family  tendency 
sometimes  exists. 

Symptoms. — The  symptoms  of  stone  in  the  kidney  may  not  appear  for 
years,  but  generally  they  are  manifested  early.  The  patient  usually  com- 
plains of  pain  in  the  loin,  and  sometimes  of  pain  in  the  iliac  region.  Deep 
percussion  over  the  kidney  causes  pain  in  the  loin,  even  when  pressure  is 
painless  (Jordan  Lloyd's  symptom).  Pain  is  aggravated  by  exercise.  The 
urine  is  often  somewhat  albuminous,  and  may  from  time  to  time  contain 
blood.  Frequency  of  micturition  is  noted  during  the  day,  but  not  at  night. 
The  urine  may  be  purulent.  Nephritic  colic  is  due  to  the  washing  of  a 
calculus  into  the  orifice  of  the  ureter,  which  it  blocks,  tears,  or  distends. 
The  pain  is  either  sudden  or  gradual  in  onset,  is  fearful  in  intensity,  and 
runs  from  the  lumbar  region  down  the  corresponding  thigh  and  spermatic 
cord  (the  testicle  being  retracted)  and  into  the  abdomen  and  back. 
There  are  nausea,  vomiting,  collapse,  sometimes  unconsciousness  or  con- 
vulsions. Frequent  attempts  at  making  water  are  productive  of  pain,  but 
of  little  urine.  The  urine  is  usually,  but  not  always,  smoky  from  blood. 
After  a  time  the  pain  vanishes,  the  stone  having  passed  into  the  bladder  or 
having  fallen  back  into  the  pelvis  of  the  kidney.  A  calculus  retained  in 
the  kidney  eventually  excites  pyelitis,  pus  appears  in  the  urine,  and  sore- 
ness or  pain  in  the  loin  exists.  Kelly  says:  Even  if  pus  is  found  we  are  not 
always  sure  from  which  kidney  it  came.  Pain  or  swelling  may  point  to  one 
side,  but  we  are  not  sure  that  the  other  organ  is  not  also  affected.  If  able 
to  pass  the  renal  catheter  into  one  ureter,  attach  a  syringe,  and  by  making 
suction  draw  out  any  pus  which  may  be  present.  In  renal  calculi  cases 
this  fluid  is  apt  to  contain  fragments  of  uric  acid.  By  using  a  renal  bougie 
coated  with  dental  wax  it  may  be  possible  to  make  scratches  on  the  instru- 
ment when  it  comes  in  contact  with  a  concretion.*  Slight  attacks  of  colic 
occur  from  the  passage  of  small  stones  or  of  plugs  of  mucus.  When  a  stone 
is  impacted  in  the  pelvis  the  point  of  greatest  tenderness  on  pressure  is  below 
the  last  rib,  by  the  edge  of  the  erector  spinas  muscle.  In  many  cases  a  stone 
in  the  kidney  or  ureter  can  be  skiagraphed.  Nephrolithiasis  may  cause 
death  by  exhaustion,  by  sepsis,  by  ru]jture  of  a  hydronephrosis,  or  by  amyloid 
degeneration. 

Treatment. — For  the  gravel  of  the  uric-acid  diathesis  use  alkalies,  espe- 
cially the  liquor  potassii  citratis,  and  reduce  the  amount  of  nitrogen  in  the 
diet  to  a  minimum,  at  the  same  time  washing  out  the  organs  by  copious 
draughts  of  Poland  water  or  Londonderry  lithia.  Piperazin,  in  doses  of  gr.  v 
to  gr.  viij  three  times  a  day,  is  highly  commended.  Exercise  is  to  be  insisted 
on.     When  gravel  is  phos[)hatic,  order  strychnin,  the    mineral    acids,   and 

*  Howard  Kelly,  in  Med:  News,  Nov.  30,  1895. 


Calculus  in  the  Ureter  941 

rest  at  the  seaside.  When  oxalate  of  lime  is  found,  restrict  the  diet,  use  the 
mineral  acids,  recommend  travel  or  rest  amid  new  surroundings,  and  give 
an  occasional  course  of  sodii  phosphas,  ,^ss  three  times  a  day,  drunk  in 
Buffalo  lithia  water.  Nephritic  colic  is  relieved  by  hypodermatic  injection 
of  morphin  and  atropin,  the  hot  bath,  diluent  drinks,  or  the  inhalation  of 
ether.  After  the  attack  wash  out  the  bladder  with  an  evacuator.  If  a  stone 
impacts  in  the  ureter,  perform  the  operation  of  ureterolithotomy.  The 
diagnosis  of  this  impaction  is  in  many  cases  aided  by  the  .v-rays,  but  is  some- 
times possible  only  after  exploratory  laparotomy.  If  the  symptoms  point  to 
stone  in  the  kidney,  medical  treatment  having  been  used  without  avail, 
always  take  a  skiagraph.  If  this  shows  a  stone,  and  if  there  are  no  evidences 
of  organic  disease  of  the  other  kidney,  operate.  If  in  doubt  in  spite  of  the 
skiagraph,  make  an  exploratory  lumbar  incision;  feel  the  surface  of  the 
kidney  with  the  finger,  .sound  the  inside  of  the  organ  with  a  needle,  and  if 
a  stone  is  detected,  incise  the  kidney  and  remove  the  stone.  Keen  is  of  the 
opinion  that  operation  .should  not  be  performed  if  the  urea  is  below  i  per 
cent.  If,  after  nephrohthotomy,  suppression  of  urine  occurs,  cut  into  the 
other  kidney,  as  in  half  of  all  cases  a  stone  will  be  found  lodged  there. 

Calculus  in  the  Ureter. — A  ureteral  calculus  comes  from  the  kidney, 
sometimes  dropping,  but  more  often  being  forced,  into  the  tube.  A  stone 
may  be  arrested  just  below'  the  renal  pelvis,  at  the  pelvic  brim,  or  near  the 
opening  into  the  bladder. 

Symptoms. — Attacks  of  violent  pain  of  the  nature  of  renal  colic,  and 
not  unusually  a  rigor  with  the  attack  and  fever  after  it.  Such  an  attack 
may  be  followed  by  hematuria.  Tenderness  can  be  developed  at  the  point 
of  impaction,  the  point  of  greatest  tenderness  being  in  the  loin  below  the 
level  of  the  kidney  or  in  the  iliac  region  (Perkins).  If  a  stone  partly  obstructs 
the  ureter,  the  urine  is  pale,  of  low  specific  gravity,  and  free  from  albumin. 
Impaction  near  the  bladder  causes  symptoms  similar  to  stone  in  the  bladder 
(Jordan  Lloyd).  Impaction  near  the  kidney  is  accompanied  by  hematuria 
and  pyuria.  In  stone  in  the  ureter  pain  is  not  developed  by  pressure  in  the 
loin  at  the  level  of  the  kidney.  Complete  obstruction  of  the  ureter  causes 
hydronephrosis  or  pyonephrosis.  In  some  cases  a  stone  acts  as  a  ball-valve, 
plugs  the  ureter  for  a  time,  during  which  a  lumbar  mass  develops,  and  then 
allows  the  urine  to  flow.  A  copious  flow  of  urine  is  accompanied  by  dis- 
appearance of  the  lumbar  mass. 

In  a  woman,  a  stone  lodged  in  front  of  the  broad  ligament  may  be  felt 
bv  a  finger  in  the  vagina.  Back  of  this  region  and  up  to  the  pelvic  brim 
a  stone  may  be  felt  by  a  finger  in  the  rectum.  A  cystoscopic  e.xamination, 
in  unu.sual  cases,  may  show  a  portion  of  stone  projecting  from  a  ureter  (Kelly). 
If  a  ureteral  catheter  tipped  with  wax  is  introduced,  a  calculus  will  make 
distinct  scratches  upon  it  (Kelly).     The  a^-rays  are  very  valuable  in  diagnosis. 

Treatment. — During  a  painful  paroxysm  give  morphia  and  use  hot 
packs.  The  attack  may  pass  away  not  to  return,  because  the  calculus  passes. 
If  .such  an  attack  does  pass  away,  the  urine  should  be  examined  after  every 
act  of  micturition  to  see  if  the  stone  is  voided  from  the  bladder.  After  a 
day  or  two,  if  the  .stone  does  not  appear,  the  Bigelow  evacuatina;  apparatus 
must  be  used.  Otherwise,  the  retained  fragment  will  enlarge  and  give 
trouble  .subsequently.     If  the  stone  is  impacted,   operate.     The  extraperi- 


942  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

toneal  operation  is  to  be  chosen.  Even  when  the  stone  is  impacted  below 
the  peh'ic  brim,  it  is  better  to  do  the  extraperitoneal  operation,  stripping 
the  peritoneum  and  reaching  the  ureter  from  behind.    (See  Ureterohthotomy.) 

Abscess  of  the  kidney  is  caused  by  traumatism,  by  calculus,  by  stric- 
ture of  the  urethra,  by  disease  of  the  bladder,  by  the  union  of  mihary 
abscesses,  or  by  pyemia. 

The  symptoms  are  pus  in  the  urine  (this  is  usual,  but  not  invariable), 
hematuria  in  traumatic  cases,  and  pain  running  into  the  groin.  The  urine 
is  usually  alkahne.  Constitutional  symptoms  of  suppuration  exist,  the 
fever  being  far  higher  than  that  usually  met  vi^ith  in  renal  tuberculosis.  The 
bladder  should  be  examined  with  a  cystoscope  to  determine  that  the  turbid 
urine  flows  from  a  ureter  and  to  identify  the  diseased  side.  It  is  well,  if 
possible,  to  catheterize  the  ureters. 

The  treatment  in  the  early  stage  is  rest,  morphin,  purgation,  anodynes, 
an  ice-bag  to  the  loin,  followed  in  forty-eight  hours  by  hot  fomentations. 
When  the  diagnosis  is  clear  incise  the  loin,  open  and  stitch  the  kidney  to 
the  abdominal  wall,  or,  if  the  organ  be  badly  damaged,  remove  it. 

Pyelitis  and  pyelonephritis,  which  usually  affect  only  one  gland,  are 
caused  by  urethral  stricture,  by  stopping  of  the  ureter  by  blood-clot,  by 
vesical  paralysis,  by  stone  in  the  bladder  or  in  the  kidney,  and  by  enlargement 
of  the  prostate  gland. 

Symptoms. — A  patient  who  has,  or  who  has  had,  retention  of  urine  de- 
velops high  fever,  often  preceded  by  a  chill,  and  headache,  stupor,  and  dry 
tongue  are  noted.  Unhke  acute  Bright's  disease,  there  is  neither  edema 
nor  dry  skin,  convulsions  do  not  occur,  and  the  urine  is  plentiful  and  con- 
tains pus  and  but  rarely  blood.     The  prognosis  is  very  bad. 

The  treatment  is  to  remove  the  obstruction  if  possible.  If  the  urine  be 
acid,  give  liquor  potassii  citratis;  if  alkaline,  give  benzoic  acid.  Gallic  acid, 
eucalyptol,  and  small  doses  of  copaiba  or  cubebs  are  recommended.  Venice 
turpentine,  camphor,  and  opium  may  be  given  in  pill  form.  Quinin  is  used 
to  stimulate  the  patient.  The  bladder  is  to  be  washed  out  every  day  with 
boric-acid  solution  (gr.  iij  to  §j  of  water).  Cups,  dry  or  moist,  and  hot 
sand-bags  or  bran-bags  are  to  be  applied  to  the  loin.  Alcohol  may  be  spar- 
ingly administered.     Urotropin  is  a  useful  drug. 

Perinephritis  is  an  inflammation  of  the  perinephric  fatty  tissue  pro- 
duced by  cold,  febrile  disease,  slight  traumatism,  or  the  spread  of  inflamma- 
tion from  another  part. 

The  symptoms  of  this  condition  are  rigidity  of  the  spine,  the  inchnation 
being  toward  the  affected  side,  flexion  of  the  thigh,  pain  in  the  loin  and 
iliac  region,  and  often  pain  in  the  knee.  The  symptoms  resemble  those 
of  hip-joint  disease  in  the  second  stage.  Suppuration  may  or  may  not  take 
place. 

The  treatment  is  wet  cups  to  the  loin,  ice-bags  to  the  loin,  rest,  purga- 
tion by  salines,  morphin  for  pain,  and,  after  the  acute  stage,  potassium  iodid 
internally  and  ichthyol  locally. 

Perinephric  Abscesses.— An  abscess  in  the  perinephric  fat  is  known 
as  a  perinephric  or  perirenal  abscess.  Primary  abscess  is  caused  by  chills, 
acute  febrile  disturbances,  or  by  pus  flowing  from  some  other  part,  as  the 
Sfjine.     Slight  traumatisms  by  producing  hemorrhage  make  the  perinephric 


Hydronephrosis  943 

region  a  point  of  least  resistance,  and  lead  to  abscess.  The  causative  injury 
may  be  produced  by  digging,  stamping,  coughing,  falhng,  carrying  a  burden, 
lifting  a  weight,  riding  on  a  horse  or  in  a  jolting  wagon.  Consecutive  abscess 
is  secondary  to  kidney  inflammation,  suppuration,  calculus,  tuberculosis,  or 
cyst.  In  the  consecutive  form  the  symptoms  may  be  masked  by  the  malady 
to  which  perinephric  abscess  is  secondary.  As  a  rule,  in  perinephric  abscess 
there  are  found  the  constitutional  symptoms  of  suppuration.  The  local 
symptoms  are  a  deep  aching  and  paroxysmal  pain  in  the  loin  intensified  by 
lumbar  pressure.  There  may  Vje  pain  in  the  iliac  region  and  pain  in  the 
knee.  Edema  of  the  corresponding  foot  and  lameness  are  not  unusual.  The 
thigh  is  often  drawn  up.  The  spine  is  rigid  and  inclined  toward  the  diseased 
side.  Edema  of  the  skin  is  usual,  but  fluctuation  is  not.  The  exploratory 
incision  will  settle  a  doubtful  diagnosis. 

The  treatment  is  to  lay  open  the  abscess,  wash  it  out,  and  drain. 

Hydronephrosis  is  a  condition  of  the  kidney  in  which  an  impediment 
to  the  outflow  of  urine  is  caused  by  obstruction  in  the  ureter,  the  bladder, 
or  the  urethra,  the  calyces  of  the  kidney  becoming  over-distended  with  urine 
and  the  glandular  tissue  being  absorbed  by  pressure.  It  has  been  asserted 
by  Albaran  that  secretion  of  urine  ceases  in  a  kidney  whose  ureter  is  blocked, 
distention  being  due  purely  to  congestion.  Hydronephrosis  may  be  con- 
genital, due  usually  to  twisting  of  the  ureter,  or  to  valve-formation  obstructing 
the  ureter  at  its  point  of  junction  with  the  pelvis  of  the  kidney,  the  valve 
being  produced  because  the  ureter  passes  into  the  kidney  pelvis  at  an  un- 
natural angle.  Occasionally  imperforate  meatus  produces  hydronephrosis 
of  both  kidneys.  The  causes  of  the  acquired  form  are  the  pressure  of  pelvic 
growths  or  pregnancy,  inflammation  or  tumor  of  the  bladder,  stone  in  the 
bladder,  kidney,  or  ureter,  twisting  or  kinking  of  the  ureter  of  a  movable 
kidnev,  enlargement  of  the  prostate  gland,  and  stricture  of  the  urethra. 
Acquired  hydronephrosis  may  involve  both  kidneys,  all  of  one  kidney,  or 
only  a  part  of  a  single  gland. 

Symptoms. — Hydronephrosis  is  most  frequent  in  females.  When  a  lum- 
bar tumor  is  absent  there  may  be  no  symptoms,  or  there  may  be  pain  in  the 
back  and  abdomen,  frequent  micturition,  a  persistent  or  intermittent  diminu- 
tion in  urine,  or  even  occasional  anuria.  A  tumor  may  be  found  in  the  loin, 
which  growth  is  dull  on  percussion  and  may  come  and  go,  a  large  urinary  flow 
occasionally  occurring  when  it  disappears.  Hydronephrosis  may  last  a  long 
while  if  only  one  kidney  be  involved,  but  death  is  not  far  distant  if  both 
glands  suffer.  Death  occurs  from  uremia,  from  pre.ssure  on  adjacent  organs, 
or  from  rupture  into  the  peritoneal  cavity.  The  diagnosis  is  aided  by  the 
use  of  the  cystoscope  and  by  catheterizing  the  ureters. 

Treatment  by  aspiration  may  cure,  but  the  operation  may  have  to  be 
done  repeatedly.  Tapping  on  the  left  side  is  performed  just  below  the  last 
intercostal  space;  on  the  right  side  the , tap  is  made  midway  between  the 
last  rib  and  the  crest  of  the  ilium.  Some  few  cases  have  been  cured  by 
catheterizing  the  ureter  (Pawlik).  The  proj)er  operation  in  mo.^^t  cases  is 
nephrotomy,  stitching  the  edges  of  the  cut  kidney  to  the  surface.  After  the 
kidney  has  been  opened  explore  the  ureter  by  means  of  a  uterine  sound 
or  an  elastic  bougie.  A  healthy  ureter  will  permit  the  passage  of  an  instru- 
ment of  the  size  of  from  No.  9  to  No.  12  of  the  French  scale  (Fenger).      If 


944  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

the  opening  of  the  ureter  into  the  peh'is  cannot  be  found,  open  the  pelvis 
or  open  the  ureter.  A  valve  should  be  slit  longitudinally  (Fenger).  If  a 
permanent  suppurating  fistula  ensues  or  if  the  organ  is  found  extensively 
damaged,  nephrectomy  is  to  be  performed,  provided  the  other  kidney  is  in 
reasonably  good  condition. 

Pyonephrosis  or  surgical  kidney  is  a  condition  in  which  the  pelvis 
and  the  calyces  of  the  kidney  are  distended  with  pus  or  with  pus  and  urine. 
The  whole  kidney  may  be  destroyed.  This  condition  has  the  same  causes 
as  has  hydronephrosis,  for  it  is  in  reality  usually  an  infected  hydronephrosis. 
In  some  cases  the  inaugural  malady  is  pyelitis,  which  causes  blocking  of 
a  ureter.  Watson,  of  Boston,  has  reported  two  cases  associated  with  oblitera- 
tion of  the  ureter  by  a  mass  of  fibrous  tissue  (stricture  of  the  ureter). 

Symptoms. — At  first  the  symptoms  are  those  due  to  the  obstructing  cause, 
plus  pyelitis.  Pus  may  appear  in  the  urine  in  incomplete  obstruction,  or 
it  may  intermittently  come  and  go.  Constitutional  symptoms  of  suppuration 
are  soon  manifest.  A  tumor  may  appear  in  the  loin,  like  the  tumor  of  hydro- 
nephrosis. If  only  one  kidney  is  involved,  and  if  the  disease  is  due  to  block- 
ing of  a  ureter,  recovery  is  to  be  expected.  The  diagnosis  is  rendered  more 
certain  by  the  use  of  the  cystoscope  and  by  catheterizing  the  ureters. 

The  treatment  in  the  early  stages  comprises  removal,  if  possible,  of  the 
cause  of  obstruction  and  the  employment  of  measures  directed  to  the  cure 
of  the  pyelitis.  If  obstruction  is  not  complete,  palliative  measures  may  be 
employed  for  the  tumor.  If  fever  is  continued,  if  there  is  great  visceral 
derangement,  if  pain  is  severe  and  constant,  and  if  the  tumor  continually 
grows,  perform  a  nephrotomy,  stitching  the  organ  to  the  surface  if  possible, 
or  removing  it  if  it  is  hopelessly  disorganized  and  the  other  kidney  is  in  a 
good  or  a  fairly  good  condition. 

Chronic  Tuberculosis  of  the  Kidney. — This  condition  may  begin 

in  one  kidney,  no  other  area  of  infection  existing  in  the  body.  In  such 
cases  the  bacteria  were  deposited  from  the  blood.  Even  when  the  bacteria 
are  deposited  from  the  blood  there  is,  in  most  cases,  a  causal  focus  of  tubercu- 
losis somewhere  in  the  body.  The  other  kidney  is  usually  involved  subse- 
quently, the  process  in  the  first  kidney  affecting  the  bladder  and  secondarily 
the  other  kidney.  The  important  point  is  that  tuberculosis  of  the  kidney 
arising  in  this  manner  is  at  first  a  unilateral  disease. 

Tuberculosis  of  the  kidney  is  seldom  a  primary  disease  and  usually  arises 
secondarily  to  tuberculosis  of  the  prostate,  bladder,  or  epididymis.  In 
such  a  condition  the  kidney  disease  is  bilateral.  Renal  tuberculosis  is  par- 
ticularly common  in  the  third  and  fourth  decades  of  life,  and  is  more  fre- 
quent in  males  than  in  females. 

Symptoms. — Renal  tuberculosis  of  arterial  origin  may  exhibit  no  symp- 
toms until  the  disea.se  is  far  advanced.  Renal  tuberculosis  secondary  to 
disease  of  the  bladder  or  prostate  always  presents  symptoms.*  A  very  com- 
mon .symptom  of  renal  tuberculosis  is  the  sudden  onset  of  polyuria  and  fre- 
quent micturition.  The  patient  is  annoyed  day  and  night,  and  in  some  cases 
micturition  is  di.stinctly  painful.  Paroxysms  of  renal  pain  are  not  unu.sual. 
The  urine  is  acid,  and  may  contain  pus  or  bloofl.  Tubercle  bacilU  may  be 
found  in  the  urine  or  in  the  sediment,  but  they  may  be  absent.     Re])eated 

*  F.  Tilden  Brown,  New  York  Med.  Jour.,  April  lo,  1897. 


Operations  on  the  Kidney  and  Ureter  945 

examinations  should  be  made  before  it  can  be  stated  certainly  that  bacilli  are 
absent.  The  presence  of  bacilli  proves  the  diagnosis,  but  their  ab.sence  does 
not  negative  it  (Willy  Meyer).  If  bacilli  are  not  found,  inject  some  of  the 
urinary  sediment  into  a  guinea-pig,  and  note  if  tuberculosis  arises  in  the 
animal.  Czerny  has  shown  that  in  cases  of  tuberculous  kidney  in  which 
bacilli  are  not  found  in  the  urine,  the  administration  of  tuberculin 
will  cause  great  numbers  to  appear.  This  agent  will  also  cau.se  a  marked 
febrile  reaction  if  tuberculosis  exists.  The  urine  may  or  may  not  be 
albuminous. 

In  many  cases  the  kidney  is  obviously  enlarged,  and  the  renal  area  is  fre- 
quently tender  and  occasionally  painful.  The  patient  loses  flesh,  and  there  is 
nocturnal  fever  followed  by  sweating.  The  use  of  the  cystoscope  furnishes 
important  information.  It  shows  from  which  ureter  turbid  urine  is  coming. 
Catheterization  of  the  ureters  should  be  practised  by  some  one  who  is 
accustomed  to  employ  it.  Always  examine  carefully  to  determine  if  one  or 
both  kidneys  are  involved,  if  the  bladder  is  diseased,  and  if  the  prostate 
gland  or  seminal  vesicles  are  tuberculous. 

Treatment. — Nephrectomy  is  not  justifiable  in  the  very  beginning  of  a 
case,  because  such  a  patient  may  be  cured  by  a  combination  of  medical 
and  hygienic  treatment,  and  the  weakening  effect  of  the  operation  of  nephrec- 
tomy may  cause  the  other  kidney  to  rapidly  develop  tuberculosis.  Tell  such 
a  patient  to  lead  an  outdoor  life.  Brown  recommends  camp-hfe  in  the 
Adirondacks  during  the  summer,  and  sends  such  patients  South  during  the 
winter.  If  a  patient  cannot  go  to  another  climate,  urge  upon  him  the  necessity 
of  being  much  out  of  doors.  Insist  upon  the  taking  of  plenty  of  nutritious 
food.     Order  courses  of  creasote  or  guaiacol  carbonate. 

If  the  kidney  is  markedly  enlarged,  if  there  is  profuse  hematuria,  if  the 
fever  is  high  and  persistent,  if  only  one  kidney  is  involved,  and  if  the  bladder 
and  prostate  are  free  from  disease,  perform  nephrectomy.  In  cases  with  in- 
volvement of  the  other  kidney  or  of  the  genito-urinary  tract  lower  down, 
nephrectomy  is  not  justifiable,  although  nephrotomy  for  drainage  may 
greatly  benefit  the  patient  for  a  time. 

Operations  on  the  Kidney  and  Ureter.— Operation  for  Chronic 
Nephritis. — In  1897  Mr.  Reginald  Harrison  advocated  puncture  of  the 
kidney  to  reheve  tension  in  cases  of  albuminuria,  and  in  igoi  advocated 
incision  of  the  true  capsule  of  the  kidney  and  puncture  of  the  gland  to  accom- 
plish the  same  purpose  ("Brit.  Med.  Jour.,''  Oct.  19,  1901).  Alexander 
Hugh  Fergu-son,  in  March,  1899,  reported  two  cases  of  interstitial  nephritis 
cured  symptomatically  by  decapsulation  and  multiple  punctures  ("Jour. 
Amer.  Med.  Assoc,"  March  11,  1S99).  Dr.  Geo.  M.  Edebohls  observed 
between  1892  and  1897  that  in  certain  cases  of  movable  kidney  with  albu- 
minuria the  albumin  and  casts  disappeared  after  nephropexy.  Rose,  Wolft", 
and  Ferguson  have  observed  the  same  fact.  Harrison  believes  that  reni- 
puncture  removes  the  symptoms  by  abating  tension,  but  Edebohls  concludes 
that  nephropexy  relieves  the  condition  and  possibly  cures  it  by  e.stablishing 
vascular  adhesions  which  carry  an  additional  supply  of  blood.  He  proposed 
to  operate  for  Bright's  disease  in  1899  ("Med.  News, "  April  22,  1899). 
Edebohls  deliberately  operated  for  chronic  nephritis  and  claims  8  complete 
recoveries  from  chronic  Bright's  disease  ("Med.  Record,"  Dec.  21,  1901). 
60 


94^  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

There  can  be  no  doubt  whatever  that  operation  is  sometimes  followed  by 
polyuria,  disappearance  of  edema  and  other  symptoms,  and  apparent  cure. 
But  in  some  cases  the  disappearance  of  symptoms  has  been  too  rapid  to 
permit  of  the  assumption  that  new  vessels  have  caused  it.  In  such  cases 
it  seems  much  more  probable  that  relief  of  tension  is  the  real  curative  factor. 
Edebohls  says  that  the  polyuria  begins  about  the  tenth  day  after  operation; 
that  improvement  begins  in  one  month  and  is  gradual;  that  the  cure  is 
due  to  vascular  adhesions;  that  the  adhesions  contain  more  arteries  than 
veins;  that  the  free  blood-supply  absorbs  exudate  and  products  of  inflamma- 
tion, frees  the  tubes  and  glomeruli  from  pressure  and  constriction,  causes 
the  re-establishment  of  a  normal  circulation  and  the  regeneration  of  epithe- 
lium ("Med.  Record,"  Dec.  21,  1901). 

The  exact  status  of  the  operation  is  not  as  yet  determined.  It  does, 
however,  seem  to  be  proved  that  operation  is  in  some  cases  followed  by 
apparent  cure  or  great  amelioration  of  the  condition.  Whether  permanent 
cure  is  ever  thus  obtained  is  doubtful,  and  the  part  played  by  rest  in  bed 
and  drugs  in  effecting  an  improvement  must  not  be  lost  sight  of.  Cases 
with  pain  and  bloody  urine  are  often  much  improved  by  incising  the  capsule. 
Post-operative  suppression  and  the  anuria  of  acute  infectious  diseases  may 
be  favorably  influenced  by  the  operation.  An  important  fact  which  Rovsing 
maintains  and  Edebohls  proves  is  that  chronic  nephritis  may  be  for  some  time 
a  unilateral  disease.  (Read  the  views  of  Schmidt  in  "  Med.  Record, "  Sept. 
13,  1902;  of  Rovsing,  of  Copenhagen,  in  "  Mittheilungen  aus  den  Grenzge- 
bieten  der  Medizin  und  Chirurgie,"  vol.  x,  1902,  and  editorial  in  "Jour. 
Amer.  Med.  Assoc,"  Jan.  11,  1902.) 

The  operation  as  practised  by  Edebohls  may  be  done  on  both  kidneys 
at  one  sitting  or  in  two  seances.  In  some  cases  only  one  kidney  is 
subjected  to  operation.  Edebohls  takes  a  very  radical  view  and  would 
operate  on  any  case  free  from  incurable  complications — if  an  anesthetic 
can  be  given  and  if  the  life-expectancy  without  operation  is  not  less  than 
one  month  ("Med.  Record,"  Dec.  21,  1901).  Ether  is  given  or  nitrous 
oxid  and  oxygen.  Lay  the  patient  prone  with  an  air-cushion  under  the  belly 
and  expose  the  kidney  by  a  vertical  incision  at  the  edge  of  the  erector  spina? 
mass,  which  cut  does  not  open  the  sheath  of  the  muscle.  Remove  the  fatty 
capsule  from  the  true  capsule,  continuing  the  dissection  around  each  pole 
until  the  pelvis  of  the  kidney  is  reached.  The  kidney  is  extruded  from  the 
wound,  the  true  capsule  is  incised  along  the  convex  border  and  around 
each  pole,  is  separated  from  the  kidney,  and  is  cut  away  close  to  its  junction 
with  the  kidney  pelvis.  The  kidney  is  then  returned  to  its  bed  of  fat,  and 
the  wound  is  closed.  (See  "Med.  Record,"  Dec.  21,  1901.)  Edebohls  does 
not  drain  unless  there  is  considerable  edema.  Edebohls  reports  18  opera- 
tions without  a  death.  In  9  of  the  cases  the  operation  was  done  more  than 
one  year  ago,  and  8  of  them  are  said   to  be  cured. 

Nephrotomy. — Nephrotomy  means  incision  of  a  kidney,  but  the  term  is 
sometimes,  though  wrongly,  ap]jlied  to  the  exploratory  exposure  of  the  kidney 
without  incision.  The  operation  is  employed  to  evacuate  infectious  material, 
relieve  ten.sion,  permit  of  the  removal  of  a  calculus  or  exploration  of  the  ure- 
ter, and  for  diagnosis  of  renal  di.sease.  The  instruments  required  are  scalpels, 
a  blunt-pointed  bistoury,  dissecting-forceps,  toothed  forceps,  a  grooved  direc- 


Nephrolithotomy  947 

tor,  hemostatic  forceps,  spatulae,  metal  retractors,  a  fountain  syringe,  an  Allis 
dissector,  Hagedorn  needles,  and  an  Abbe  needle-holder.  If  looking  for  a 
stone,  have  a  large  harelip-pin  to  sound  with,  forceps  and  a  scoop  to  remove 
the  stone,  and  a  periosteum-elevator  to  scrape  away  adherent  calculi.  The 
patient  lies  upon  the  sound  side,  a  sand-pillow  being  placed  under  the  loin. 
The  incision  is  made  half  an  inch  below  the  last  rib  and  clo.se  to  the  outer 
border  of  the  erector  spinae  mass,  and  runs  obliquely  downward  and  forward 
toward  the  iliac  crest  for  three  inches,  the  incision  being  enlarged  later  if 
required.  Divide  the  skin,  the  superficial  fascia,  the  fat,  the  external  oblique, 
the  posterior  border  of  the  internal  oblique,  and  the  outer  edge  of  the  latis- 
simus  dorsi.  This  incision  exposes  the  lumbar  fascia.  Push  aside  the  last 
dorsal  nerve  and  incise  the  lumbar  fascia,  when  the  perirenal  fat  will  bulge 
into  the  wound.  Two  distinct  layers  of  fat  exist.  Tear  this  fat  through 
with  dissecting-forceps  or  with  an  Allis  dissector  to  expose  the  kidney,  which 
can  now  be  opened  while  it  is  forced  into  the  wound  by  the  hand  of  an  assistant 
making  abdominal  pressure. 

Kocher's  incision  for  nephrotomy  is  begun  in  the  angle  between  the 
sacrolumbalis  muscle  and  the  twelfth  rib,  and  is  carried  downward,  forward, 
and  outward  to  the  axillary  line  (Fig.  141).  This  incision  divides  the  skin, 
subcutaneous  tissues,  lumbar  fascia,  the  latissimus  dorsi,  and  the  serratus 
posticus  inferior  muscles. 

Edebohls's  method  enables  the  surgeon  to  most  thoroughly  explore  the 
kidney,  because  this  organ  is  brought  outside  of  the  body.  The  patient  lies 
prone,  with  a  large  cylindrical  inflated  rubber  pad  beneath  his  abdomen.  A 
vertical  incision  is  made  close  to  the  border  of  the  erector  spinae  muscle, 
from  just  below  the  last  rib  to  just  above  the  iliac  crest.  The  sheath  of  the 
muscle  is  not  opened.  The  fibers  of  the  latissimus  dorsi  are  separated  by 
blunt  dissection.  The  iliohypogastric  nerve  is  found  and  retracted.  The 
transversalis  fascia  is  incised  and  the  fatty  capsule  reached.  The  two  layers 
of  the  fatty  capsule  are  torn  through  and  the  kidney  exposed.  The  fatty 
capsule  is  well  separated  from  the  kidney  front  and  back.  The  patient  is 
pulled  by  the  legs  toward  the  foot  of  the  table,  the  pad  remaining  stationary. 
This  change  of  position  brings  the  pad  beneath  the  chest,  abdominal  respi- 
ration takes  place,  the  kidney  is  forced  out  of  the  wound,  and  can  be  thor- 
oughly examined. 

Nephrolithotomy. — In  this  operation  the  incision  is  the  same  as  in 
nephrotomy.  If  the  kidney  is  not  much  enlarged,  it  can  be  brought  out 
by  Edebohls's  method.  Feel  the  kidney  for  a  stone,  or,  if  this  procedure 
fails,  explore  with  a  needle  or  a  pin.  If  no  stone  is  found,  open  the  pelvis, 
let  an  assistant  grasp  the  pedicle  with  his  fingers  or  with  a  pair  of  forceps, 
each  blade  of  which  is  covered  with  a  bit  of  rubber  tube,  while  the  surgeon 
opens  into  the  kidney  and  explores  with  the  finger.  If  a  stone  is  detected 
by  a  pin  or  by  palpation,  open  the  kidney-tissue,  loosen  the  calculus  with 
the  nail,  and  remove  it  with  the  finger,  with  a  scoop,  or  with  forceps.  After 
removing  the  stone  suture  the  incision  with  catgut,  and  release  the  pressure 
on  the  pedicle.  Hemorrhage  will  rarely  occur.  If  in  spite  of  this  plan 
bleeding  occurs,  take  out  the  stitches  and  apply  pressure  and  hot  water, 
or  in  some  cases  plug  with  iodoform  gauze  for  twenty-four  hours.  When 
hemorrhage  ceases,  put   a  large  drainage-tube  down  to  the  kidney.     Close 


948  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

the  wound  in   the  muscles  and    integument  and  dress    antiseptically.     The 
dressings  must  be  changed  frequently  and  the  tube  should  be  shortened  daily. 

Nephrectomy. — Nephrectomy  is  the  removal  of  a  kidney.  There  are  two 
methods  of  nephrectomy,  the  lumbar  and  the  ahdominal.  Before  performing 
nephrectomy  ascertain  the  competence  of  the  kidneys.  If  at  least  i  per 
cent,  of  urea  is  not  being  excreted,  it  is  very  unsafe  to  operate.  Be  sure  the 
patient  possesses  two  kidneys.  Examination  of  the  bladder  by  cystoscope 
will  show  the  ureteral  orifices,  a  strong  indication  that  both  kidneys  are 
present.  Nevertheless,  when  we  reflect  that  a  horseshoe  kidney  has  two 
ureters  the  proof  is  not  absolute.  Catheterization  of  the  ureters  is  advisa- 
ble if  it  can  be  performed,  but  it  will  probably  require  a  specialist  to  perform 
it.  Proof  absolute  of  the  presence  of  two  kidneys  consists  in  feeling  both  of 
them.  If  in  doubt  as  to  the  question,  and  if  uncertain  as  to  the  competence 
of  the  organ  which  is  to  be  left,  feel  each  kidney  during  the  operation  and 
before  removing  either,  or  perform  a  preliminary  exploratory  laparotomy. 

Lumbar  Nephrectomy. — The  instruments  required  for  this  operation  are 
scalpels,  a  blunt-pointed  bistoury,  forceps  as  used  in  the  preceding  operation, 
a  clamp,  retractors,  spatulae,  blunt  hooks,  an  aneurysm-needle,  a  pedicle 
needle,  a  grooved  director,  stout  silk,  an  Allis  dissector,  sharp  spoons,  and 
a  Paquelin  cautery.  The  patient  is  placed  on  the  sound  side  and  a  pillow 
is  placed  under  the  loin.  Several  incisions  have  been  proposed.  In  many 
cases  the  oblique  incision  is  first  made  to  permit  of  exploration.  This  in- 
cision is  begun  half  an  inch  below  the  last  rib  and  by  the  edge  of  the  erector 
spinae  muscle,  and  is  carried  downward  and  forward  toward  the  iliac  crest. 
In  some  cases  a  kidney  can  be  removed  through  this  cut.  In  other  cases 
the  cut  must  be  enlarged.  It  can  be  enlarged  by  extending  the  cut  down- 
ward. Morris  enlarges  it  by  adding  to  it  a  vertical  incision,  which  begins 
one  inch  below  the  origin  of  the  oblique  cut.  Konig's  incision  for  nephrec- 
tomy consists  of  a  vertical  cut  by  the  edge  of  the  erector  spinae,  carried  almost 
to  the  iliac  crest,  from  which  point  it  is  curved  forward  toward  the  umbilicus, 
and  is  carried  to  or  even  through  the  rectus  muscle.  After  thorough  ex- 
posure lift  the  kidney,  and  separate  it  from  the  peritoneum;  if  possible, 
with  the  finger;  clamp  the  pedicle;  pass  an  armed  aneurysm-needle  between 
the  vessels  of  the  pedicle;  ligate  in  two  places;  cut  between  the  threads; 
and  arrest  hemorrhage  by  ligature  or  by  the  cautery.  If  the  ureter  be  healthy, 
ligate  it  with  silk  and  drop  it  back;  if  it  be  foul  and  purulent,  scrape  it  with  a 
sharp  spoon,  wash  it  with  corrosive  sublimate,  and  touch  it  with  pure  carbolic 
acid,  and  then  either  ligate  it  and  drop  it  back  or  sew  it  into  the  wound. 
If  hemorrhage  persists  from  the  wound,  plug  with  gauze.  Insert  a  drainage- 
tube  and  clo.se  the  wound.  If  the  peritoneum  be  accidentally  opened,  close 
it  with  Lembert  sutures.  Kocher's  method  is  excellent,  and  enables  the 
surgeon  to  feel  the  opposite  kidney  before  removing  the  one  which  is  known 
to  be  diseased.  The  incLsion  is  begun  as  described  on  page  947,  and  is 
carried  forward  so  as  to  expose  the  reflection  of  the  peritoneum  onto  the 
colon  in  the  posterior  axillary  line  (Fig.  141).*  At  this  point  the  peritoneum 
is  opened,  and  the  surgeon's  hand  is  inserted  into  the  abdominal  cavity  and 
feels  the  other  kidney.  If  another  kidney  exists  and  it  is  found  to  be 
healthy,  the  diseased  organ  may  be  removed. 

*  Kocher's  "Text-book  of  Operative  Surgery." 


Nephrorrhaphy  949 

Abdominal  nephrectomy  is  more  dangerous  than  the  lumbar  operation. 
The  same  instruments  are  required  as  are  used  in  the  preceding  operation. 
The  position  is  supine.  The  incision  is  that  of  Langenbeck — four  inches 
long  in  the  linea  semilunaris,  its  center  corresponding  to  the  umbilicus. 
Open  the  abdomen,  introduce  a  hand,  feel  the  Icidneys,  and  if  both  show 
serious  disease  do  not  perform  nephrectomy.  If  we  decide  to  remove  one 
kidney,  keep  the  small  intestine  away  by  sponges,  push  the  colon  toward 
the  umbilicus,  incise  the  outer  layer  of  the  mesocolon,  and  bare  the  kid- 
ney. Strip  off  the  peritoneum  from  the  kidney  and  its  vessels,  and  ligate 
the  vessels  by  passing  strong  silk  through  the  center  of  the  pedicle  with 
an  aneurysm-needle.  Ligate  the  ureter  if  healthy,  and  cut.  If  the  ureter 
is  septic,  fasten  it  to  an  opening  made  in  the  loin  by  cutting  onto  forceps 
pushed  to  the  outer  edge  of  the  quadratus  lumborum.  Stop  bleeding,  irri- 
gate the  belly-cavity,  and  dress  as  usual,  employing  drainage  only  when  septic 
matter  has  gotten  into  the  peritoneal  cavity  or  when    oozing  is  persistent. 

Nephrectomy  in  Children. — The  operation  is  proper  in  certain  non- 
malignant  troubles.  Jepson  did  a  successful  nephrectomy  for  a  congenital 
cystic  kidney  on  a  patient  four  months  and  fourteen  days  of  age.  Rovsing 
did  it  successfully  for  congenital  hydronephrosis,  the  patient  being  nine 
months  old.  Roswell  Park  did  a  successful  nephrectomy  for  congenital  cystic 
kidney  on  a  child  twenty-three  months  of  age.  The  value  of  nephrectomy 
for  sarcoma  is  more  than  doubtful.  The  operation  never  really  cures,  and 
if  an  operative  recovery  is  obtained,  the  disease  appears  after  a  time  in  the 
other  kidney.  Jessup  performed  nephrectomy  in  eleven  children  and  every 
case  died  within  two  and  one-half  years  of  the  operation.  The  operation 
often  prolongs  life  and  relieves  discomfort,  but  does  not  cure. 

Partial  Nephrectomy. — This  operation  may  be  performed  in  some  cases 
for  wounds,  cysts,  and  innocent  tumors.  After  removing  the  damaged  or 
diseased  part  bleeding  points  are  ligated  with  catgut.  The  wound-surfaces 
are  appro.ximated  as  well  as  possible  by  catgut  sutures.  Drainage  is  intro- 
duced. The  value  of  partial  nephrectomy  in  some  cases  seems  certain,  and 
we  should  apply  it  when  possible  instead  of  the  complete  operation,*  except 
in  cases  of  malignant  disease. 

Renipuncture. — This  is  an  operation  devised  by  Reginald  Harrison  for 
the  relief  of  albuminuria  due  to  elevated  tension.  The  kidney  is  e.xposed  in 
the  loin,  the  capsule  is  incised,  and  punctures  are  made  in  the  kidney.  Simple 
incision  of  the  capsule  will  usually  relieve  nephralgia.  (See  Operations  for 
Chronic  Nephritis.) 

Nephrorrhaphy  (or  nephropexy)  is  fixation  of  a  mobile  kidney.  The 
kidney  is  exposed  in  the  loin  as  detailed  in  the  section  cm  Nephrotomy. 
The  best  incision  is  vertical.  After  exposure  the  kidney  is  forced  out  of 
the  wound  by  Edebohls's  method.  The  fibrous  capsule  is  incised  longitu- 
dinally and  a  cuff  is  turned  down  on  each  side.  Sutures  traverse  the  kid- 
ney-substance and  two  layers  of  capsule  on  each  side.  The  upper  suture 
catches  the  periosteum  of  the  last  rib,  the  lower  sutures  catch  the  lumbar 
fascia.  Drainage  is  not  required.  The  suture-material  is  kangaroo-tendon 
or  chromicized   catgut.     Many  surgeons    simply   pass   sutures   through    the 

*  See  Oscar  Bloch  in  Brit.  Med.  Jour.,  Oct.  17,  1S96;  also  reports  of  Czerny,  Bardeii- 
heuer,  Tuffier,  and  Kiimmell. 


950  Diseases  and  Injuries  of  the  Genito-urinaiy  Organs 

uncut  capsule  and  kidney-substance,  and  fasten  the  kidney  to  the  lumbar 
fascia.  Other  surgeons  split  the  capsule,  pull  it  into  the  wound,  and  pass 
sutures  through  the  capsule  and  wound-edges.  After  nephrorrhaphy  keep 
the  patient  in  bed  for  three  weeks.  A  kidney  which  has  been  anchored  will 
not  unusually  loosen  at  some  future  time. 

The  Elder  Senn's  Operation. — Many  surgeons  feel  that  it  is  not  de- 
sirable to  pass  sutures  through  the  kidney-substance,  and  I  have  entirely 
abandoned  the  use  of  them  in  operations  for  movable  kidney.  Urinary 
fistula  has  followed  suturing.  Again,  the  value  of  such  sutures  is  very  doubt- 
ful. The  kidney  is  a  very  soft  organ,  and  if  it  is  suspended  by  sutures 
they  are  certain  to  cut  out.  Senn's  operation  fixes  the  kidnev  without  using 
sutures. 

The  kidney  is  held  in  place  by  an  assistant.  A  vertical  lumbar  incision 
is  made,  the  perirenal  fat  is  exposed  and  is  torn  through  until  the  kidney 
is  reached.  The  kidney  is  usually  brought  out  of  the  wound.  The  posterior 
fatty  capsule  is  cut  away,  and  also  the  anterior  fatty  capsule  up  to  the  hilum. 
The  true  capsule  of  the  kidney  is  scarified.  I  always  have  packing  prepared  by 
suturing  together  with  fine  catgut  the  ends  of  two  pieces  of  iodoform  gauze. 
Two  such  strands  are  prepared.  One  piece  of  iodoform  gauze  is  placed  under 
the  upper  end  of  the  kidney,  and  another  piece  under  the  lower  end,  the 
catgut  stitch  in  each  instance  being  directly  under  the  kidney.  The  kidney 
is  replaced  and  will  then  lie  in  a  shng,  composed  of  two  pieces  of  gauze, 
the  ends  of  which  protrude  from  the  wound.  Gauze  is  packed  into  the 
opening  over  and  about  the  kidney,  and  over  this  the  two  long  pieces  are 
tied.  A  large  gauze  pad  is  placed  upon  the  abdomen  over  the  anterior 
surface  of  the  kidney,  and  the  lumbar  wound  is  dressed  with  gauze.  The 
dressing  and  gauze  pad  are  held  in  place  by  a  binder.  In  about  ten  days 
the  gauze  is  well  soaked  with  salt  solution  and  the  packing  is  removed  and 
the  granulating  surface  is  lightly  packed  with  gauze.  At  this  time  the  catgut 
is  destroyed  and  the  gauze  can  be  easily  pulled  out.  If  a  continuous  piece 
of  gauze  was  used,  ether  must  be  given  before  removal  is  attempted.  By 
this  operation  the  kidney  is  surrounded  with  granulations,  which  are  con- 
verted into  scar-tissue,  and  the  organ  becomes  encased  in  a  box  of  fibrous 
tissue. 

Ureterolithotomy. — If  the  stone  is  impacted  in  the  upper  two-thirds  of 
the  tube,  make  the  incision  advised  for  wounds  of  the  ureter  (page  939)- 
The  operation  is  extraperitoneal.  The  tube  is  opened  by  a  longitudinal 
incision.  The  stone  is  removed.  The  ureter  is  explored  by  means  of  a 
sound.  It  is  not  necessary  to  suture  the  ureter.  The  tissues  above  the  ureter 
are  sutured  and  a  drainage-tube  is  carried  to  the  duct  (Fenger).  Whenever 
possible,  and  usually  it  is  pos.sible,  reach  the  ureter  by  the  extraperitoneal 
route,  and  even  well  below  the  brim  of  the  pelvis  the  peritoneum  can  be 
stripped  and  the  ureter  opened  from  behind.  In  a  woman  a  stone  near 
the  vesical  opening  can  he  reached  by  a  vaginal  incision.  If  the  stone  cannot 
be  reached  by  the  extraperitoneal  method,  open  the  peritoneal  cavity  and 
incise  the  ureter.  After  removing  the  stone  suture  the  wound  in  the  ureter 
with  silk  inversion-sutures,  fasten  an  omental  graft  over  the  suture-line  (Fen- 
ger), and  drain. 

Uretero-ureterostomy  (Van  Hook's  Operation). — In  this  operation  ligate 


Cystoscopy 


951 


the  lower  end  of  the  divided  ureter  with  silk  or  catgut.  About  one-fourth 
of  an  inch  below  the  Hgature  make  an  incision  in  the  long  axis  of  the  tube. 
This  incision  is  in  length  equal  to  twice  the  diameter  of  the  tube.  Each 
end  of  a  piece  of  fine  catgut  is  threaded  to  a  fine  needle.  This  thread  is 
passed  through  the  upper  end  of  the  ureter  (Fig.  552).  The  needles  are 
made  to  enter  the  lower  end  of  the  tube  through  the  door  made  by  the  sur- 
geon. They  are  pushed  through  the  wall  of  the  ureter  one-half  an  inch 
below  the  door  (Fig.  552).  Traction  upon  the  strings  causes  invagination 
and  the  ligature-ends  are  tied.  If  the  operation  is  intraperitoneal,  the  ureter 
is  wrapped  about  with  peritoneum. 

Intestinal  Implantation  of  the  Ureters. — This  operation  may  be  em- 
ployed in  exstrophy  of  the  bladder  and  in  vesical  cancer,  in  which  it  is  neces- 
sary to  remove  the  bladder.  After  this  operation  there  is  danger  of  infection 
of  the  ureters  and  consequent  ascending  ureteritis,  and  pyelonephritis,  and 
the  presence  of  urine  in  the  bowel  usually  causes  inflammation  of  the  rec- 
tum, and  incontinence  of  urine  may  take  place. 


Fig.  552. — Van  Hook's  method  of  ureteral  anastomosis. 


Maydl  asserts  that  a  piece  of  the  bas  fond  should  be  removed  with  the 
ureter,  and  implanted  with  it  into  the  intestine,  the  flange  hanging  free  in 
the  lumen  of  the  gut.  If  this  is  done,  the  relations  of  the  ureter  to  the  mus- 
cular coat  of  the  bladder  are  not  interfered  with,  stricture  is  less  Ukely  to 
occur,  ascending  infection  is  antagonized,  and  suppurative  conditions  arise 
at  the  margin  of  the  flange,  rather  than,  as  in  other  methods,  directly  in  the 
cut  ureter.  Maydl  has  collected  the  records  of  fourteen  cases  operated  upon 
by  this  method,  with  two  deaths.*  In  vesical  exstrophy  Peterson  transplants 
a  vesical  flap  containing  both  ureteral  orifices  into  the  descending  colon. 

Cystoscopy. — -Cystoscopy  is  the  employment  of  the  cystoscope  for  the 
study  of  the  interior  of  the  bladder,  the  prostate,  the  ureteral  orifices,  and 
the  appearance  of  the  fluid  coming  from  each  kidney.     In  order  to  use  the 

*  Editorial  in  Jour.  .A.iner.  Med.  Assoc,  May  6,  1899. 


952  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

cvstoscope  satisfactorily  the  urethra  must  admit  instrument  No.  24  of  the 
French  scale.  The  bladder  must  hold  at  the  very  least  100  c.c.  of  fluid. 
Examination  is  either  impossible  or  unsatisfactory  if  the  prostate  is  greatly 
enlarged.  The  following  are  the  contraindications  to  cystoscopy  (Follen  Cabot 
and  Henry  G.  Spooner,  in  "Med.  Record,"  July  11,  1903):  When  it  is  ob- 
vious that  operative  intervention  would  be  useless;  when  there  is  a  very  large 
tumor;  in  acute  cystitis;  in  tuberculosis  in  which  the  diagnosis  is  evident 
without  the  cystoscope.  The  bladder  may  be  dilated  with  air,  Bransford 
Lewis's  cystoscope  being  used  (Fig.  548),  or  with  fluid,  the  instrument 
of  Nitze  being  employed  (Fig.  553).  The  Nitze-Albarran  instrument  is  a 
very  useful  catheterizing  cystoscope. 

To  arrest  bleeding  during  the  examination,  it  may  be  necessary  to  fill 
the  bladder  with  a  i  :  10,000  solution  of  adrenalin  chlorid  and  retain  it  for 
three  minutes. 


Fig.  553. — Nitze's  cystoscopes. 


In  order  to  use  the  Nitze  instrument,  it  is  rarely  necessary  to  give  ether, 
and  as  a  rule  cocain  can  be  used.  The  bladder  is  irrigated  with  boracic- 
acid  solution  until  the  fluid  emerges  clear  and  is  then  filled  with  boracic- 
acid  solution.  The  cystoscope  is  sterilized  in  formalin  vapor,  washed  off 
in  salt  solution,  and  lubricated  with  lubrichondrin.  The  current  is  turned 
on  for  a  moment  to  see  that  the  lamp  works  properly.  In  the  Nitze  instru- 
ment a  light  of  32  candle-power  is  sufficient,  and  a  rheostat  is  always  em- 
ployed. The  current  is  turned  off,  the  instrument  is  introduced,  the  current 
is  turned  on  again,  and  the  exploration  is  carefully  made.  If  blood  obscures 
the  transparency  of  the  fluid,  withdraw  the  instrument,  em]>ty  the  bladder, 
fill  it  with  adrenalin,  withdraw  the  adrenalin  in  three  or  four  minutes,  fill 
the  bladder  with  boracic-acid  .solution,  and  rein.sert  the  cystoscope.  If  this 
fails,  use  the  irrigating  cystoscope,  an  instrument  which  continually  changes 
the  fluid  while  the  examination  is  being  made.  The  cystoscope  is  an  instru- 
ment of  great  value  in  the  hands  of  an  experienced  man,  but  is  practically 


Diseases  and  Injuries  of  the  Bladder  953 

useless  when  employed  by  a  no\ice.  In  using  a  cystoscope  the  mucous  mem- 
brane may  be  burned  with  the  lamp.  This  causes  inflammation,  and  if  an 
eschar  forms  it  will  be  cast  off,  exposing  a  granulating  surface.  Schmidt 
calls  attention  to  this  injury,  speaks  of  the  condition  as  ulcer  cystoscopi- 
ciim,  says  it  is  in  the  fundus,  has  the  shape  of  the  instrument,  and  heals 
in  from  fourteen  to  twenty-one  days  ("Jour.  Amer.  Med.  Assoc,"  July  19, 
1902). 

Disinfection  of  Catheters.— Metallic  instruments  are  cleansed  by 
boiling.  Soft-rubber  and  elastic  catheters  can  be  sterilized  by  mechanical 
cleansing  with  soap  and  water  and  boiling  for  five  minutes.  The  common 
custom  of  immersing  a  soft-rubber  or  elastic  catheter  for  five  minutes  in  a 
I  :  2000  solution  of  corrosive  sublimate  is  a  useless  waste  of  time,  as  such  a 
procedure  will  not  sterilize  an  infected  instrument.  Of  course,  a  catheter 
coated  with  varnish  or  resin  cannot  be  boiled  in  water  or  placed  in  steam. 
The  best  method  of  sterilization  for  woven  or  varnished  catheters  is  formalin 
vapor.  Catheters,  after  being  cleansed  mechanically,  should  be  placed  in  a 
glass  cylinder  the  bottom  of  which  is  perforated  like  a  sieve.  This  jar  is 
placed  for  twenty-four  hours  in  the  vapor  of  formalin.  After  sterilization  the 
instruments  are  kept  ready  for  use  in  a  glass  cyhnder  containing  calcium 
chlorid  (R.  W.  Frank,  in  "Berliner  klin.  Woch.,"  No.  44,  1895).  Before 
using,  the  catheters  are  washed  in  sterile  water.  Guyon  prefers  to  scrub 
catheters  with  soap  and  water,  dry  them  outside  and  inside,  and  place  them 
in  the  vapor  of  sulphurous  acid  for  forty-eight  hours. 

Diseases  and  Injuries  or  the  Bladder. 

Retention  of  Urine. — By  this  term  is  meant  an  inability  to  empty  the 
bladder.  The  retention  may  be  complete,  not  a  drop  emerging,  or  it  may 
have  been  complete,  a  dribbling  setting  in  after  a  time,  due  to  paralysis  of  the 
bladder,  which  viscus  becomes  unable  to  contain  more  fluid,  expulsion  of  the 
overflow  from  the  ureters  being  produced  by  atmospheric  pressure.  This 
condition  is  known  as  the  engorgement,  the  overfJoic,  or  tJie  incontinence  of  re- 
tention. There  may  be  partial  retention  from  enlarged  prostate,  a  portion 
only  of  the  urine  being  voided.  Retention  may  be  caused  by  (i)  obstructiofi, 
resulting  from  urethral  stricture,  hypertrophied  prostate,  inflamed  prostate, 
occluded  meatus,  impacted  calculus,  urethral  tumor,  rupture  of  the  ure- 
thra, perineal  abscess,  complete  phimosis,  fecal  impaction  and  pressure  from 
a  large  tumor,  or  by  (2)  defective  expulsion,  resulting  from  paral}'sis,  disease 
or  injury,  atony,  reflex  inhibition,  shock,  muscular  weakness  of  fevers,  and 
the  action  of  such  drugs  as  belladonna,  opium,  or  cantharides. 

Symptoms. — In  acute  retention  there  is  an  agony  of  desire  to  urinate, 
the  patient  making  acutely  painful  straining-efi"orts,  during  which  feces  are 
often  passed.  There  are  severe  pain  and  aching  in  the  abdomen,  thighs, 
perineum,  and  penis.  All  the  symptoms  rapidly  increase,  a  typhoid  state  is 
inaugurated,  and  death  closes  the  scene  unless  relief  be  given.  If  retention 
is  from  time  to  time  alleviated  by  the  passage  of  a  little  water,  the  symptoms 
are  slower  in  evolution  and  are  less  intense,  and  the  case  is  said  to  be  chronic. 
Some  cases  of  gradual  onset,  due  to  atony,  are  very  insidious,  the  patient 
feeling  no  particular  pain  and  complaining  only  of  the  dribbling,  which  is 


954  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

really  the  overflow  of  retention,  and  is  not  a  sign  that  the  bladder  is  success- 
fully emptying  itself.  In  any  case  of  retention  the  bladder  rises  above  the 
pubes,  and  there  is  found  a  pyriform,  elastic,  fluctuating  mass  in  the  hypo- 
gastrium,  which  mass  is  dull  on  percussion  and  gradually  enlarges  until  the 
bladder  is  evacuated  or  incontinence  sets  in.  The  flanks  give  a  clear  percus- 
sion-note, and  the  tumor  is  more  prominent  when  the  patient  is  erect  than 
when  he  is  recumbent.  Long  continuation  of  obstructive  disease,  producing 
partial  retention  with  or  without  attacks  of  complete  retention,  disorganizes 
the  kidnevs.  Acute  and  complete  retention  may  induce  rupture  of  the  ure- 
thra or  urinary  suppression. 


ir^ 


Fig.  554. — Gouley's  tunnelled  catheter  threaded  on  a  filiform  bougie. 


\. 


Fig-    555-—  Points    of 
Gouley's  whalebone  guides 

(filiform  bougies). 


Treatment. — Place  the  patient  upon  his  back,  keep  him  warm,  and  if 
instrumentation  does  not  rapidly  succeed,  give  an  anesthetic.  Never  attempt 
to  use  a  catheter  when  the  patient  is  erect.  To  do  so  may  cause  serious  or 
possibly  fatal  shock.  Be  sure  that  every  instrument  is  aseptic.  In  organic 
stricture  try  to  pass  an  elastic,  olivary-pointed  catheter  (Fig.  557,  a).  Do  not 
use  any  force  until  the  neck  of  the  catheter  engages  in  the  stricture.  Then 
an  experienced  operator  may  warily  use  a  certain  amount  of  force,  but  never 
much.  When  the  instrument  enters  the  bladder,  draw  off  but  half  of  the 
urine,  withdraw  the  instrument,  wait  a  few  hours,  insert  it  again,  and  then 
empty  the  bladder  and  wash  out  the  viscus  with  warm  boric-acid  solution.  To 


Fig.  556.— Nelaton's  catheter. 


draw  off  all  of  the  urine  at  once  is  dangerous,  because  the  .sudden  relief  of  the 
pressure  upon  distended  veins  leads  to  bleeding  from  the  mucous  membrane 
and  hemorrhage  into  the  bladder-walls.  After  the  bladder  has  been  emptied 
the  patient  is  wrapped  in  blankets,  a  bag  of  hot  sand  or  of  hot  water  is 
placed  against  the  perineum,  and  a  hot-water  bag  is  laid  upon  the  hypo- 
gastric region;  when  he  recovers  from  the  effect  of  the  anesthetic  he  is 
given  suppositories  of  opium  and  belladonna,  and  tablets  of  salol  and 
boric  acid  are  administered  for  several  days.  If  it  is  found  impossible 
to  in.sert  a  rubber  instrument,  make  an  attempt  to  carry  a  filiform  bougie 
into   the    bladder.     Fig.    555    shows    filiform    bougies.     If  the   stricture  is 


Treatment  for  Retention  of  Urine 


955 


known  to  be  organic  from  previous  history,  at  once  insert  a  filiform  bougie. 
On  this  bougie,  after  it  has  been  inserted,  Gouley's  tunnelled  catheter  can 
be  threaded  (Fig.  554)  and  carried  into  the  bladder.  Instead  of  carrying  in 
the  catheter,  we  can  simply  leave  the  fihform  bougie  in  place,  and  fasten  it. 
The  filiform  bougie  will  act  as  a  capillary  drain,  and  in  a  few  hours  will 
empty  the  bladder.  Then  insert  another  bougie  beside  the  first,  and  so  on 
for  several  days,  using  also  opium,  ordering  rest  in  bed,  and  making  no 
attempt  to  dilate  the  stricture  forcibly  until  retention  has  ceased  and  inflam- 
mation has  subsided.  If  no  bougie  can  be  passed,  aspirate  or  perform  cys- 
totomy (suprapubic  or  perineal).  In  spasmodic  stricture  hold  a  good-sized 
metal  catheter  firmly  against  the  face  of  the  spasmed  area;  relaxation  will 
occur  and  the  instrument  will  eventually  pass.  Fig.  558  shows  the  proper 
curve  of  a  metal  instrument.  An  individual  who  has  an  organic  stricture 
which  has  given  but  little  trouble  may  develop  attacks  of  retention  because 
of  inflammatory  edema  of  the 
mucous  membrane  and  spasm 
of  the  urethral  muscles.  These 
attacks  are  temporary,  and  an 
instrument  can  usually  be  in- 
serted when  employed  as 
above  directed.  In  inflamma- 
tion give  a  hot  hip-bath  and 
suppositories  of  opium  and 
belladonna,  and  then  use  a 
hot  sand-bag  to  the  perineum 
and  a  hot-water  bag  over  the 
hypogastrium.  If  these  fail 
or  if  the  symptoms  are  ur- 
gent, pass  a  soft  catheter.  In  the  occluded  meatus  oj  the  new-born  incise 
with  a  tenotome.  In  a  congenital  cyst  of  the  sinus  pocu/aris  pass  a  steel 
bougie,  which  will  rupture  the  cyst.  In  complete  phimosis  split  up  the  pre- 
puce. In  impacted  stone  try  to  pull  out  the  calculus  with  urethral  forceps; 
if  this  fails,  cut  the  urethra,  or,  in  rare  cases,  push  the  stone  back  into 
the  bladder.  In  fecal  impaction  scrape  out  the  rectum  with  a  spoon.  In 
enlarged  prostate  try  to  pass  an  instrument  of  woven  silk  (Fig.  559)  or 
an  ordinary  Nelaton  catheter  (Fig.  556)  strengthened  by  the  insertion  of  a 
filiform  bougie  nearly  to  the  beak.  If,  however,  the  hypertrophied  tissue 
enters  markedly  into  the  urethra,  Mercier's  coude  catheter  is  used  (Fig.  557,  b), 
or  his  double-elbowed  instrument  (Fig.  557,  c).  If  all  the  above  instruments 
fail,  a  metal  instrument  with  a  large  curve  may  be  employed,  but  it  is  a  danger- 
ous tool  and  one  capable  of  inflicting  grave  injury.  In  retention  from  expulsive 
deject  use  a  soft  catheter  (Fig.  556).  Cases  of  retention  after  catheterization 
require  warmth,  confinement  to  bed,  the  administration  of  la.xatives,  free  action 
of  the  skin,  and  the  use  of  such  drugs  as  salol,  boric  acid,  urotropin,  and  quinin 
to  asepticize  the  urine.  In  some  few  cases  no  instrument  can  be  inserted  in  the 
bladder.  In  most  of  such  cases  aspirate — which  may  be  done  several  times 
if  necessary — and  in  a  day  or  two.  when  swelling  and  congestion  abate,  an 
instrument  can  be  passed.  A  small  asepticized  trocar  or  aspirator-needle  is 
pushed  into  the  bladder,  the  trocar  or  needle  being  inserted  in  the  median  line. 


F'g-  557- — 1'  French  olivary  gum  catheter;  6.  Mer- 
cier's elbowed  catheter  (coude)  ;  c,  Mercier'  double- 
elbowed  catheter ;  d,  curved  gum  catheter. 


956  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

just  above  the  pubes,  and  taking  a  course  downward  and  backward.  The 
parts  are  first  prepared  antiseptically,  and  the  puncture  is  dressed  with  iodo- 
form and  collodion.  Only  half  the  urine  is  withdrawn  at  a  first  aspiration. 
Rectal  puncture  is  now  obsolete.  The  perineal  incision  is  the  one  usually 
employed  for  retention.  It  may  be  done  with  or  without  a  guide.  In  pros- 
tatic retention,  not  relievable  by  a  catheter,  make  suprapubic  drainage  or  do 
prostatectomy. 

Congenital  Defects  of  the  Bladder. — Exstrophy  of  the  Bladder 
{Ectopia  Vesicce). — Exstrophy  of  the  bladder  is  a  condition  of  defective  de- 
velopment commoner  in  males  than  in  females.  The  anterior  abdominal 
wall  having  failed  to  close,  the  anterior  wall  of  the  bladder  being  absent,  and 
the  arch  of  the  pubes  not  having  developed,  epispadias  exists,  and  in  many 
cases  the  testicles  do  not  descend  into  the  scrotum.  In  this  condition  the 
posterior  wall  of  the  bladder  projects  into  or  beyond  the  gap  in  the  abdominal 
wall;  the  urine  constantly  flows  and  renders  the  condition  of  the  patient 
dreadful.  ^ 

The  only  treatment  which  offers  hope  is  operation,  and  operation  often 
fails.  If  possible,  operate  when  the  patient  is  about  five  years  of  age.  Various 
operations  have  been  suggested  for  this  condition,  viz.:  covering  with  skin- 
flaps;  implanting  the  ureters  into  the  rectum  (Maydl,  i\lbert,  Roux,  Simon, 
and  others) ;  division  of  the  posterior  ligaments  of  the  sacro-iliac  joints,  bring- 
ing the  arch  of  the  pubes  forcibly  together,  the  patient  wearing  a  support 
until  the  parts  become  firm,  when  the  defect  is  closed  in  by  flaps  (Trendelen- 
burg) ;  or  loosening  the  ureters  from  the  bladder,  drawing  them  down,  and 
attaching  them  to  the  end  of  the  penis  (Sonnenberg). 

Diseases  and  Injuries  of  tiie  Bladder. — This  viscus  is  so  deeply 
situated,  and  the  abdominal  walls  are  so  elastic,  that  it  is  rarely  injured  when 
empty.  If  the  bladder  be  full  and  the  abdomen  be  tense — which  is  common 
in  alcoholic  intoxication — force  applied  upon  the  abdomen  may  injure  the 
bladder. 

Contusion  of  the  Bladder. — In  this  condition  there  are  noted  vesical 
hematuria,  tenesmus,  severe  cystitis,  and  an  impediment  to  the  flow  of  water 
because  of  clots.  Hemorrhage  may  be  very  severe  and  sepsis  may  arise, 
even  causing  death.  When  contusion  exists  retention  is  relieved  by  means 
of  a  clean  soft  catheter;  if  this  fails  because  of  occlusion  of  the  eye  of  the 
catheter  with  blood-clot,  there  must,  from  time  to  time,  be  passed  through 
the  catheter  from  a  fountain-syringe  a  solution  of  sodium  bicarbonate  in 
cooled  boiled  water.  Gross's  blood-catheter  can  be  used,  or  the  evacuator 
of  Bigelow  may  be  employed.  The  patient  is  put  to  bed,  a  hot-water  bag  is 
applied  to  the  hypogastrium,  morphin  is  administered  in  moderate  doses, 
the  bladder  is  washed  out  several  times  a  day  with  boric-acid  solution  to  dis- 
integrate and  remove  blood-clots,  and  the  urine  is  diluted  and  rendered  aseptic 
Vjy  the  stomach  administration  of  salol,  boric  acid,  and  the  free  use  of  bland 
fluids.  Hemorrhage  usually  ceases  on  relieving  distention;  if  it  does  not, 
.some  more  radical  measure  must  be  employed  (see  Hematuria). 

Wounds  of  the  Bladder. — Besides  being  contused,  the  bladder  may  be 
injured  by  bullets;  by  stabs  or  punctures  through  the  abdomen,  the  vagina, 
or  the  uterus;  or  by  penetration  by  a  fragment  of  a  fractured  pelvic  bone. 
The  symptoms  of  such  conditions  are  those  of  rupture  of  the  bladder  {q.  v.). 


Rupture  of  the  Bladder 


957 


In  any  intraperitoneal  wound  at  once  open  the  abdomen,  suture  the  wound 
in  the  bladder-wall,  irrigate  the  peritoneal  cavity,  and  drain  the  bladder  by 
means  of  a  retained  catheter,  a  perineal  section,  or  a  suprapubic  cystotomy. 
In  an  extraperitoneal  wound  drain  the  wound  by  a  tube,  and  drain  the  bladder 
by  a  retained  catheter,  a  perineal  section,  or  a  suprapubic  opening. 

Rupture  of  the  bladder  occurs  in  three  forms:  (i)  intraperitoneal — a 
rupture  involving  the  peritoneal  coat;  (2)  extraperitoneal — a  rupture  of  a  por- 
tion of  the  bladder  not  covered  by  peritoneum;  and  (3)  subperitoneal — a 
rupture  of  the  mucous  and  muscular  coats,  the  urine  diffusing  under  the 
peritoneal  investment.     The  causes  are  of  two  kinds,  predisposing  and  ex- 


Fig-  558-—-^  S  E  shows  the  proper  curve  (reduced  in  size)  for  unyielding  male  urethral  instruments  ; 
C  B  D  shows  an  improper  cur\-e. 

citing.  Predisposing  causes  are:  distention  of  the  bladder;  drunkenness;  ul- 
ceration; degeneration  or  atony  of  the  bladder-coats.  Exciting  causes  are: 
obstruction  to  outflow  of  urine  (by  stricture  or  enlarged  prostate) ;  external 
violence;  falls  upon  the  feet  and  the  buttocks,  as  well  as  upon  the  abdomen; 
lifting;  straining  at  stool,  in  micturition,  or  during  parturition;  and  the  forcing 
of  injections  into  the  bladder.  A  distended  bladder  may  be  ruptured  by  a 
concussion.  The  most  usual  cause  of  the  injury  is  a  crush  which  forces  the 
bladder  against  the  sacral  promontory  (Alexander,  in  "  Annals  .of  Surgery," 
Aug.,  1901).  This  accident  is  commoner  in  men  than  in  women  (10  to  i), 
and  is  rare  in  children. 


Fig.  559. — English  silk-web  catheter. 


Symptoms,  Diagnosis,  and  Treatment. — The  s\mptoms  are  not  always 
definite,  and  every  characteristic  one  may  be  for  a  time  absent,  the  patient 
seeming  in  some  rare  instances  to  possess  the  power  of  retaining  his  urine  and 
of  voiding  it.  As  a  rule,  however,  there  are  found  some  or  all  of  the  following 
symptoms,  following  an  accident  or  occurring  during  the  progress  of  a  causa- 
tive disease:  collapse;  excessive  desire  to  urinate;  inabihty  to  do  so;  a  catheter, 
when  used,  brings  away  pure  blood  or  a  very  little  bloody  urine;  the  catheter 
occasionally  slips  through  the  tear  into  the  cavity,  and  more  bloody  water 
comes  awav.  In  some  reported  cases  clear  water  has  been  withdrawn.  If  a 
measured  amount  of  boric-acid  solution  is  injected,  it  is  improbable  that  all 


958  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

of  it  can  be  withdrawn  by  the  catheter,  although  in  some  cases  it  may  all 
come  away  (Alexander,  in  "Annals  of  Surgery,"  Aug.,  1901).  Injecting  fluid 
fails  to  lift  the  bladder  into  the  hypogastric  region  so  as  to  be  recogniza- 
ble on  percussion.  Severe  hypogastric  pain  and  rectal  tenesmus  come  on 
after  a  temporary  sense  of  relief  from  retention.  Shock  is  so  severe  that 
death  may  ensue;  if  reaction  follows,  there  is  delirium,  often  septicemia  and 
peritonitis;  extensi\e  infiltrations  of  urine  may  occur.  In  intraperitoneal 
rupture  general  peritonitis  is  certain  to  arise,  but  its  appearance  may  be 
postponed  for  several  days  if  the  urine  is  healthy.  In  these  cases  the  ex- 
travasation is  noted  as  a  simple  swelling,  probably  on  one  side  only.  In 
extraperitoneal  rupture  the  urine  may  infiltrate  the  perineum,  the  scrotum, 
the  thighs,  and  under  the  integuments  of  the  abdomen  and  the  back,  and  may 
soon  induce  sloughing.     In  subperitoneal  rupture  peritonitis  is  apt  to  arise. 

In  doubtful  cases  pump  air  or  hydrogen  into  the  bladder.  To  insert  air 
a  bicycle  pump  can  be  used  (Brown),  or  a  Davidson  syringe  (Keen).  Keen's 
directions  are  to  insert  a  catheter,  empty  the  bladder  of  urine,  and  connect  to 
the  catheter  a  disinfected  Davidson's  syringe,  a  mass  of  absorbent  cotton 
being  fastened  over  the  distal  end  of  the  syringe.  Air  after  it  has  filtered 
through  the  cotton  is  pumped  into  the  bladder;  an  unruptured  bladder  will 
rise  above  the  pubes  as  a  pyriform  tumor,  tympanitic  on  percussion.  A 
ruptured  bladder  will  not  so  rise.  In  intraperitoneal  rupture  the  air  will 
pass  into  the  general  peritoneal  cavity  and  distention  will  occur.  In  extra- 
peritoneal rupture  injection  will  produce  emphysema  of  the  extravesical 
connective  tissues.  On  removing  the  syringe  the  air  rushes  out  again  if  the 
bladder  is  unruptured,  but  little  if  any  comes  away  if  it  is  ruptured.  Alex- 
ander considers  gaseous  distention  unreliable,  and  claims  that  it  adds  to 
shock  and  disseminates  infection.  His  rule  is  the  wisest  to  follow;  that  is, 
in  a  case  of  suspected  rupture  of  the  bladder,  make  a  suprapubic  incision 
and  inspect  the  prevesical  space  for  signs  of  extraperitoneal  rupture.  If 
extraperitoneal  rupture  is  not  found,  open  the  belly  and  explore. 

Treatment. — In  extraperitoneal  rupture  after  incision  down  to  the  blad- 
der insert  a  drainage-tube.  In  intraperitoneal  rupture,  place  the  patient  in 
the  Trendelenburg  position,  expose  the  bladder  by  incision,  and  suture  the 
opening  in  the  viscus. 

Results. — In  intraperitoneal  ruptures  if  operation  is  not  performed  the 
mortality  is  98  per  cent.  If  it  is  performed  the  mortahty  is  49  per  cent.  In 
extraperitoneal  rupture  without  operation  there  are  11  per  cent,  cures  and 
with  operation  30  per  cent,  (see  Daniel  N.  Eisendrath,  "Jour.  Amer.  Med. 
Assoc,"  Oct.  25,  1902;  Samuel  Alexander,  "Annals  of  Surgery,"  Aug.,  1901). 

Atony  of  the  bladder  is  a  condition  in  which  the  expulsive  power  of 
the  bladder  is  diminished  or  lost  because  of  impairment  of  muscular  tone. 
The  bladder  is  very  thin,  and  the  muscles  are  flaccid  and  often  the  seat  of 
fatty  degeneration.  Sometimes  the  viscus  is  very  large  and  .sometimes  it  is 
very  small.  A  slight  degree  of  atony  is  physiological  after  middle  age.  The 
causes  are  senility,  distention  from  true  paralysis,  chronir  overdistention 
from  oVjstruction,  and  acute  overdi.stention. 

Symptoms. — In  atony  of  the  bladder  the  patient  passes  water  frequently 
(a  symptom  probably  existing  for  some  years),  and  especially  at  night;  he 
may  even  do  so  while  asleep.     The  stream,  when  voluntarily  passed,  has  no 


Vesical  Calculus,  or  Stone  in  the  Bladder  959 

projection,  but  drops  at  once  from  the  end  of  the  penis.  Residual  urine 
exists  for  years  and  may  at  any  time  set  up  cystitis,  and  retention  with  incon- 
tinence is  apt  to  occur.  This  condition  is  not  vesical  paralysis  resulting  from 
a  lesion  of  the  nervous  system. 

Treatment. — In  treating  atony  of  the  bladder  measure  the  residual 
urine:  if  it  amounts  to  four  ounces,  use  a  soft  catheter  night  and  morning;  if 
it  amounts  to  six  ounces,  use  the  catheter  every  eight  hours;  if  it  amounts 
to  eight  ounces,  use  the  catheter  every  six  hours  (J.  W.  White).  The  patient 
should  be  taught  how  to  use  the  catheter  and  how  to  keep  it  sterile.  (For 
methods  of  disinfecting  catheters  see  article  on  page  953.)  The  bladder  is 
from  time  to  time  washed  out  with  gr.  iij  to  the  ounce  of  boric-acid  solution 
at  a  temperature  of  100°  F.  Strychnin,  electricity,  ergot,  and  urotropin  may 
be  ordered. 

Vesical  Calculus,  or  Stone  in  the  Bladder.— The  sahs  normally 
in  solution  in  the  urine  may  deposit  as  calculi  and  may  be  imprisoned  in  any 
portion  of  the  urinary  tract.  The  commonest  calculi  are  those  composed  of 
uric  acid,  urates,  calcium  oxalate,  and  fusible  phosphates.  The  formation 
of  uric-acid  and  urate  calculi  is  explained  under  Renal  Calculus  (page  939). 
Vesical  calculi  are  usually  renal  calculi  that  have  passed  the  ureter  and  become 
enlarged  by  new  accretions.  Phosphatic  calculi  may  be  formed  in  the  bladder 
when  chronic  cystitis  causes  and  maintains  an  alkaline  urine.  Uric-acid 
calculi  are  smooth,  round  or  oval,  and  hard,  but  easily  broken.  On  section 
they  present  the  color  of  brick-dust  and  are  marked  b}'  concentric  rings. 
Their  nuclei  are  dark  by  comparison.  They  are  soluble  in  dilute  potassium 
hydrate,  and  with  effervescence  in  nitric  acid.  They  are  combustible,  and 
leave  scarcely  any  ash.  Urate  of  sodium  and  urate  of  ammonium  often  occur 
together  in  stones,  and  these  calculi  are  not  in  rings,  are  not  so  hard  as  the 
uric-acid  stones,  and  are  fawn-colored  on  section.  Oxalate-of-lime  stones 
are  round,  with  many  projecting  nodes  like  the  mulberry,  hence  the  term 
"mulberry  calculus."  They  are  very  hard,  and  section  shows  the  color  to 
be  brown  or  green  and  that  they  possess  wavy,  concentric  rings.  This  form 
of  calculus  is  soluble  in  hydrochloric  acid.  Fusible  calculus,  which  is  com- 
posed of  magnesic  ammonic  phosphate  with  phosphate  of  hme,  constitutes 
the  commonest  form  of  phosphatic  stone  and  of  large  stone.  It  is  light,  soft, 
smooth,  and  white,  and  shows  no  laminae  on  section.  Some  rare  forms  of 
stone  are  composed  of  xanthic  oxid,  cystic  oxid,  calcium  phosphate  or  car- 
bonate, and  magnesic  ammonic  phosphate  (triple  phosphate). 

A  stone  may  be  formed  having  layers  of  different  substances;  for  instance, 
there  is  often  found  a  uric-acid  nucleus  surrounded  by  phosphates,  the  latter 
surrounded  by  some  uric  acid  or  urates,  and  these  again  by  phosphates.  In 
.some  cases  oxalate  of  lime  alternates  with  uric  acid,  urates,  or  phosphates 
(Bowlby).  Bowlby  states  that  the  alternating  uric-acid  and  phosphatic 
layers  are  due  to  the  altering  reactions  of  the  urine;  that  when  the  urine  is 
acid  uric  acid  is  deposited  on  the  stone,  but  when  cvstitis  makes  the  urine 
alkaline  the  stone  receives  a  phosphatic  coat. 

Anything  that  favors  the  formation  of  an  excessive  urinary  deposit  may 
cause  vesical  calculus,  and  among  such  causes  are  defective  digestion,  failure 
in  processes  of  oxidation,  excess  of  solids  and  nitrogenous  elements  in  the  diet, 
deficient  exercise,  etc.     If  to  the  urinarv  condition  established  bv  the  above 


960  Diseases  and  Injuries  of  the  Genito-urinan'  Organs 

factors  catarrh  of  the  genito-urinary  tract  is  added,  pus  or  mucopus  in  the 
concentrated  urine  may  induce  stone.  Children  are  predisposed  to  uric-acid 
stones,  and  old  people  to  phosphatic  stones.  In  an  old  man  with  enlarged 
prostate  and  chronic  cystitis  a  stoUe  forms  rapidly  about  any  accidental 
nucleus.  The  nucleus  may  be  phosphate-crystals  glued  together  by  mucus, 
a  blood-clot,  uric-acid  gravel,  or  a  foreign  body.  Stone  is  rare  in  females 
because  of  the  shortness,  the  large  diameter,  and  the  ready  dilatability  of  the 
urethra.  Stone  is  very  rare  in  the  negro.  Gout,  rheumatism,  lithemia, 
enlarged  prostate,  vesical  atony,  urethral  stricture,  and  catarrhal  inflamma- 
tion of  the  kidney,  the  ureter,  and  the  bladder  are  predisposing  causes. 

Symptoms. — In  not  a  few  cases  the  vesical  symptoms  are  antedated  by  an 
attack  of  nephritic  coHc.  The  severity  of  the  symptoms  of  stone  in  the  bladder 
depends  more  on  the  roughness  of  the  stone  than  on  its  size.  A  small,  rough 
calculus  will  produce  intolerable  anguish,  whereas  several  large,  smooth  stones 
will  cause  but  moderate  pain.  A  patient  with  stone  in  the  bladder  com- 
plains of  frequency  of  micturition,  particularly  in  the  daytime,  the  desire  being 
sudden,  uncontrollable,  and  invoked  or  aggravated  by  exercise.  This  symptom 
is  more  positive  in  youth  than  in  old  age.  Pain  of  a  sharp,  burning  character 
is  experienced  at  the  end  of  micturition,  due  to  the  contraction  of  the  empty 
bladder  upon  the  stone  or  stones.  The  usual  seat  of  this  pain  is  the  under  sur- 
face of  the  head  of  the  penis,  a  httle  behind  the  meatus,  and  the  pain  may 
continue  for  some  time.  By  pulling  on  the  penis  to  relieve  this  pain  the  prepuce 
often  becomes  pendulous.  This  pain  varies  in  severity,  being  worse  during 
cystitis  and  after  exercise;  it  may  be  absent  in  encysted  stone,  it  may  even 
almost  disappear,  and  it  is  always  worse  in  the  young  than  in  the  old.  Stone 
in  chronic  cases  of  atony  and  in  cases  of  vesical  paralysis  causes  neither  marked 
pain  nor  frequency  of  micturition.*  Attacks  of  cystitis  in  a  man  with  calculus 
are  spoken  of  as  attacks  of  stone.  When  a  stone  is  small  it  may  during 
micturition  roll  into  the  urethral  orifice,  and  so  cause  a  sudden  interruption 
of  the  flow  of  water,  the  stream  again  starting  when  the  patient  changes  his 


%tr^»-— -—eijr^-  ^i^-n    it-.i  >  jtiu<.-|i-i  imni 


Fig.  560. — Thompson's  calculus  sound. 

position.  This  symptom  is  rare  in  the  old,  the  stone  in  them  dropping  into 
the  sac  back  of  the  prostate  and  below  the  urethral  orifice.  Hematuria  may 
or  may  not  be  noted ;  it  is  most  usual  after  exercise,  and  occurs  at  the  end  of 
the  urinary  act.  Pus  or  mucopus  will  be  observed  if  cystitis  occurs.  Pri- 
apism occurs  in  some  cases.  Pain  of  a  reflex  nature  may  be  felt  in  the  rectum, 
in  the  perineum,  or  in  some  distant  part. 

The  above  symptoms,  even  if  all  are  pre.sent,  do  not  prove  that  an  indi- 
vidual has  a  .stone  in  the  bladder.  To  prove  the  presence  of  a  stone,  it  must 
be  touched  with  a  sound  and  the  contact  must  be  felt  and  heard.  To  sound 
a  patient,  have  the  bladder  well  filled  with  water,  and  place  him  recumbent 
with  the  knees  drawn  up.  Never  sound  a  person  while  he  is  standing,  be- 
cause of  the  danger  of  syncope.     In  an  ordinary  case  in  a  male  use  a  sound 

*  "American  Text-book  of  Surgery." 


Cystitis  961 

with  a  very  slight  curve  (Fig.  560) ;  in  a  man  with  hypertrophied  prostate  use 
a  sound  with  a  short  and  decided  curve.  The  cah'ber  of  a  stone-sound  is 
No.  13  of  the  French  scale.  The  instrument  is  carefully  boiled  and  anointed 
with  lubrichondrin.  Examine  the  entire  bladder  .systematically,  and  be  sure  a 
stone  is  present  only  when  contact  with  the  sound  is  both  heard  and  felt. 
The  stone  may  be  hard  to  find,  or  it  may  elude  the  instrument  entirely  when  it 
is  encysted,  when  it  rests  in  a  diverticulum,  when  it  is  fixed  to  the  roof  or  ante- 
rior wall  of  the  viscus,  or  when  it  is  crusted  with  lymph  or  blood-clot.  In 
doubtful  cases  always  insist  on  a  second  examination,  giving  ether  if  the  first 
was  very  painful.  Occasionally  a  small  stone  will  be  found  by  using  a  Bigelow 
e\acuator,  the  current  causing  the  calculus  to  knock  against  the  tube.  Examine 
for  stone  in  females  with  a  straight  sound,  and  in  cases  of  uncertainty  dilate 
the  urethra  and  explore  the  bladder  with  the  little  finger.  In  many  cases  stone 
in  the  bladder  may  be  detected  by  means  of  the  A--rays.  A  stone,  when  it  is 
detected,  should  always  be  measured  by  an  arrangement  like  a  Hthotrite. 
The  composition  of  the  stone  is  assumed  from  an  examination  of  fragments 
which  pass  by  the  urethra  or  which  adhere  to  the  measure.  Remember  that 
the  outer  layer  of  a  calculus  may  be  soft  phosphate  and  the  inner  portion 
may  be  the  harder  uric  acid,  urate,  or  oxalate. 

Treatment. — In  people  predisposed  to  stone  (for  instance,  by  lithemia) 
the  physician  should  foresee  the  danger  and  essay  to  antagonize  it.  Insist 
on  the  urine  being  kept  dilute  by  the  freest  use  of  water  and  of  milk,  and 
reduce  to  a  minimum  the  amount  of  alcohol,  meat,  sugar,  and  fat  which  is 
taken.  Let  the  patient  live  chiefly  on  green  vegetables,  salads,  bread,  fruit, 
eggs,  fish,  poultry,  weak  tea  or  cofifee,  water,  milk,  and,  if  desired,  a  little  red 
wine.  Continued  purging  does  harm  by  concentrating  the  urine,  though  a 
laxative  may  be  employed  when  indicated.  Moderate  open-air  exercise  is 
of  immense  importance,  sunshine  and  fresh  air  being  Nature's  correctives 
for  a  condition  of  imperfect  oxidation  power.  If  the  urine  be  very  acid,  use 
piperazin,  gr.  xv  to  gr.  xx  daily,  liquor  potassii  citratis,  phosphate  of  sodium, 
or  borocitrate  of  magnesium.  If  the  urine  be  phosphatic,  order  mineral  acids 
and  strychnin,  or  what  seems  to  be  very  efficient,  urotropin.  Urotropin  is 
given  in  gr.  v  capsules  four  times  daily.  If  the  urine  be  filled  with  oxalate, 
use  the  mineral  acids  with  an  occasional  course  of  phosphate  of  sodium. 
Travel  and  rest  at  the  seaside  or  at  some  Spa  are  often  of  service  in  all  forms. 
Always  endeavor  to  prevent  cystitis,  and  treat  it  promptly  when  it  does  occur. 
When  a  stone  is  once  formed  it  is  an  idle  dream  to  think  of  dissolving  it.  An 
operation  must  be  done.  The  operation  selected  depends  upon  the  age,  the 
state  of  the  bladder  and  the  prostate,  the  dilatability  of  the  urethra,  the  kidney 
condition,  the  size  and  composition  of  the  stone,  and  the  number  of  calculi 
present  (see  Operations  on  the  Bladder). 

Cystitis. — Inflammation  of  the  bladder  is,  as  a  rule,  a  complication 
of  some  other  disease  of  the  genito-urinary  tract,  but  it  may  arise  from  cold 
and  wet.  Traumatism  from  a  catheter,  the  presence  of  a  stone,  the  spread 
of  a  urethral  inflammation,  pus  infection,  the  existence  of  tuberculosis  or 
cancer,  and  the  use  of  such  a  drug  as  cantharides,  may  produce  it.  It  appears 
not  unusually  during  an  exanthematous  fever  or  in  conditions  of  vesical 
paraly.sis;  it  often  follows  retention,  frequently  accompanies  enlarged  pros- 
tate and  urethral  stricture,  and  sometimes  arises  from  concentration  of  urine 
61 


962  Diseases  and  Injuries  of  the  Genito-urinaiy  Organs 

or  accompanies  bladder  growths.  Acute  cystitis  causes  discoloration  and 
swelling  of  the  bladder-walls,  and  there  is  present  a  catarrhal  discharge  which 
is  mixed  with  urinary  elements,  serum,  mucus,  often  pus  and  epithelial  debris. 
Ulceration,  sloughing,  or  false-membrane  formation  may  occur.  Chronic 
cystitis  is  an  inflammatory  condition  always  due  to  bacteria.  We  frequently 
speak  of  a  chronic  cystitis  as  due  to  stone  in  the  bladder,  hypertrophy  of  the 
prostate  gland,  or  tumor  of  the  bladder.  These  conditions  do  not  cause 
chronic  cystitis,  but  act  by  rendering  the  bladder  vulnerable  to  micro-organ- 
isms. x\mong  the  causative  organisms  we  may  mention  the  bacillus  coli 
communis,  the  gonococcus,  the  bacillus  tuberculosis,  the  bacillus  typhosus, 
and  the  various  pyogenic  bacteria  (Leonard  Freeman).  These  bacteria  may 
gain  entrance  on  instruments;  or  by  way  of  the  ureter,  urethra,  the  lymph- 
vessels,  and  possibly  in  rare  instances  by  the  blood. 

In  chronic  cystitis  there  is  an  enormous  production  of  thick,  sticky  mucus 
and  the  urine  becomes  alkaline.  The  excessive  secretion  of  mucus  and  the 
great  number  of  bacteria  convert  the  urea  into  carbonate  of  ammonium,  and 
this  product,  being  irritant  to  the  bladder-walls,  makes  the  inflammation 
worse.  In  chronic  cystitis  the  bladder  is  contracted  and  has  very  thick  walls, 
and  the  mucous  membrane  is  thick,  edematous,  congested,  and  filled  with 
large  veins.  The  bladder  may  be  ulcerated  or  encrusted  with  urinary  salt. 
The  urine  contains  bacteria,  triple  phosphate,  pus,  blood,  and  mucus,  the 
blood  emerging  with  the  last  drops  of  water.  Pyelitis  may  arise  as  a  result 
of  chronic  cystitis. 

Symptoms  of  Acute  Cystitis. — Great  frequency  of  micturition,  with  the 
passage  at  each  act  of  a  very  small  quantity  of  urine;  the  desire  to  urinate  is 
almost  constant,  and  there  is  intensely  painful  straining  (tenesmus).  The 
pain  is  acute  and  scalding,  and  may  be  felt  above  the  pubes  or  in  the  peri- 
neum; it  often  runs  into  the  loins  and  the  thighs  and  radiates  over  the  sacrum. 
Pain  above  the  pubes  indicates  involvement  of  the  fundus,  and  pain  in  the 
perineum  and  in  the  head  of  the  penis  points  to  inflammation  of  the  bladder- 
neck.  The  urine,  at  first  clear,  loses  its  transparency,  becomes  full  of  thick 
mucus,  and  often  contains  a  little  blood  or  pus.  The  patient  not  unusually 
has  some  fever.  A  rectal  examination  causes  violent  pain.  If  ischuria 
takes  place,  there  will  be  a  chill  and  high  fever,  and  anuria  may  occur  or 
vesical  rupture  may  ensue. 

Treatment. — In  treating  acute  cystitis  endeavor  to  remove  the  cause. 
By  allaying  an  irritation  or  removing  an  obstruction  the  bladder  will  often 
become  able  to  empty  itself  of  retained  urine,  which  urine  causes  congestion 
of  the  bladder  and  thus  renders  infection  probable  or  may  be  itself  filled  with 
bacteria.  If  cystitis  arises  from  the  administration  of  cantharides,  put  the 
patient  in  bed  and  give  him  liquor  potassii  citratis.  If  it  comes  from  the  use 
of  a  clean  sound,  order  rest  in  bed,  suppositories  of  opium  and  belladonna, 
diluent  drinks,  and  ammonii  benzoas  or  lupulin.  If  the  inflammation  is 
septic  (as  from  the  use  of  a  dirty  sound),  or  is  very  acute,  put  the  patient  in 
bed,  keep  him  warm,  and  use  a  hot  sand-bag  to  the  perineum  and  hot 
fomentations  or  poultices  to  the  hypogastrium.  Hot  hip-baths  may  be  used. 
The  hips  should  be  elevated  and  the  bowels  should  be  emptied  by  the  admin- 
istration of  salines  and  by  glycerin  enemata.  An  exclusive  milk-diet  is  de- 
.sirable.     The  patient  should  drink  copiously  of  sweetened  water  containing  a 


Symptoms  of  Chronic  Cystitis  963 

few  drops  of  aromatic  sulphuric  acid  or  of  mill<:  of  almonds.  Sterilize  the 
urine  by  the  administration  of  urotropin,  giving  a  capsule  containing  gr.  7^ 
of  the  drug  three  times  a  day.  Other  remedies  which  may  be  of  service  in 
sterilizing  the  urine  are  quinin,  boric  acid,  salol,  borocitrate  of  magnesium, 
and  salicylate  of  sodium.  A  valuable  remedy  consists  of  15  grains  of  sali- 
cylate of  sodium  and  15  grains  of  benzoic  acid,  given  three  times  a  day  in  a 
little  chloroform  water.     If  the  pain  and  straining  still  continue,  order — 

tjc .     Ext.  sem.  hj-oscyamin.,  gr.  viij  ; 

Ext.  cannabis  indicK,  gr.  viij  ; 

Sacchar.  alba,  gr.  xlviij. — M. 
Div.  in  pulv.  No.  xx. 
Sig. — One  powder  every  three  hours.  (Von  Zeissl. ) 

Or, 

H .      Camphora,  gr.  viij  ; 

Ext.  cannabis  indica?,  gr.  viij  ; 

Sacchar.  alba,  gr.  xlviij. — M. 
Div.  in  pulv.  No.  xx. 
Sig. — One  powder  every  three  hours.  (Von  Zeissl.) 

Suppositories  of  extract  of  belladonna  are  of  great  value.  Suppositories  each 
containing  gr.  j  of  ichthyol  are  of  service;  and  one  should  be  used  every  four 
hours.  If  these  remedies  fail,  the  surgeon  will  be  driven  to  order  opium, 
which,  unfortunately,  constipates;  when  it  is  given,  secure  evacuations  by  the 
use  of  glycerin  suppositories,  by  the  administration  of  saline  cathartics,  or 
by  the  employment  of  enemata.  If  opium  is  necessary  it  is  given  in  a 
suppository  containing  gr.  j  of  powdered  opium  and  gr.  ^  of  the  extract  of 
belladonna  every  three  or  four  hours.  Hypodermatic  injections  of  morphin 
may  be  required.  Wash  the  bladder  out  daily  with  warm  normal  salt  solu- 
tion or  warm  boric-acid  solution.  This  can  be  done  through  a  soft  catheter 
or  better  by  hydrostatic  pressure.  If  retention  occurs,  use  a  soft  catheter. 
If  much  blood  is  passed,  give  internally  the  tinctura  ferri  chloridi  and 
blister  the  perineum.  A  very  acute  cystitis  is  rarely  arrested  within  a  week 
or  ten  days. 

Symptoms  of  Chronic  Cystitis. — This  condition  may  be  a  legacy  from 
acute  cystitis  or  it  may  appear  without  any  acute  precursory  phenomena. 
There  will  be  found  frequency  of  micturition,  but  not  so  great  as  in  the  acute 
form.  There  will  be  slight  tenesmus,  and  moderate  pain  from  time  to  time, 
running  toward  the  head  of  the  penis.  Constitutional  symptoms  arise  only 
when  kidney-damage  has  become  pronounced  or  sepsis  has  occurred  from 
absorption.  The  urine  is  ammoniacal,  fetid,  and  turbid;  it  is  filled  with 
viscid,  tenacious  mucus  or  with  mucopus;  it  contains  a  great  ex'cess  of  phos- 
phates, and  occasionally  clots  of  blood.  The  condition  of  chronic  cystitis 
with  the  production  of  immense  quantities  of  thick  mucus  is  often  called 
"chronic  catarrh  of  the  bladder."  Chronic  cystitis  may  eventuate  in  the 
formation  of  stone  or  in  the  production  of  serious  disease  of  the  bladder, 
the  ureters,  and  the  kidneys.     It  often  occasions  retention. 

Chronic  Tuberculous  Cystitis. — Chronic  cystitis  may  be  due  to  tubercu- 
losis. Primary  tuberculosis  is  ver\-  uncommon.  iMost  cases  of  vesical 
tuberculosis  are  secondary  to  renal  tuberculosis  or  to  tuberculosis  of  the 
prostate,  seminal  vesicles,  or  epididymis.     Some  cases  come  on  suddenly, 


964  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

many  tubercle  bacilli  being  found  in  the  urine.  In  many  cases  no  tubercle 
bacilli  are  found.  The  tuberculous  products  caseate  and  ulcers  or  fibrous 
organization  take  place.  A  cystitis  for  which  no  cause  can  be  found,  and 
which  is  accompanied  by  pyuria  and  severe  and  lasting  pain,  is  possibly 
tuberculous.  Pyuria  is  usually  present,  but  in  some  cases  the  urine  is  per- 
fectly clear.  In  some  cases  the  patient  has  painful  paroxysms  of  varying 
duration  and  feels  well  between  the  attacks.  The  urine  seldom  con- 
tains the  bacilli  of  tubercle.  Finding  tuberculosis,  if  of  the  kidney,  pros- 
tate, vesicle,  or  epididymis,  increases  the  probability  that  tuberculous  cystitis 
exists.  The  diagnosis  is  made  by  the  cystoscope.  Tuberculous  ulceration 
is  most  common  in  the  trigone  and  about  the  inner  orifice  of  the  urethra.  A 
tuberculous  ulcer  is  small.  The  adjacent  mucous  membrane  is  not  inflamed, 
but  contains  grayish-white  nodules  (Louis  E.  Schmidt,  in  "Jour.  Amer. 
Med.  Assoc,"  July  19,  1902). 

Treatment. — In  treating  chronic  cystitis  remove  the  cause,  if  possible 
(get  rid  of  a  stone,  evacuate  residual  urine  frequently,  dilate  a  stricture,  and 
remove  a  tumor).  For  chronic  cystitis  certain  remedies  are  taken  by  the 
mouth.  Water  is  drunk  in  large  amounts,  also  iron  spring- water  (Marienbad, 
etc.).  Salol  and  boric  acid,  gr.  v  of  each  four  times  a  day,  are  very  valuable. 
Salol  in  fluid  extract  of  triticum  repens  does  good;  so  does  chlorate  of  potas- 
sium, gr.  X  daily.  Either  borocitrate  of  magnesium,  quinin,  or  salicylate  of 
sodium  with  benzoic  acid  may  often  be  used  with  benefit.  Alum,  tannic 
acid,  uva  ursi,  copaiba,  cubebs,  buchu,  and  turpentine  have  all  been  recom- 
mended, and  possibly  may  be  of  some  benefit.  Urotropin  is  useful  in 
many  cases.  This  drug  prevents  the  development  of  bacteria  in  the  urine 
(Nicolaier),  and  antagonizes  the  tendency  to  sepsis  and  urinary  poisoning. 
It  is  given  in  5-grain  capsules,  from  four  to  six  being  given  daily.  Whatever 
remedy  is  used,  see  that  the  bowels  move  once  a  day,  and  that  the  skin  is  ac- 
tive. Champagne  and  beer  must  be  avoided.  If  residual  urine  gathers,  a  soft 
catheter  must  be  regularly  employed.  If  it  is  possible  to  introduce  a  catheter 
of  considerable  size,  catheterization  may  be  all  that  is  needed  in  the  case.  In 
some  cases  of  chronic  cystitis  the  retention  of  a  catheter  from  three  to  five 
weeks  is  of  the  greatest  service.  If  the  case  is  very  severe,  the  bladder  must 
be  washed  out  daily  with  peroxid  of  hydrogen  (25  to  40  per  cent,  solution), 
nitrate  of  silver  (i  :  8000),  boric  acid  (5  to  10  per  cent.),  carbolic  acid  (i  :  500), 
corrosive  sublimate  (from  i  :  5000  to  i  :  20,000),  or  permanganate  of  potas- 
sium (i  ;  4000).  If  nitrate  of  silver  or  permanganate  of  potassium  is  used, 
first  rinse  out  the  bladder  with  distilled  water.  If  any  other 'agent  is  used,  first 
wash  out  the  bladder  with  either  boiled  water  or  distilled.  The  daily  injection 
of  a  2  per  cent,  .solution  of  ichthyol  may  prove  useful.  Some  surgeons  occa- 
sionally employ,  at  intervals  of  a  number  of  days,  strong  silver  solutions  (30  or 
40  grains  to  the  ounce).  If  a  strong  solution  is  used,  after  the  drug  flows  away 
wash  out  the  bladder  with  a  solution  of  common  salt.  The  bladder  is  usually 
washed  out  by  attaching  to  the  free  end  of  a  soft  catheter,  the  other  end  of 
which  is  in  the  bladder,  a  tube  which  is  connected  with  a  graduated  bottle, 
the  force  being  obtained  by  elevating  the  reservoir  (fountain  irrigation). 
The  bladder  can  be  irrigated  without  using  a  catheter,  the  resistance  of  the 
compressor  mu.scle  of  the  urethra  being  overcome  by  the  pressure  of  a  column 
of  water.     The  reservoir  is  raised  to  the  height  of  six  feet.     The  patient  sits 


Ulcer  of  the  Bladder  965 

in  a  chair.  The  tube  of  the  reservoir  has  upon  it  a  clamf)  to  control  the  flow, 
and  in  its  end  a  large  bulbous  tip  which  will  fill  the  meatus  (\'alentine's  in- 
strument). The  tip  is  inserted  into  the  urethra,  the  clamp  on  the  tube  is 
loosened,  and  the  patient  is  directed  to  take  a  deep  inspiration.  In  a  short 
time  the  bladder  fills  with  water,  the  tube  is  removed,  and  the  patient  empties 
the  viscus  naturally.  In  some  cases  it  is  necessar\-  to  wait  quite  a  while  for 
the  column  of  water  to  tire  out  the  muscle.  If  the  fiuid  will  not  enter,  direct 
the  patient  to  make  efforts  as  in  micturating,  the  pressure  of  the  fluid  on 
the  anterior  surface  of  the  cut  off  muscles  being  kept  up.  If  this  fails  direct 
him  to  urinate,  and  then  the  surgeon  makes  another  attempt  to  get  the  fluid 
to  enter.     After  a  little  practice  a  patient  learns  how  to  admit  the  fluid. 

In  tuberculous  cystitis  Collin  advises  the  instillation  of  30  minims  of  the 
following  mi.xture  into  the  bladder  and  posterior  urethra:  5  gm.  of  guaiacol, 
I  gm.  of  iodoform,  100  gm.  of  sterile  olive  oil.  About  30  minims  of  this  are 
injected  once  a  day.  If  the  cystoscope  discloses  an  ulcer  and  the  kidney  is 
tuberculous,  it  is  useless  to  operate  on  the  ulcer  until  operation  has  been  per- 
formed on  the  kidney.  Sometimes  curetting  through  a  cystoscope  is  useful. 
In  other  cases  the  bladder  must  be  opened,  curetted,  and  drained.  In  ordinary 
non-tuberculous  cystitis  he  uses  a  i  per  cent,  solution  of  guaiacol  carbonate 
in  oil. 

If  the  ordinary  methods  of  treatment  fail  to  cure  chronic  cystitis,  if  the 
bladder  resents  catheterization  and  irrigation,  if  in  spite  of  irrigation  the 
urine  does  not  become  clear,  and  if  there  are  evidences  of  infection  of  the 
patient  and  breaking  down  of  his  general  health,  drain  by  perineal  or  supra- 
pubic cystotomy  and  through  the  incision  wash  the  bladder  frequently  and 
thoroughly.  If  the  persistent  cystitis  is  due  to  stricture  which  dilatation 
fails  to  cure,  perform  external  perineal  urethrotomy  and  employ  perineal 
drainage. 

Ulcer  of  the  Bladder. — May  be  due  to  injury,  cystitis,  tuberculosis, 
malignant  tumor,  or  gonorrhea.  A  form  of  ulceration  particularly  common 
in  anemic  women  is  a  solitary,  punched-out  ulcer  (Louis  E.  Schmidt,  "Jour. 
Amer.  Med.  Assoc,"  July  19,  1902).  Ulcers  may  be  single  or  multi])le. 
Perforation  may  occur. 

A  perforation  may  occur  into  the  peritoneal  cavity  or  into  the  perivesical 
cellular  tissue.  In  the  former  case,  after  the  onset  of  marked  hematuria, 
there  are  shock,  abdominal  pain,  and  peritonitis.  In  the  latter  case  there  is 
extravasation  of  urine  or  abscess-formation. 

Tuberculous  ulcer  is  discussed  on  page  964. 

Schmidt  ("Jour.  Amer.  Med.  A.ssoc,"  July  19,  1902)  points  out  that 
gonorrheal  ulceration  is  apt  to  be  multiple,  and  causes  severe  pain  and  bloody, 
turbid  urine.  As  a  rule,  when  the  bladder  is  ulcerated,  the  urine  contains 
blood,  blood-clots,  or  tissue  debris,  but  the  urine  may  be  clear  when  there  is  a 
tuberculous  ulcer  or  solitary  ulcer  (Schmidt,  in  previously  quoted  paper). 

Diagnosis  is  usually  made  by  the  cystoscope.  In  some  cases  it  is  made 
by  exploratory  suprapubic  incision. 

Treatment. — If  there  is  one  ulcer,  or  if  there  are  a  few  ulcers,  curel  through 
an  operating  cystoscope  (Schmidt),  use  irrigations,  and  keep  the  urine  aseptic. 
In  widespread  ulceration  perform  suprapubic  cystotomy,  curet  the  diseased 
mucous  membrane,  and  insert  a  drainage-tube.     In  some  cases  of  malignant 


966  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

growth  the  cautery  is  used  as  a  palHative  measure.  Perforation  is  treated 
as  is  rupture  of  the  bladder  (page  957). 

Tumors  of  the  Bladder. — Tumors  of  the  bladder  may  be  either  inno- 
cent or  malignant,  the  latter  being  the  commonest.  Innocent  tumors  which 
may  arise  from  the  bladder  are  papillomata  or  villous  tumors,  mucous  polypi, 
and  fibrous  polypi;  malignant  tumors  are  sarcoma  (rare)  and  carcinoma 
(encephaloid,  rare;  epithehoma,  common). 

Symptoms. — The  innocent  tumors  rarely  cause  cystitis  or  irritation, 
though  by  obstructing  the  ureters  or  the  urethra  they  may  induce  disease  of 
the  kidneys.  Often  hemorrhage  is  the  only  phenomenon  produced  by  a 
papilloma  or  a  mucous  polyp.  Malignant  tumors  cause  cystitis,  and  the  urine 
contains  mucus,  blood,  and  pus.  Innocent  tumors  are  felt  with  difficulty 
with  the  sound,  but  mahgnant  tumors  are  easily  felt.  In  some  cases  a  tumor 
can  be  detected  by  a  bimanual  examination  (a  finger  in  the  rectum  and  the 
fingers  of  the  other  hand  on  the  abdomen).  Make  a  careful  study  to  deter- 
mine whether  or  not  a  growth  has  infiltrated  the  prostate,  the  seminal  vesicles, 
the  rectum,  or  the  perivesical  tissues.  The  bleeding  in  bladder-growths  is 
apt  to  be  profuse,  and  it  occurs  intermittently.  Bleeding  follows  the  use  of  a 
sound.  There  may  be  difficulty  in  starting  the  stream  in  micturition,  or 
there  may  be  interruption  or  "  stammering"  of  the  stream.  The  urine  should 
be  examined  microscopically  to  see  if  it  contains  viUi,  portions  of  fibroma, 
colonies  of  cancer-cells,  or  fragments  of  epithelioma  (White).  A  cystoscope 
should  be  employed  in  order  to  reach  a  diagnosis.  In  doubtful  cases  ex- 
ploratory suprapubic  cystotomy  is  advisable. 

Treatment. — Complete  extirpation  has  been  performed  by  Bardenheuer 
and  others.  It  is  usually  done  in  two  stages,  in  the  first  operation  the  ureters 
of  a  man  being  transplanted  into  the  rectum,  the  ureters  of  a  woman  into  the 
rectum  or  vagina.  About  three  weeks  later  the  bladder  is  removed.  The 
complete  procedure  has  been  carried  out  successfully  at  one  operation  (Tuffier 
and  Dujarier,  "Rev.  de  Chir.,"  April,  1898).  The  operation  of  complete  extir- 
pation is  of  questionable  value.  As  a  rule,  a  surgeon  contents  himself  with 
suprapubic  cystotomy,  removing  the  growth  (Fig.  567),  and  if  removal  is  not 
possible,  with  drainage.  The  perineal  operation  only  enables  the  surgeon  to 
reach  and  remove  growths  of  small  size,  pedunculated  growths,  and  growths 
near  the  neck  of  the  bladder.  (See  Operations  on  the  Bladder.)  Chismore 
has  suggested  the  removal  of  polypoid  growths  by  means  of  Bigelow's  evacu- 
ator.  When  the  growth  catches  in  the  eye  of  the  instrument  it  is  torn  off  by 
sKght  traction  and  gentle  rocking,  and  the  suction  which  is  being  made  carries 
it  into  the  reservoir.  Henry  Morris  lays  down  the  following  rule:  "When  an 
infiltrating  growth  is  felt,  per  rectum  or  per  vaginam,  or  with  the  sound,  to 
be  involving  a  large  surface  of  the  bladder-wall,  to  be  infiltrating  its  coats, 
especially  in  the  neighborhood  of  the  ureters  and  neck  of  the  bladder,  no 
operation  whatever  should  be  proposed  unless  the  hemorrhage  is  copious  or 
the  symptoms  of  cystitis  severe,  and  then  an  incision  for  paUiative  purposes 
only  should  be  made"  (Treves's  "System  of  Surgery"). 

Operations  on  the  Bladder. — Lateral  Lithotomy. — Lithotomy  is 
the  removal  of  a  stone  from  the  bladder.  Lateral  lithotomy  is  an  operation 
which  is  every  year  becoming  less  popular,  but  which  is  still  employed  by 
many   famous  surgeons,   especially  for  stone  in   children.     This  operation 


Operations  on  the  Bladder  967 

should  not  be  performed  if  the  stone  is  over  two  inches  in  its  short  diameter; 
it  is  rarely  justifiable  if  the  stone  weighs  three  ounces  or  more  (Cage) ;  and 
it  must  not  be  performed  for  encysted  stone,  or  on  a  person  with  a  deep  peri- 
neum, a  narrow  pelvic  outlet,  or  an  enlarged  prostate.  For  one  week  before 
the  operation  keep  the  patient  in  bed,  wash  out  the  bladder  daily  with  hot 
boric-acid  solution,  and  administer  salol  and  boric  acid  by  the  mouth,  gr.  v 
of  each  four  times  a  day.  The  night  before  the  operation  give  a  saline,  order 
a  hot  bath,  and  have  the  perineum,  the  scrotum,  the  buttocks,  and  the  inner 
sides  of  the  thighs  cleansed  and  dressed  antisepticall}-.  In  the  morning  an 
enema  is  to  be  given.  At  the  time  of  operation  the  bladder  should  con- 
tain several  ounces  of  boric-acid  solution.  The  instruments  required 
are  a  lithotomy  knife,  a  straight  probe-pointed  bistoury,  a  grooved  staff,  a 
stone-sound,  stone-forceps  and  scoops,  a  tenaculum,  an  aneurysm  needle, 
a  fountain  syringe,  curved  needles  and  a  needle-holder,  hemostatic  forceps,  a 
tube  with  chemise  (Fig.  125),  a  Paquelin  cautery,  a  Clover  crutch,  and 
a  Hthotrite. 

Place  the  patient  upon  his  back,  anesthetize  him,  and  find  the  stone  by 
sounding.  If  the  stone  is  not  discovered  by  the  sound,  do  not  operate.  Place 
the  buttocks  so  that  they  project  beyond  the  edge  of  the  table,  introduce  the 
staff  into  the  bladder,  flex  the  legs  and  thighs,  and  fasten  the  patient  in  the 
lithotomy  position  with  a  crutch.  During  the  first  incision  the  handle  of  the 
staff  is  held  toward  the  belly;  after  the  first  cut  the  staff  is  set  perpendicularly 
and  is  hooked  up  under  the  pubes.  An  incision  is  made,  starting  just  to  the 
left  of  the  raphe  of  the  perineum  and  one  and  a  quarter  inches  in  front  of  the 
edge  of  the  anus,  and  passing  downward  and  outward  to  between  the  anus 
and  the  ischial  tuberosity,  but  one-third  nearer  the  former  than  the  latter.  In 
the  adult  this  incision  is  three  inches  long.  The  first  incision  is  superficial 
and  does  not  reach  the  staff,  but  it  is  this  incision  which  may  cut  the  rectum. 
After  making  the  first  cut  the  nail  of  the  left  index-finger  feels  for  the  groove 
of  the  staff,  the  staff  is  hooked  up,  the  knife  is  entered  into  the  groove  and  is 
pushed  into  the  bladder,  and  as  it  is  withdrawn  the  wound  is  enlarged.  As 
the  knife  enters  the  bladder  there  is  a  gush  of  fluid.  The  finger  follows  the 
knife  and  stretches  the  wound,  the  staff  is  withdrawn,  and  the  stone  is  felt  for 
and  extracted  with  forceps.  Liston  showed  years  ago  the  value  of  keeping 
the  finger  in  the  woiyid.  This  maneuver  retains  some  water  in  the  bladder, 
and  as  a  consequence  causes  the  stone  to  rest  at  the  lowest  part  of  the  viscus, 
and  when  the  forceps  are  introduced  they  at  once  come  upon  the  stone.  In 
withdrawing  the  stone  make  traction  in  the  axis  of  the  pelvis,  and  do  not  rotate 
the  calculus  until  it  is  entirely  out  of  the  prostatic  urethra.  Wash  or  scrape 
away  debris  or  incrustation  from  the  wall  of  the  bladder,  see  that  no  other 
stone  is  present,  syringe  out  the  viscus  with  warm  salt  solution,  insert  a  tube, 
apply  antiseptic  dressings  around  the  tube,  and  put  on  a  T-bandage.  The  end 
of  the  tube  which  is  external  to  the  dressings  is  fastened  to  the  tails  of  the 
T-bandage.  A  rubber  cloth  is  put  on  the  bed,  under  the  body  and  legs,  and 
the  patient's  buttocks  rest  upon  a  mass  of  old  linen,  the  .scrotum  being  raised 
on  a  pad.  The  knees  are  bent  oxer  jnllows.  Change  the  linen  as  soon  as 
it  becomes  wet.  Remove  the  tube  in  forty-eight  hours.  The  urine  begins 
to  come  by  the  urethra  from  the  eighth  to  the  twelfth  day.  In  children  the 
incision  is  not  so  long,  it  is  dilated  with   forceps  instead  of  with  the  finger, 


968  Diseases  and  Injuries  of  the  Genito-urinaiy  Organs 

and  no  tube  is  required.  In  lateral  lithotomy  the  prostatic  and  membranous 
portions  of  the  urethra  are  opened,  the  prostate  gland  is  partly  divided  with 
the  knife,  and  the  wound  is  dilated  with  the  finger.  One  objection  to  the 
operation  is  that  it  is  possible  to  cut  the  rectum,  and  another  is  that  inflam- 
mation mav  occlude  the  ejaculatory  ducts. 

Suprapubic  Lithotomy. — This  operation  is  the  removal  of  a  stone 
through  an  opening  above  the  pubes.  It  is  in  many  instances  the  preferable 
operation.  The  mortality  of  this  operation  is  higher  in  children  than  that  of 
lateral  hthotomy;  in  adults  and  in  individuals  beyond  middle  life  the  mor- 
tality is  decidedly  less  than  is  that  following  the  lateral  operation.  It  is  used 
for  the  removal  of  multiple  calculi,  for  very  hard  stones,  for  stones  above 
one  and  a  half  inches  in  diameter,  for  calcuh  in  men  with  enlargement  of 
the  prostate,  for  foreign  bodies  incrusted  with  sediment,  when  the  perineum 
is  deep,  when  the  pelvic  outlet  is  narrow,  for  encysted  stones,  for  calculi  asso- 
ciated with  a  vesical  tumor,  and  when  the  urethra  will  not  permit  the  use  of  a 
lithotrite.  The  patient  is  prepared  as  for  lateral  lithotomy,  except  that  the 
pubes  are  shaved,  and  the  lower  part  of  the  abdomen  and  the  upper  part  of 
the  thighs  are  disinfected.  During  the  operation  the  penis  is  wrapped  with 
a  piece  of  antiseptic  gauze.  The  instruments  required  are  a  scalpel,  a  probe- 
pointed  bistoury,  scissors,  a  tenaculum,  blunt  hooks,  hemostatic  forceps, 
retractors,  dissecting  forceps,  a  dry  dissector,  an  electric  forehead-light,  a 
rectal  bag,  a  brass  syringe  or  a  bicycle  pump,  a  sound,  rubber  tubing,  rubber 
catheters,  stone-forceps  and  scoops,  a  bladder-tube,  curved  needles  and  a 
needle-holder,  and  a  graduated  glass  jar  for  injecting  the  bladder. 

In  performing  the  operation  place  the  patient  in  the  Trendelenburg  posi- 
tion. It  is  necessary  to  distend  the  bladder  and  raise  it  in  order  to  have  the 
prevesical  space  uncovered  by  peritoneum.  Have  an  assistant  oil  the  rectal 
bag  and  push  it  above  the  sphincters.  Draw  off  the  urine  with  a  soft  catheter, 
wash  out  the  bladder  with  warm  boric-acid  solution  (gr.  iij  of  boric  acid  to 
.5j  of  water),  and  inject  the  bladder  with  the  same  solution.  In  a  child  under 
the  age  of  five  inject  three  to  four  ounces;  in  an  adult  inject  ten  to  twelve 
ounces.  Withdraw  the  catheter  and  tie  a  tube  around  the  penis  to  prevent 
the  escape  of  fluid.  After  injecting  the  bladder  with  fluid,  if  the  viscus  is  not 
well  lifted,  inject  the  rectal  bag  with  water  and  clamp  its  tube  with  forceps. 
In  a  child  inject  from  two  to  four  ounces  of  warm  water  into  the  rectal  bag; 
in  an  adult  inject  ten  ounces.  Bristow  suggested  the  injection  of  air  into  the 
bladder.  Some  surgeons  simply  inject  air  by  means  of  a  catheter  and  a  brass 
syringe  or  a  Davidson  .syringe.  If  air  is  injected,  a  rectal  bag  is  not  used, 
and  the  patient  is  placed  on  his  back  rather  than  in  the  position  of  Trendelen- 
burg. The  best  method  of  injecting  air  is  that  of  F.  Tilden  Brown,  by  means 
of  a  bicycle  pump.  A  catheter  is  introduced,  the  bladder  is  washed  out,  the 
catheter  is  fastened  to  a  bandage,  the  bicycle  pump  is  attached,  the  opera- 
tion is  proceeded  with,  and  when  the  transversalis  fascia  is  exposed  the 
bladder  is  filled  with  air,  the  soft  catheter  is  clamped,  and  the  bladder  is 
opened.*  Make  a  three-inch  longitudinal  incision  in  the  median  line  of  the 
hypogastric  region,  terminating  over  the  symj^hysis.  When  the  prevesical 
connective  tissue  is  reached,  cut  it.  If  the  peritoneum  should  appear,  push 
it  up.  Hold  the  wound-edges  apart  with  retractors.  The  large  veins  are 
*F.  Tilden  Brown,  Annals  of  Surgery,  Feb.,  1897. 


Litholapaxy 


969 


seen,  giving  the  bladder  a  blue  color.  Avoid  these  veins  if  possible,  but  even 
if  they  should  be  cut  bleeding  will  usually  cease  when  the  bladder  is  opened 
and  the  rectal  bag  is  removed.  Clamp  bleeding  vessels;  catch  the  bladder 
transversely  with  a  tenaculum  at  the  upper  angle  of  the  wound;  open  the 
viscus  in  the  middle  line  above,  and  cut  toward  the  pubes;  catch  the  edges  of 
the  bladder  with  hemostatic  forceps,  and  remove  the  tenaculum.  Explore  the 
bladder,  remove  the  stone  or  stones,  scrape  away  incrustations,  ligate  bleed- 
ing vessels  outside  the  bladder,  and  irrigate  the  viscus  with  hot  saline  solu- 
tion. Introduce  a  tube  into  the  bladder,  and  attach  to  its  external  end  a  long 
tube  to  siphon  off  the  urine.  The  blad- 
der can  be  drained  very  satisfactorily  by 
Keen's  siphonage  apparatus  (Fig.  561). 
Suture  the  muscles  and  fascia  at  the 
upper  part  of  the  wound.  Dress  with 
dry  antiseptic  gauze  and  a  rubber-dam, 
the  dressings  and  binder  being  split  to 
go  around  the  tube.  Catch  the  urine 
which  siphons  over  in  a  bottle  contain- 
ing some  antiseptic  fluid.  Change  the 
dressings  as  often  as  they  become  wet. 
Take  out  the  tube  in  four  or  five  days, 
and  allow  the  wound  to  heal  by  granu- 
lation. The  patient  may  get  up  in  two 
weeks.  Many  Continental  surgeons  ad- 
vocate immediate  suture  of  the  bladder 
after  incision.  Albert,  Vincent,  Bassini, 
DeVlaccos,  and  others  advocate  imme- 
diate suture.  The  suture  material  should 
be  silk  or  catgut.  After  suture  a  cathe- 
ter is  kept  in  the  bladder  to  drain  the 
viscus.  Immediate  suture  may  be  em- 
ployed in  patients  of  any  age,  but  should 
not  be  used  if  the  urine  is  very  septic  or 
if  pyelonephritis  exists.  In  some  cases 
the  attempted  closure  will  fail;  in  others 
it  will  only  partially  succeed;  in  many 
it  will  prove  successful;  but  even  if  it  only  partially  succeeds  it  will  tend  to 
prevent  dissemination  of  urine  in  the  prevesical  cellular  tissue.  The  chief 
causes  of  death  after  suprapubic  lithotomy  are  septicemia,  secondary  hem- 
orrhage, cellulitis,  peritonitis,  and  suppression  of  urine.  J.  W.  White  esti- 
mates the  relative  mortality  of  suprapubic  and  lateral  lithotomy  as  follows: 
In  children  the  suprapubic  operation  gives  a  mortality  of  12  per  cent., 
the  perineal  of  3  per  cent.  In  adults  the  suprapubic  gives  a  mortality  of  12 
per  cent.,  the  perineal  from  8  to  12  per  cent.  In  old  men  the  suprapubic 
gives  a  mortality  of  25  to  30  per  cent.,  the  perineal  30  to  40  per  cent. 

Crushing  of  Vesical  Calculi. — This  is  now  done  in  one  sitting,  the  old 
operation  of  Civiale,  which  rc(|uired  repeated  crushings,  being  obsolete. 

Litholapaxy  (Bigelow's  operation,  or  rapid  lithotrity)   is  the  operation 
for  removing  a  stone  from  the  bladder  in  one  sitting  by  thoroughly  crushing 


Fig.  561. — Keen's  modification  of  Cath- 
cart's  siphonage  apparatus  :  A',  Cavity  to  be 
drained  ;  A,  reservoir;  A',  tube  from  cavity; 
B,  tube  from  reservoir;  I/,  clamp  on  tube 
from  reservoir  ;  L,  L,  B,  glass  tubes  ;  C,  rub- 
ber tube  connecting  cavity-drain  with  reser- 
voir-drain ;  £,  S-shaped  rubber  tube  main- 
tained in  shape  by  hooking  up  at  /^;  G,  ves- 
sel containing  antiseptic  fluid. 


970 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


the  stone  and  completely  washing  away  the  fragments.  This  operation  is 
wonderfully  successful  if  done  by  an  expert.  Few  of  us  do  it  sufficiently 
often  to  learn  how  to  perform  it  with  great  rapidity,  certainty,  and  safety. 
It  is  the  best  operation  in  most  cases,  if  performed  by  a  very  skilful  man.  It  is 
the  operation  in  the  majority  of  cases  for  even  the  general  surgeon  to  select, 
but  the  general  surgeon  will  have  better  results  in  certain  difficult  cases  after 
suprapubic  lithotomy  than  after  litholapaxy.  Sir  H.  Thompson  says  this 
method  is  suited  to  twenty-nine  cases  out  of  thirty.  Litholapaxy  should  be 
employed  if  the  bladder  will  hold  at  least  four  ounces  of  fluid  and  is  in  a  fairly 
healthy  condition;  if  the  urethra  is  tolerant  and  penetrable  by  instruments; 
if  the  stone  is  not  too  hard,  does  not  weigh  over  two  and  three-quarter  ounces, 
and  is  not  over  two  inches  in  diameter.  It  is  not  suited  for  multiple  calculi, 
for  large  and  hard  calculi,  for  encysted  stones,  or  for  a  patient  with  marked 


Fig.  562. — Bigelow's  latest  evacuator. 


enlargement  of  the  prostate  gland,  with  vesical  atony,  or  with  cystitis.  An 
easily  dilatable  stricture  need  not  prevent  the  surgeon  doing  litholapaxy. 
The  stricture  can  first  be  dilated,  and  later  Bigelow's  operation  can  be  per- 
formed, but  firm,  gristly  strictures  demand  a  cutting  operation.  If  the  ure- 
thra is  intolerant  of  instrumentation,  the  patient  being  prone  to  febrile 
attacks  when  it  is  attempted,  cut  instead  of  crushing.  An  individual  labor- 
ing under  kidney  disease  will  do  better  after  this  operation  than  after 
cutting  (Cage).  In  diabetes,  locomotor  ataxia,  and  conditions  of  exhaustion 
patients  are  best  treated  by  Bigelow's  operation,  unless  cystitis  exists. 

The  Indian  surgeons  have  had  the  most  admirable  results  from  litho- 
lapaxy. It  has  often  been  claimed  that  such  results  were  due  to  racial  pecu- 
liarities of  the  patients  and  various  factors  regarding  their  habits,  diet,  etc. 
The  fact,  however,  that  some  of  these  very  surgeons  have  returned  to  England 


Litholapaxy 


971 


and  repeated  their  successes  in  London,  shows  how  large  a  part  masterly 
dexterity  played  in  obtaining  success. 

J.  A.   Cunningham  *  reports  upon   10,073   Indian  cases  of  litholapaxy. 
The  mortality  was  3.96  per  cent. 

Cabot,  of  Boston,  in  116  cases  had  but  four  deaths,  and 
two  of  these  were  due  to  pneumonia. 

The  preparation  of  the  bladder  is  the  same  as  for 
lithotomy.  Be  sure  to  measure  the  stone,  and  to  ascertain 
also  whether  a  lithotrite  can  readily  be  introduced  and 
manipulated.  The  instruments  required  are  a  stone- 
sound,  lithotrites  (several  sizes,  Figs.  563-565),  an  evacu- 
ating bulb  and  tubes  (straight  and  curved,  Figs.  562, 
566),  soft  catheters,  a  glass  irrigator  to  inject  the  bladder, 


Fig.  563. — Bigelow's 
lithotrite. 


Fig.  564. — Thompson's 
lithotrite. 


Fig.  565. — Forbes's 
lithotrite. 


and  instruments  in  case  the  surgeon  is  forced  to  cut.  The  patient  is 
anesthetized  and  is  placed  upon  his  back,  a  pillow  is  inserted  under  the 
pelvis,  and  he  is  well  wrapped  up.  The  urine  is  drawn  and  a  measured 
amount  of  warm  boric   acid   is   allowed   to  flow  into   the   bladder.     This 

*Brit.  Med.  Jour.,  Aug.  7,  1887. 


972 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


_^  STOHLMAN'Na 


plan  is  better  than  having  the  patient  retain  his  urine,  as  in  the  latter  case  there 
is  no  certainty  as  to  the  amount  of  fluid  in  the  viscus.  It  is  well  to  introduce 
at  least  five  or  six  ounces  of  fluid,  if  possible.  If  the  bladder  will  not  hold 
four  ounces  the  operation  is  unsafe  (Thompson).  The  lithotrite,  preferably 
the  instrument  of  Forbes  (Fig.  565),  is  now  introduced,  the  handle  being 
gradually  raised  to  a  vertical  position  as  the  penis  is  drawn  up  on  the  shaft,, 
but  not  being  depressed  until  the  instrument  has  passed  by  its  own  weight 
into  the  prostatic  urethra.  Thompson's  plan  for  catching  the  stone  is  as 
follows:  After  introducing  the  hthotrite,  let  its  lower  end  rest  for  a  few  seconds 
on  the  bottom  of  the  bladder,  so  that  currents  will  subside;  then  draw  back 

the  male  blade,  wait  a  moment,  close  the 
blades,  and  in  almost  every  instance  the 
stone  will  be  caught.  If  the  stone  is. 
caught,  press  firmly  to  see  that  the  cal- 
culus is  well  held,  lock  the  instrument,, 
and  break  the  foreign  body  by  screwing. 
When  resistance  suddenly  ceases  the 
stone  has  either  slipped  or  has  been 
crushed;  if  crushed,  the  blades  should 
have  been  felt  forcing  through  the  stone 
and  the  calculus  should  have  been  heard 
to  break.  When  resistance  ceases  catch 
and  crush  again  as  above  directed.  Rapid 
movements  with  the  lithotrite  are  im- 
proper, as  they  estabhsh  currents  which 
are  apt  to  push  away  the  stone.  If  the 
above  maneuver  does  not  catch  the  stone, 
see  if  the  calculus  be  near  the  neck  of  the 
bladder.  Pull  the  instrument  close  to  the 
vesical  neck,  and  open  it,  not  by  pulling 
the  male  blade,  but  by  pushing  the  female 
blade.  If  the  operator  still  fails  to  catch 
the  stone,  or  if,  after  crushing,  a  large 
fragment  knocks  against  the  evacuator, 
which  fragment  cannot  pass,  conduct  a  careful  search:  turn  the  blades  to  the 
right  side,  open,  and  close;  then  to  the  left  side,  open,  and  close;  next  turn  the 
point  around  behind  the  prostate  and  open,  and  close.  After  making  a  side 
search  with  the  hthotrite,  turn  the  instrument  very  slowly,  so  as  to  detect  the 
catching  of  the  bladder-wall  if  it  has  occurred,  and  crush  the  .stone  in  the 
middle  of  the  bladder  with  the  blades  up.  After  crushing  several  times, 
proceed  to  evacuate.  Fill  the  aspirator  with  warm  saline  fluid.  Insert 
an  evacuating  catheter,  its  point  being  in  the  center  of  the  bladder,  let 
the  fluid  and  fragments  run  out,  and  attach  the  aspirator  to  the  catheter; 
turn  the  valve,  and  compress  and  relax  the  bulb  so  that  an  ounce  or  more 
of  fluid  is  forced  in  at  each  squeeze,  the  compression  coinciding  with  expira- 
tion. The  debris  fafls  into  a  bulb,  and  the  pumping  is  continued  until  the 
fragments  cease  to  pass,  whereupon  the  point  of  the  catheter  is  pushed  against 
the  floor  of  the  bladder  and  another  trial  is  made.  If  fragments  which  cannot 
gain  exit  are  felt  knocking  against  the  tube,  withdraw  the  evacuator,  crush 


Fig.  566. — Thompson's  evacuator. 


Litholapaxy  in  Male  Children  973 

again,  and  again  use  the  aspirator.  When  no  more  debris  comes  away  and 
no  more  fragments  are  felt,  withdraw  the  tube  and  carefully  sound  the  blad- 
der. Keyes  advises  the  operator  to  seek  for  a  final  fragment  by  listening 
with  a  stethoscope  while  pumping  at  the  bulb  and  searching  the  bladder 
with  the  tube.  This  operation  will  rarely  occupy  over  forty  minutes,  though 
Bigelow  has  protracted  it  for  three  hours,  the  patient  recovering.  A  serious 
complication  is  severe  bleeding,  due  to  damage  done  with  the  instrument  or 
to  the  presence  of  a  tumor  which  easily  bleeds.  The  injection  of  moderately 
hot  water  or  of  adrenalin  solution  (i  :  10,000)  usually  checks  hemorrhage, 
but  if  bleeding  is  dangerous  in  amount  the  operation  of  litholapaxy  should  be 
abandoned  and  suprapubic  lithotomy  be  performed. 

If  clogging  of  the  lithotrite  with  fragments  occurs,  forcible  pushing  of 
the  blades  together  repeatedly  will  probably  amend  it;  but  it  will  never  happen 
if  the  surgeon  uses  a  proper  form  of  instrument.  A  lithotrite  with  a  fenes- 
trated blade  will  not  lock.  Forbes's  lithotrite  is  a  very  powerful  instrument, 
the  blades  of  which  will  not  lock.  If  the  blades  of  a  lithotrite  should  become 
forciblv  and  hopelessly  locked,  make  a  perineal  section,  clear  out  the  blades, 
close  them,  and  then  withdraw  the  instrument. 

Ajter-trealment. — Put  the  patient  to  bed,  apply  a  bag  of  hot  water  to  the 
hypogastrium,  and  give  him  a  hypodermatic  injection  of  morphin  as  he  re- 
covers from  ether.  Give  a  hot  hip-bath  every  night,  and  administer  lirjuor 
potassii  citratis  in  moderate  doses  every  day.  If  urethral  fever  occurs,  use 
quinin  and  morphin,  wash  out  the  bladder  several  times  daily  with  warm 
boric-acid  solution,  and  tie  in  a  rubber  catheter.  If  retention  occurs,  use 
the  catheter.  If  cystitis  appears,  treat  as  in  an  ordinary  case.  The  urine 
ceases  to  be  bloody  in  two  or  three  days,  and  the  patient  may  get  up  in  a  week. 

Litholapaxy  in  Male  Children. — It  was  considered  until  quite  recently 
that  a  child,  because  of  the  small  size  of  its  bladder,  the  small  diameter  of  the 
urethra,  and  the  readiness  with  which  the  mucous  membrane  is  lacerated  by 
even  slight  violence,  was  a  bad  subject  for  crushing.  Lateral  lithotomy  is 
known  to  be  eminently  successful  when  performed  upon  children.  The 
elder  Gross  did  this  operation  upon  72  children  with  only  2  deaths.  Keegan, 
however,  has  persuaded  the  profession  that  rapid  lithotrity  is  perfectly  appli- 
cable to  children:  He  shows  that  the  bladder  of  a  child  of  even  less  than  two 
years  of  age  is  quite  large  enough  to  allow  the  .surgeon  to  manipulate  an  in- 
strument; that  the  mucous  membrane  is  in  no  danger  if  the  operator  be  care- 
ful, and  that  the  urethra  is  by  no  means  so  small  as  was  supposed.  The 
urinary  meatus  must  often  be  incised,  and  after  doing  this,  Keegan  states, 
there  can  be  passed  in  a  boy  of  from  three  to  six  years  a  No.  7  or  8  lithotrite 
(English),  and  in  a  boy  of  from  eight  to  ten  years  a  No.  10  or  even  a  No.  14. 
It  is,  however,  just  to  state  that  the  operation  is  more  delicate  than  a  like 
procedure  on  older  persons,  and  that  no  one  is  justified  in  doing  it  who  has 
not  had  considerable  experience  in  adult  cases.  Furthermore,  it  .should  be 
noted  that  Keegan's  mortality  by  this  operation  has  been  4.3  per  cent.,  while 
Gross's  mortality  from  lateral  lithotomy  on  children  was  2.67  per  cent. 

Special  points  oj  litholapdxy  on  nialc  cJiihircn  are  as  follows:  use  well- 
fenestrated  lithotrites;  have  a  stylet  to  punch  out  the  fragments  blocking  the 
evacuator;  and  crush  the  stone  to  a  fine  mass.  There  can  usually  be  em- 
ployed a  No.  8  lithotrite  and  a  No.  8  evacuating-tube  (English  scale). 


974 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


Perineal  Lithotrity  (Keith's  Operation). — This  operation  is  employed 
by  some  surgeons  in  dealing  with  very  hard  or  very  large  calculi  in  male 
adults,  or  in  cases  in  which  it  is  impossible  to  introduce  a  lithotrite  into  the 
bladder.  Keith's  operation  consists  in  opening  the  urethra  from  the  peri- 
neum, passing  a  hthotrite  through  the  wound,  into  the  urethra  and  along  the 
urethra  into  the  bladder,  and  crushing  the  stone,  introducing  an  evacuator 
and  removing  the  fragments.  In  Keith's  operation  the  incision  is  median, 
and  opens  the  membranous  urethra.  In  very  large  stones,  Milton  thinks 
the  surgeon  should  open  the  bladder  as  in  ordinary  lateral  lithotomy,  in- 
troduce a  lithotrite  through  the  incision,  and  crush  the  stone  before  extract- 
ing it,  thus  avoiding  the  infliction  of  injury  upon  important  structures. 


Fig.  567. — Thompson's  vesical  forceps  for  removing  growths  in   the  bladder ;  for  growths  close  to 
the  neck  of  the  bladder,  with  separation  of  the  blades,  to  avoid  nipping  the  neck  of  the  bladder. 


Operation  for  Stone  in  Women, — If  the  stone  be  small,  give  the  patient 
ether,  place  her  in  the  lithotomy  position,  dilate  the  urethra  with  the  uterine 
dilator  until  it  admits  the  index-finger,  and  remove  the  stone  with  the  finger, 
the  scoop,  or  the  forceps.  If  the  stone  is  found  to  be  too  large  to  pass,  crush 
it  with  a  lithotrite  and  get  rid  of  the  debris  by  the  evacuator.  Large  stones 
(two  ounce.s)  may  require  suprapubic  lithotomy.  Vaginal  lithotomy  is  never 
required.  If  done,  it  is  very  likely  to  leave  as  a  legacy  a  vesicovaginal  fistula. 
In  female  children  dilate  the  urethra,  crush  the  stone,  and  evacuate. 

Cystotomy. — This  term  means  the  opening  of  the  bladder,  and  it  is 
usually  applied  to  an  opening  made  for  drainage,  for  diagnosis,  for  the  re- 
moval of  .stones  or  tumors,  or  for  the  treatment  of  ulcers.  This  opening  may 
be  done  by  (i)  a  suprapubic  cut  (as  in  suprapubic  lithotomy),  (2)  a  lateral 


Suprapubic  Cystotomy 


975 


Fig.  56S. — Seim's  sil 


perineal  cut  (as  in  lateral  lithotomy),  or  (3)   a  median  perineal  cut  (as  in 
median  lithotomy). 

The  operation  may  be  completed  in  one  sittintj;.  or  the  hhulder  may  be 
only  exposed,  the  opening  of  it  being  delayed  for  several  days  until  it  becomes 
adherent  to  the  margins  of  the  wound  (Senn's  operation).  Senn's  operation 
prevents  infiltration  of  urine  into 
the  prevesical  space,  and  it  is  ad- 
visable to  select  it  if  the  urine  is 
very  foul. 

A  sinus  may  persist  after 
suprapubic  cystotomy,  but  usu- 
ally the  w^ound  heals  unless  it  is 
kept  open  by  some  expedient. 

The  effects  of  suprapubic 
drainage  are  very  beneficial  in 
cases  of  chronic  cystitis  associated 

with  hypertrophy  of  the  prostate  gland,  the  urine  being  foul.  Drainage 
causes  the  urine  to  become  clear  and  the  mucous  membrane  of  the  bladder 
to  become  normal.  If  the  opening  is  made  as  a  permanent  drain,  there 
will  usually  be  incontinence,  as  the  new  channel  has  no  sphincter  action 
(Dandridge).  Figs.  568,  569,  570,  571,  have  tubes  for  prolonged  drainage. 
Suprapubic  Cystotomy. — The  operation  is  employed  to  allow  the  sur- 
geon to  explore  the  bladder,  to  treat 
an  ulcer,  to  provide  drainage,  or  to 
remove  a  tumor.  If  the  operation 
is  for  calculi,  it  is  known  as  supra- 
pubic lithotomy  (page  968).  After 
the  bladder  is  opened  its  interior 
can  be  illuminated  by  the  rays  of 
an  electric  lamp,  which  appliance  is 
fastened  with  a  mirror  to  the  fore- 
head of  the  operator.  If  an  ulcer 
is  found,  it  is  scraped  with  a  curet 
or  a  spoon.  Most  cases  of  tumor 
require  suprapubic  cystotomy.  It  is 
true  that  a  smali  single  growth  at 
the  vesical  neck  is  accessible  by 
median  cvslotoniw  Init  the  area  for 
manipulation  is  very  narrow  and  the 
growth  cannot  be  seen.  Every  large 
growth,  all  cases  of  multiple  tumors, 
and  all  cases  of  tumor  in  individuals 
with  great  depth  of  perineum  or  with 
enlarged  prostate  require  suprajnibic 
cystotomy,  an  operation  which  allows 
one  to  feel  and  to  see  the  growth,  which  gives  room  for  manipulation,  and  which 
permits  thorough  exploration  of  the  entire  bladder.  The  patient  is  put  in 
the  Trendelenburg  position  if  water  distention  is  used,  but  is  placed  horizon- 
tallv  if  air  distention  is  emploved.     After  t)pcning  the  lihidder  as   for  stone 


Fig.  569. — Senn's  tube  applied.  The  instrument 
does  not  press  upon  the  sensitive  neck  of  the  blad- 
der. 


9/6  Diseases  and  Injuries  of  the  Genito-urinaiy  Organs 

(page  968)  hold  the  edges  of  the  incision  apart  by  means  of  a  speculum 
(speculum  of  Keen  or  Watson)  or  with  retractors,  and  reflect  the  electric 
light  into  the  wound.  Growths  when  seen  can  be  twisted  off,  a  pair  of 
forceps  holding  the  base  and  another  pair  being  used  to  twist.  Broad 
growths  should  be  transfixed,  hgated,  and  severed.  Some  growths  (as  can- 
cer) are  removed  piece  by  piece  with  Thompson's  forceps  (Fig.  567),  the  base 
of  the  tumor  being  scraped.  Soft  growths  are  scraped  away  with  a  curet, 
a  spoon,  or  a  finger-nail.  If  bleeding  is  severe,  check  it  by  pressure,  by  hot 
water,  by  a  i  :  10,000  solution  of  adrenalin  chlorid,  or  even  by  the  actual 
cautery.  In  some  cases  the  wound  is  allowed  to  heal  rapidly.  In  others  the 
bladder  is  drained  for  a  considerable  time.  In  some  it  is  kept  open  perma- 
nently. Permanent  drainage  is  desirable  in  some  cases  of  enlarged  prostate, 
and  in  such  cases  Senn's  tube  may  be  employed  (Figs.  568  and  569),  or 
Stevenson's  tube  (Figs.  570  and  571). 

Median  Cystotomy. — The  same  incision  is  made  in  the  perineal  raphe  in 
median  cystotomy  as  for  median  lithotomy.  A  grooved  staff  is  introduced 
and  is  hooked  up  under  the  pubes;  an  incision  is  made  into  the  membranous 
urethra,  and  is  extended  backward  for  three-quarters  of  an  inch,  and  a  finger 
is  carried  into  the  bladder.  If  searching  for  a  growth,  find  it  with  the  finger, 
catch  it  with  Thompson's  forceps,  and  twist  it  off.  Soft  growths  can  be 
scraped  away.  Stop  bleeding  by  digital  pressure  or  by  injections  of  hot 
water  or  adrenahn  chlorid  (i  :  10,000).  If  median  cystotomy  does  not  allow 
access  to  the  tumor,  perform  suprapubic  cystotomy. 

Growths  in  the  Female  Bladder, — Dilate  the  urethra  as  in  a  case  of 
stone,  and  scrape,  twist,  or  pull  the  growth  away  or  ligate  it.  If  the  growth 
is  large  or  if  there  are  multiple  growths,  perform  suprapubic  cystotomy. 


Diseases  and  Injuries  of  the  Urethra,  Penis,  Testicle,  Prostate, 
Seminal  Vesicle,  Spermatic  Cord,  and  Tunica  Vaginalis. 

Injuries  of  the  penis  and  urethra  may  arise  from  traumatism  to  the  peri- 
neum or  the  penis,  from  cuts  and  twists  of  the  penis,  from  the  popular  "break- 
ing" of  a  chordee,  from  tying  strings  around  the  organ,  from  forcing  rings 
over  it,  from  the  passage  of  instruments,  or  from  the  impaction  of  calculi. 

Violence  inflicted    upon  an  erect    penis 
may    fracture    the    corpora    cavernosa. 
The  writer  saw  one   man  with  a  glass 
rod  broken  off  in  the  canal,  he  having 
been  in  the  habit  of  introducing  it  at  the 
dictate  of  morbid  sexual  excitement.     A 
patient  in  the  Insane  Department  of  the 
Philadelphia  Hospital  pushed  a  ring  over 
his  penis,  which  organ  was  lacerated  into 
the  urethra.     These  injuries  are  treated 
on  general  principles. 
Perineal    Bruises. — If    the    perineum  be  bruised   without   rupture  of 
the  urethra,  the  perineum  and  scrotum  swell  and  become  discolored;  water 
is  passed  with  difficulty  because  the  extravasated  mass  of  blood  in  the  peri- 
urethral tissues  occludes  more  or  less  the  canal;  the  water  is  not  bloody;  and 


Fig.  570.' 


-Stevenson's   su|)rapubic   drainage- 
tube. 


Rupture  of  the  Urethra 


977 


there  are  pain  and  profound  shock.  Some  authors  designate  as  rupture  those 
cases  in  which  laceration  of  the  spongy  tissue  occurs,  without  invoh-ement  of 
the  mucous  membrane  or  of  the  fibrous  coat,  but  they  are  properly  contusions. 

Treatment. — Place  the  patient  in  bed  and  establish  reaction,  and  when 
reaction  is  complete  employ  opiates  for  the  relief  of  pain.  Apply  an  ice-bag 
to  the  perineum.  If,  not- 
withstanding these  measures, 
swelling  continues,  introduce 
a  silver  catheter  (No.  12  Eng- 
lish), tie  it  in,  and  make  pres- 
sure upon  the  perineum  by  a 
firmly  applied  T-bandage  or 
by  a  crutch  braced  against  the 
foot-board  of  the  bed.  Even 
when  swelling  is  slight,  reten- 
tion of  urine  may  occur  from 
projection  of  a  submucous 
blood-clot  into  the  canal  of 
the  urethra.  In  some  cases  it 
may  become  necessary  to  in- 
cise and  evacuate  the  blood- 
clot.  After  twenty-four  hours 
have  passed,  if  hemorrhage 
has  ceased,  substitute  a  hot- 
water  bag  for  the  ice-bag, 
and  empty  the  bladder  regu- 
larly with  a  soft  catheter. 
Occasionally,  though  rarely, 
an  abscess  forms.  Punctured 
wounds  oj  the  urethra  require 
ordinary    dressings.      Incised 

■wounds  oj  the  urethra,  when  longitudinal,  are  closed  by  suture.  Healing  is 
rapid,  and  ill  consequences  are  not  to  be  feared.  Stricture  does  not  follow. 
When  the  wound  is  transverse,  introduce  a  catheter,  suture  the  wound  over 
the  instrument,  and  remove  the  catheter  at  the  end  of  the  third  day.  If  a 
catheter  cannot  be  introduced,  employ  sutures,  but  at  the  first  evidence  of 
extravasation  open  the  wound,  and  if  drainage  is  not  free  perform  external 
perineal  urethrotom}'. 

Rupture  of  the  Urethra. — By  this  term  is  meant  a  lacerated  or  a  con- 
tused wound  of  the  urethra,  destroying  partially  or  entirely  the  integrity  of 
the  canal.  A  lacerated  wound  may  be  induced  by  fracture  of  the  cavernous 
bodies  during  erection,  the  .symptoms  being  severe  hemorrhage,  intense  pain, 
retention  of  urine,  and  inability  to  pass  an  instrument;  infiltration  of  urine 
occurs,  and  gangrene  is  a  common  result.  The  writer  has  seen  one  case  of 
rupture  of  the  penile  urethra  due  to  a  man's  slipping  while  .shaving,  the  penis 
being  caught  in  a  partially  open  drawer,  the  drawer  being  shut  by  his  body 
coming  against  it.  Rupture,  however,  is  almost  invariably  located  in  the  peri- 
neum, and  it  arises  when  the  urethra  is  suddenl)-  and  forcibly  pressed  against 
the  arch  of  the  pulses  In-  a  blow,  h\  a  kick,  or  bv  fallinij  astride  a  beam  or  a 
62 


Fig.  571- 


-Stevenson's  suprapubic  drainage-tube  in  place 
and  attached  to  a  receptacle  for  urine. 


978 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


fence-rail.  Retention  of  urine  due  to  stricture  may  lead  to  extravasation 
of  urine.  The  lesion  of  urethral  rupture  consists  in  some  cases  of  lacera- 
tion of  the  spongy  tissue  and  the  mucous  membrane,  a  cavity  being  formed 
which  communicates  with  the  canal,  and  which  fills  with  urine  during  mic- 
turition. In  other  cases  not  only  the  spongy  tissue  and  the  urethral  mucous 
membrane  are  rent  asunder,  but  the  fibrous  coat  is  also  torn,  the  canal  opening 
directly  into  the  perineal  tissues,  among  which  a  huge  cavity  forms,  that 
fills  with  blood  and  later  with  urine  and  pus.  The  urethra  may  be  torn 
entirely  across,  but  in  most  cases  a  small  portion  at  least  of  its  circumference 
is  uninjured.  Rupture  never  occurs  primarily  and  alone  in  the  prostatic 
urethra;  it  is  extremely  rare  in  the  membranous  urethra  unless  due  to  pelvic 
fracture;  and  it  is  very  unusual  in  the  penile  urethra.     The  seat  of  rupture 

in  the  great  majority  of 
cases  is  in  the  region  of 
the  bulb.  Very  rarely  is 
the  skin  broken. 

Symptom  s. — The 
symptoms  of  rupture  of 
the  urethra  are  consider- 
able pain,  aggravated  by 
motion,  pressure,  and  at- 
tempts to  pass  water; 
great  shock;  in  some 
cases  micturition  is  still 
possible,  blood  preceding 
and  also  discoloring  the 
stream,  for  some  blood 
usually  runs  into  the 
bladder;  retention  of  urine 
quickly  arises;  in  a  vast 
majority  of  the  cases  re- 
tention is  absolute  from  the  very  first,  and  it  is  due  to  the  interrup- 
tion in  the  integrity  of  the  canal  and  to  the  occlusion  of  the  chan- 
nel by  blood-clots.  Bleeding,  which  is  usually  free,  lasts  for  several 
hours,  some  little  blood  generally  appearing  externally  and  much  being 
retained  in  the  perineum,  inducing  progressive  swelling.  The  pres- 
ence of  a  large  swelling  is  regarded  as  evidence  of  urethral  rupture.  The 
blood  which  is  effused  in  the  perineum  may  extend  under  the  fascia  to 
the  penis  and  scrotum  (Fig.  572).  The  swelling  soon  becomes  reddish, 
purple,  or  even  black,  pressure  upon  it  is  apt  to  cause  blood  to  run  from  the 
meatus,  and  it  is  augmented  in  volume  when  attempts  are  made  to  urinate. 
After  a  time,  if  the  surgeon  does  not  act,  the  urine  fills  the  perineal  cavity  and 
widely  infiltrates,  and  there  ensue  gangrene,  sloughing,  and  sepsis,  life  being 
endangered  or  fistula*  Ijeing  left  as  legacies.  The  course  of  the  extravasated 
urine  will  often  enable  one  to  locate  the  seat  of  injury.  In  rupture  of  the 
membranous  urethra,  if  uncomplicated,  the  urine  remains  between  the  two 
layers  of  the  triangular  ligament  until  a  channel  is  opened  for  it  by  sloughing 
or  by  the  knife.  When  extravasation  occurs  behind  the  posterior  layer  of 
the  ligament  the  urine  finds  its  way  to  the  perineum  in  the  neighborhood  of 


Fig.  572. — Ruptured  urethra. 


Foreign  Bodies  in  the  Urethra  979 

the  anus.  \Mien  the  rupture  is  in  front  o{  the  anterior  layer  of  the  h'gament 
the  urine,  directed  by  the  deep  layer  of  the  superficial  fascia,  finds  its  way 
into  the  scrotum  and  up  on  the  belly,  but  does  not  pass  into  the  thighs.  A 
contusion  is  distinguished  from  a  rupture  by  the  facts  that  in  the  former  the 
perineal  swelling  is  not  very  extensive  and  does  not  enlarge  on  attempting 
micturition,  while  in  the  latter  it  is  exten.sive  and  does  enlarge  on  attempting 
to  pass  water.  Furthermore,  contusion  does  not  cause  urethral  hemorrhage, 
while  rupture  does.  A  contusion  sometimes,  but  not  often,  prevents  the 
passage  of  a  catheter;  a  rupture  almost  always,  but  not  invariably,  does  so. 
The  mortahty  from  severe  rupture  with  extravasation  is  about  14  per  cent. 
(Kaufman). 

Treatment. — In  some  cases  it  is  possible  to  suture  the  urethra,  and  this 
procedure  should  be  carried  out  when  possible.  In  order  to  suture,  perform 
suprapubic  cystotomy  and  also  make  a  perineal  section.  Find  the  posterior 
end  of  the  ruptured  urethra  by  passing  a  catheter  from  the  bladder  into  the 
urethra.  Suture  with  silk.  The  sutures  pass  through  all  of  the  coats  of  the 
urethra.  The  roof  of  the  canal  is  sutured  first,  then  a  steel  sound  is  intro- 
duced from  the  meatus,  and  the  urethra  is  sutured  around  the  instrument. 
The  sound  is  withdrawn  and  the  bladder  is  drained  by  Cathcart's  siphon  as 
modified  by  Keen  (Fig.  561).*  In  recent  cases  of  ruptured  urethra  the  usual 
treatment  is  as  follows:  Immediately  perform  median  perineal  section  and  turn 
out  the  clot;  trim  ofi  lacerated  edges;  find  the  proximal  end  of  the  urethra, 
pass  a  catheter  from  the  meatus  into  the  bladder,  and  leave  it  in  situ  until  heal- 
ing has  begun  around  it.  If  the  catheter  cannot  be  passed  from  the  meatus, 
open  the  bladder  above  the  pubes  and  find  the  posterior  urethra  by  retrograde 
catheterization.  In  retrograde  catheterization  we  push  an  instrument  from 
the  bladder  into  the  wound  and  use  it  to  guide  a  catheter  from  the  meatus  into 
the  bladder.  When  rupture  occurs  back  of  a  stricture  it  is  a  good  plan  to 
excise  the  cicatricial  tissue.  In  cases  with  extravasation  make  a  median 
incision  and  numerous  transverse  cuts  to  secure  drainage  for  areas  of  retained 
urine  or  pus.  Then,  at  once  perform  suprapubic  cystotomy.  Drain  supra- 
pubically  and  from  the  perineum  for  about  two  weeks,  by  which  time  slough- 
ing tissue  will  have  separated.  Then  find  the  posterior  urethra  by  retrograde 
catheterization  and  do  a  perineal  operation  to  repair  the  damaged  urethra. 
(See  Eugene  Fuller,  in  "N.  Y.  Med.  Jour.,"  Nov.  23,  1901.)  The  wound 
is  packed  with  iodoform  gauze,  and  the  bowels  are  tied  up  with  opium  for  a 
few  davs.  Alanv  surgeons  strongly  disapprove  of  the  custom  of  retaining 
the  catheter,  believing  that  the  instrument  does  no  real  good,  as  urine  is  cer- 
tain to  get  between  the  catheter  and  the  walls  of  the  urethra.  In  fact,  it  is 
quite  enough  to  stuff  the  wound  with  gauze,  the  patient  urinating  through 
the  wound  for  the  first  few  days,  after  which  time  a  catheter  is  used  at  regular 
intervals.  Whatever  method  is  employed,  healing  will  require  from  six  to 
eight  weeks,  and  the  patient  must  during  the  rest  of  his  life,  from  time  to 
time,  introduce  large-sized  bougies. 

Foreign  Bodies   in   the   Urethra. — The.se  bodies  may  be  calculi, 

bodies  introduced  by  injury,  as  shot,  bone,  etc.,  bodies  entering  from  a  fis- 
tulous opening  into  the  rectum,  or  bodies  introduced  from  the  meatus,  as 
broken  bits  of  catheters,  straws,  pins,  etc. 

*  See  Weir's  report  in  Medical  Record,  May  9,  1S96. 


980  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

The  symptoms  vary  with  the  size  and  the  nature  of  the  body.  Some- 
times there  are  almost  no  symptoms;  at  other  times  there  are  found  great 
pain,  retention  of  urine,  and  hemorrhage.  Examination  is  made  by  feeling 
carefully  with  a  finger  in  the  rectum  and  b}'  searching  very  gently  with  a 
sound,  taking  care  not  to  push  the  body  back.  If  the  bladder  is  well  filled 
with  water  when  the  body  becomes  impacted,  inject  a  little  oil  into  the  meatus, 
close  the  lips  with  the  fingers,  and  direct  the  patient  to  forcibly  attempt 
urination,  the  surgeon  opening  the  meatus  when  the  urethra  is  widely  dis- 
tended, the  foreign  body  being  often  forced  out.  If  this  maneuver  fails,  and 
the  foreign  body  is  impacted  in  the  pendulous  urethra,  prevent  its  backward 
passage  by  at  once  tying  a  rubber  tube  around  the  penis.  Try  to  squeeze  the 
body  out,  and,  if  unsuccessful,  endeavor  to  catch  it  with  a  wire  loop,  with  a 
scoop,  or  with  the  long  urethral  forceps.  If  these  methods  fail,  cut  down 
upon  the  body  and  remove  it,  dividing  any  existing  stricture.  If  it  is  lodged 
just  back  of  the  meatus  incision  of  the  meatus  will  permit  extraction.  If  a 
hairpin  is  in  the  canal,  the  feet  of  the  pin  are  almost  always  pointing  to  the 
meatus;  to  prevent  them  catching  on  attempted  withdrawal,  the  penis  must 
be  squeezed  to  approximate  the  feet,  and  when  they  are  adjacent  a  part  of  a 
silver  catheter  is  slipped  over  to  retain  them  in  this  position,  when  the  pin 
can  be  extracted.  If  this  fails,  drag  the  penis  against  the  belly,  by  rectal 
touch  force  the  sharp  ends  of  the  pin  out  through  the  integument,  cut  one 
end  off,  and  then  withdraw  the  other.  An  ordinary  large-headed  pin  is  forced 
out  in  the  same  way,  and  when  the  head  is  turned  externally  it  is  extracted 
by  way  of  the  meatus.  If  a  hard  or  sharp  foreign  body  is  lodged  in  the 
prostatic  urethra,  do  not  catch  it  with  an  instrument  and  try  to  drag  it  for- 
ward. To  do  so  will  be  apt  to  tear  the  membranous  urethra.  It  is  better  to 
push  it  into  the  bladder  and  remove  it  later  by  cutting,  or,  if  it  be  a  stone,  by 
crushing  (H.  Hartmann,  in  "La  Presse  Med.,"  July  24,  1901).  If  a  litho- 
trite  loaded  with  fragments  be  caught  in  the  urethra,  the  surgeon  must 
perform  a  perineal  section,  to  enable  him  to  clean  and  close  the  blades. 
After  the  blades  have  been  closed  the  instrument  may  be  easily  withdrawn. 

Urethrorrhea  is  not  urethral  inflammation,  but  is  a  condition  of  sensi- 
tiveness of  the  urethra  and  over.secretion  of  the  glandular  elements.  It  may 
be  due  to  masturbation,  sexual  excess,  and  also,  as  Sturgis  points  out,  to  with- 
drawal during  sexual  intercourse,  and  to  ungratified  sexual  passion.  A  drop 
or  two  of  transparent  mucus  is  found  at  the  meatus  in  the  morning,  and  a 
considerable  amount  may  flow  away  while  straining  at  stool  or  upon  the  dimi- 
nution of  an  erection.  This  ilow  at  .stool  is  often  called  defecation  spermat- 
orrhea. This  discharge  stains  but  does  not  stiffen  linen  (Sturgis).  The 
discharge  contains  mucus,  mucous  corpuscles,  epithelial  cells,  sometimes 
.spermatozoids,  but  no  gonococci  or  pus  organisms.  The  patient  may  be 
well  in  all  other  respects,  but  in  many  cases  there  are  neurasthenic  symp- 
toms, sexual  weakness,  or  even  impotence. 

Treatment. — In  an  uncomplicated  ca.se  improvement  or  cure  will  follow 
uj)on  the  abandonment  of  evil  habits.  If  complications  arise,  they  must  be 
treated. 

Urethritis,  or  Inflammation  of  the  Urethra.— Urethral  inflamma- 
tions can  Ije  divided  into  two  classes:  (i)  simple,  in  which  infection  is  due 
alone  to  pyogenic  cocci,  and  (2)  specific,  in  which  the  gonococcus  is  present. 


Tuberculous  Urethritis  g8  I 

Simple  urethritis  may  he  due  to  several  causes,  such  as  traumatism; 
great  acidity  of  the  urine;  chancre  in  the  urethra;  contact  with  menstrual 
fluid,  leukorrheal  discharge,  the  discharge  from  malignant  disease  of  the 
uterus,  ordinary  pus,  or  acrid  vaginal  discharge;  the  passage  of  instruments; 
the  administration  of  irritant  diuretics;  strong  injections;  worrr^s  in  the  rec- 
tum; a  febrile  m.alady;  venereal  excess  and  masturbation;  and  the  passage 
or  impaction  of  foreign  bodies.  A  temporary  and  mild  urethritis  sometimes 
accompanies  early  syphilitic  eruptions.  Simple  urethritis  is  less  severe  and 
prolonged  than  gonorrheal  urethritis,  though  clinically  in  the  early  stage 
the  physician  cannot  invariably  distinguish  between  the  two  forms.  The 
gonococcus  is  never  found  in  the  discharge  of  simple  urethritis.  In  the  ncjn- 
specific  inflammation  pus  is  not  always  present,  many  cases  stopping  short 
of  pus-formation  after  a  varying  period  of  catarrh,  but  any  catarrh  may  be- 
come purulent.  A  simple  urethritis  may  be  caused  or  may  be  prolonged  for 
an  indefinite  period  by  the  presence  of  large  amounts  of  oxalate  in  the  urine 
or  the  existence  of  the  uric-acid  diathesis  (see  Gouty  Urethritis). 

Treatment. — Seek  for  the  cau.se  and  remove  it.  Correct  anv  abnormal 
condition  of  the  urine  by  means  of  suitable  diet,  drugs,  and  mode  of  life. 
Mild  astringent  injections  are  useful.  It  may  be  necessary  to  flush  the  urethra 
repeatedly  with  a  solution  of  silver  nitrate  (i  :  Sooo). 

Traumatic  Urethritis. — The  pain  in  traumatic  urethritis  is  coincident 
with  the  introduction  of  the  foreign  body.  The  discharge,  which  may  be 
bloody,  mucous,  mucopurulent,  or  purulent,  comes  on  within  twenty-four 
hours. 

Treatment. — If  the  inflammation  is  slight,  prescribe  diluent  drinks,  pare- 
goric, and  a  saline.  If  severe,  put  the  patient  to  bed,  apply  hot  fomentations 
to  the  perineum,  give  diluent  drinks,  employ  suppositories  of  opium  and 
belladonna,  and  watch  for  fever  and  other  complications. 

Gouty  Urethritis. — This  condition  first  manifests  it.self  in  the  posterior 
urethra,  not  in  the  anterior,  as  does  clap.  Its  symptoms  are  great  vesical 
irritability;  pain  on  urination;  discharge,  usually  scanty,  associated  with  uric 
acid  in  the  urine  or  other  symptoms  of  gout.  The  treatment  comprises  dieting 
and  the  usual  remedies  for  gout.  Purgatives  are  given  freelv,  and  full  doses 
of  colchicum,  piperazin,  urotropin,  or  the  alkalies;  hot  ])alhs,  low  diet,  diluent 
drinks,  and  diaphoretics  are  indicated.  A  chronic  discharge  from  the  i)ros- 
tatic  region  is  apt  to  linger;  for  this  there  is  nothing  better  than  the  u.'^ual 
gouty  remedies  and  .'valine  waters  with  copaiba,  cubebs,  or  sandalwootl  oil. 
In  many  cases  it  is  necessary  to  flush  the  urethra  once  a  day  with  a  solution 
of  silver  nitrate  (i  :  8000). 

Eczematous  Urethritis. — Berkley  Hill  states  that  tliis  disease  is  very 
obstinate,  is  probably  associated  with  gout,  and  is  nut  with  in  adults  of  full 
habit  or  who  are  beer-drinkers  and  who  have  eczema  of  the  surface  of  the 
body.  ?Ie  states  also  that  the  glans  penis  near  the  meatus  is  red  and  tender, 
and  that  the  interior  of  llie  urethra  is  in  the  same  condition.  Pain  is  constant, 
and  it  is  aggravated  on  miclurili<)n.  The  discharge  is  scanty.  The  treatment 
comprises  injections  of  cold  water  or  irrigation  with  iced  water,  and  internally 
the  administration  of  arsenic  with  the  alkalies. 

Tuberculous  urethritis  is  due  to  a  tuberculous  ulcer,  which  is  most  apt 
to  be  seated  near  the  ve.sical  neck.     There  is  a  little  pain  on  micturition,  but 


982  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

there  is  intense  pain  at  one  spot  on  passing  a  bougie.  The  discharge  is  sHght 
and  at  times  bloody.  The  bladder  is  very  irritable,  and  severe  cystitis  arises 
and  persists.  The  treatment  includes  warmth,  nutritious  diet,  and  cod-liver 
oil,  removal  to  an  equable  climate,  and  living  as  much  as  possible  out  of 
doors.  The  bladder  is  washed  out  once  a  day  with  boric-acid  solution. 
Iodoform  emulsion  is  injected  daily,  but  after  a  time  the  surgeon  will  be  forced 
to  drain  by  perineal  or  suprapubic  cystotomy. 

Examination  when  a  Urethral  Discharge  Exists. — Learn  accu- 
rately the  history.  Obtain  some  of  the  discharge  and  examine  an  unstained 
slide  and  a  shde  stained,  for  gonococci.  In  some  cases  take  cultures.  Learn 
the  amount  of  the  twenty-four  hours'  urine  and  study  a  sample  chemically 
and  microscopically,  being  sure  to  determine  the  amount  of  urea.  Learn  if 
the  discharge  discolors  or  stiffens  linen;  if  it  is  only  found  in  the  morning; 
if  it  simply  glues  the  lips  of  the  meatus  together;  if  it  is  seen  during  the  day; 
if  it  is  noted  particularly  or  only  after  sexual  excitement  or  straining  at  stool. 
Inquire  as  to  pain,  frequency  of  micturition,  passage  of  blood,  nocturnal 
emissions,  manner  of  urinating,  etc.  In  many  cases  insert  a  finger  in  the 
rectum,  feel  the  prostate  and  vesicles,  massage  them,  and  see  if  discharge 
appears  at  the  meatus  after  stripping  the  penis.  If  discharge  does  ap- 
pear, collect  a  specimen  and  examine  it.  In  some  cases  it  is  necessary  to 
pass  a  sound.  Follow  Valentine's  advice  and  cleanse  the  meatus,  glans, 
prepuce,  and  urethra  before  passing  a  sound.  Cleanse  the  meatus,  glans, 
and  prepuce  with  a  i  :  6000  solution  of  corrosive  sublimate.  Irrigate  the 
urethra  with  boracic-acid  solution  and  fill  the  clean  urethra  with  emulsion 
of  iodoform  and  glycerin  (5  per  cent.),  and  after  using  the  instrument  irrigate 
again  with  boracic-acid  solution  (Valentine's  method).  Examine  the  urine 
by  the  three-glass  test. 

The  Three-glass  Test  (Valentine's  Plan). — Take  as  many  three-ounce 
tubes  as  are  required  to  receive  all  the  urine  from  the  bladder.  The  first  tube 
■contains  the  washings  from  the  anterior  urethra.  The  second  and  other 
tubes,  additional  material  from  the  bladder.  The  last  tube  contains  material 
expressed  from  the  posterior  urethra,  prostate,  and  seminal  vesicles.  Ex- 
amine the  urine  and  the  sediment  in  the  first  two  glasses  and  in  the  last 
glass.  Note  particularly  if  shreds  are  present.  The  shreds  of  gonorrhea  are 
white  in  color  and  of  variable  length,  and  float  in  the  urine.  They  are  com- 
posed of  pus-corpuscles  and  of  epithelial  cells  which  have  undergone  fatty 
degeneration.  Many  of  these  shreds  form  in  the  ducts  of  Cowper's  glands, 
but  the  glands  of  the  entire  length  of  the  urethra  also  furnish  them. 

Gonorrhea    (Clap;    Specific    Urethritis;    Tripper;    Venereal 

Catarrh). — Gonorrhea  is  an  acute  inflammation  of  the  genital  mucous 
membrane,  of  venereal  origin,  due  to  the  deposition  and  multiplication  of 
gonococci  in  the  cells  of  the  membrane  and  a  mixed  infection  with  the  cocci 
of  suy^puration.  In  the  male,  clap  begins  within  the  meatus  and  fossa  navicu- 
laris  and  extends  backward  throughout  the  length  of  the  urethra.  The  mucous 
membrane  swells  and  becomes  hyperemic,  and  there  is  a  discharge,  first  of 
mucus  and  serum,  and  then  of  pus.  In  .severe  cases  the  discharge  is  bloody 
(black  gonorrhea).  For  a  week  or  more  the  inflammation  increases,  then 
becomes  .stationary  for  a  time,  and  then  declines,  the  discharge  growing  less 
profuse  and  thinner,  a  watery  discharge  lasting  for  some  little  time.     An 


Gonorrhea  98  3 

« 

ordinary  case  of  genuine  gonorrhea  kists  from  six  to  ten  weeks,  and  even  a 
case  hmited  purely  to  the  anterior  urethra  will  rarely  be  cured  within  four  or 
five  weeks.  During  the  acute  stage  the  entire  penis  swells  and  the  corpus 
spongiosum  becomes  infiltrated  with  inflammatory  exudate.  Gonorrhea 
may  produce  systemic  complications  and  tends  particularly  to  attack  serous 
membranes  or  other  endothelial  structures  (joints,  pericardium,  pleura, 
tendon-sheaths,  intima  of  vessels,  etc.).  Among  the  complications  are  gonor- 
rheal arthritis,  myelitis,  poliomyelitis,  and  multiple  neuritis.  There  are  3 
cases  of  gonorrheal  myositis  on  record  (Martin  \\".  Ware,  "Am.  Jour.  Med. 
Sciences,"  July,  1901).  Phlebitis  or  endocarditis  may  ari.se  and  cerebral 
embolism  may  result.  Cerebrospinal  meningitis  can  occur  (fluid  obtained 
by  lumbar  puncture  contains  gonococci).  , 

Gonorrheal  rheumatism  is  discussed  on  page  485.  Gonorrheal  peritonitis 
is  rare.  Infection  of  the  peritoneum  through  the  blood  is  very  rare.  The 
majority  of  cases  of  gonorrheal  peritonitis  occur  in  women  and  are  due  to 
direct  extension  from  the  Fallopian  tubes.  Gonococci  have  not  been  found 
in  the  exudates  of  cases  of  pleuritis  and  pericarditis  supposed  to  be  of  gonor- 
rheal origin.  True  gonorrheal  septicemia  occasionally  occurs.  In  one  case 
Blumer  and  Hayes  found  the  bacteria  in  the  blood.  A  child  may  contract 
gonorrheal  ophthalmia  during  delivery,  and  any  person  may  develop  it  by 
getting  gonococci  into  the  eyes. 

Symptoms  oj  Acute  Inflammatory  Gonorrhea. — The  period  of  incubation 
of  gonorrhea  is  from  a  few  hours  to  two  weeks.  The  patient  notices  on  arising 
a  drop  of  thin  fluid  which  glues  together  the  lips  of  the  meatus,  and  he  feels 
some  pain  on  urination.  The  meatus  is  red  and  swollen.  Within  forty- 
eight  hours  the  first  stage,  or  the  stage  of  increase,  becomes  established.  The 
meatus  is  now  red,  swollen,  and  everted  (fish-mouth  meatus);  micturition 
causes  severe  pain  (ardor  urinae) ;  chordee  occurs,  especially  when  the  patient 
is  warm  in  bed.  Bv  chordee  we  mean  a  condition  of  painful  erection  in  which 
the  penis  is  markedly  bent.  The  rigid  infiltration  of  the  corpus  spongiosum 
prevents  it  distending  to  accommodate  itself  to  the  enlarged  corpora  caver- 
nosa, and  in  consequence  the  organ  curves.  There  is  frequent  micturition 
with  tenesmus,  and  a  profuse  discharge  which  is  yellow,  greenish,  or  even 
bloody.  The  complications  of  this  stage  are  balanitis  (inflammation  of  the 
mucous  membrane  of  theglans  penis),  ba/auopostlritis (inHammationoi  the  sur- 
face of  the  glans  and  the  mucous  membrane  of  the  prepuce),  phimosis  (thicken- 
ing and  contraction  of  the  foreskin  so  that  the  glans  cannot  be  uncovered),  and 
paraphimosis  (catching  and  fixation  of  the  retracted  prepuce  behind  the  corona 
glandis).  In  the  second  or  stationary  stage,  which  lasts  from  the  end  of  the 
first  to  the  end  of  the  second  week,  the  acute  symptoms  of  the  first  stage  con- 
tinue. The  complications  of  this  stage  are  peri-urethral  abscess,  lymphan- 
gitis, solitary  and  painful  bubo  of  the  groin  which  may  suppurate,  inflam- 
mation of  Cowper's  glands,  inflammation  of  the  prostate  or  of  the  bladder, 
and  gonorrheal  ophthalmia.  In  the  third  or  subsiding  stage  the  symptoms 
graduallv  abate,  the  discharge  becoming  scantier  and  thinner,  and  finally 
drying  up.  This  stage  is  of  uncertain  duration,  and  in  it  there  may  occur 
epididymitis,  or  inflammation  of  the  epididymis.  Among  other  possible 
complications  we  may  mention  gonorrheal  arthritis  (page  485),  infective 
endocarditis,    tenosynovitis,    pyehtis,    purulent    ophthalmia,    perichondritis, 


984  Diseases  and  Injuries  of  the  Genito- urinary  Organs 

and  peritonitis.  Every  urethral  discharge  should  be  examined  for  gonococci 
in  order  to  make  a  positive  diagnosis.  This  examination  is  made  several 
times  during  the  progress  of  the  case,  so  as  to  determine  when  the  organisms 
disappear.  The  examination  can  be  easily  made.  Place  a  drop  of  discharge 
upon  a  cover-glass,  lay  another  coter-glass  over  this,  and  slide  the  glasses 
apart.  Dry  the  shdes  in  the  flame  of  an  alcohol  lamp.  Bring  the  cover- 
glasses  in  contact  with  a  saturated  solution  of  methylene-blue  in  5  per  cent, 
carbolic-acid  water.  The  staining-material  is  allowed  to  remain  in  contact 
with  the  slides  for  five  or  ten  minutes,  the  glasses  are  washed  with  water,  are 
then  placed  in  a  solution  of  5  drops  of  acetic  acid  to  20  c.c.  of  water,  and  kept 
there  ''  long  enough  to  count  one,  two,  three  slowly,"  and  again  washed  with 
water.  Examination  with  the  microscope  shows  the  gonococci  stained  blue.* 
In  doubtful  cases,  when  the  microscope  fails  to  show  gonococci,  make  cul- 
tures. Cultures  should  always  be  taken  from  a  discharge  in  a  child,  from  the 
fluid  of  an  inflamed  joint,  from  the  discharge  in  gleet  or  purulent  ophthalmia, 
and  from  the  blood  in  obscure  infections. 

Subacute  or  catarrhal  gonorrhea  develops  in  men  who  have  previously 
had  gonorrhea,  as  a  result  of  prolonged  or  repeated  coition  or  of  contact  with 
menstrual  fluid  or  leukorrheal  discharge.  There  is  profuse  mucopurulent 
discharge,  very  little  pain  on  micturition,  but  seldom  chordee  or  marked  irri- 
tability of  the  bladder. 

Irritative  or  Abortive  Gonorrhea. — In  this  disease  the  symptoms, 
which  are  identical  with  those  of  beginning  clap,  do  not  increase,  but  are  apt 
to  disappear  within  ten  days. 

Chronic  Urethral  Discharges.— Chronic  urethral  catarrh,  which 
may  follow  gonorrhea,  is  characterized  by  the  occasional  presence  of  a  drop 
of  clear,  tenacious  liquid.  This  discharge  becomes  more  profuse  as  a  result 
of  sexual  excitement  or  the  abuse  of  alcohol. 

The  persistence  of  a  small  amount  of  milky  discharge,  because  of  locali- 
zation of  inflammation  in  one  spot  or  the  production  of  a  granular  patch  or  a 
superficial  ulcer,  characterizes  chronic  gonorrhea.  There  is  some  scalding 
on  urination;  erections  produce  aching  pain;  there  are  pain  in  the  back  and 
redness  and  sweUing  of  the  meatus.  All  the  symptoms  are  intensified  by 
sexual  excitement,  by  coitus,  by  violent  exercise,  or  by  alcoholic  excess. 

Gleet. — If  a  chronic  urethritis  lasts  over  ten  weeks,  it  is  called  gleet.  In 
gleet  the  lips  of  the  meatus  are  stuck  together  in  the  morning,  and  squeezing 
them  discloses  a  drop  of  opalescent  mucopurulent  fluid.  During  the  day  the 
discharge  is  rarely  found.  The  discharge  is  yellow  or  has  a  yellowish  hue; 
it  stains  the  linen  distinctly,  and  contains  pus,  shreds,  epithelium,  and  at 
times  gonococci.  The  urine  is  clear  and  contains  pus,  gonorrheal  shreds, 
and  comma-shaped  hooks.  The  discharge  is  not  obviously  purulent,  and 
contains  amyloid  corpuscles.  There  are  frequency  of  micturition,  pains 
in  the  back,  and  dribbling  of  urine,  and  a  bougie  may  find  a  stricture  of 
large  cahber,  or  at  least  will  discover  that  the  urethra  is  rigid  from  in- 
flammatory infiltration.  A  discharge  may  be  maintained  by  chronic  pros- 
tatitis. In  this  condition  there  are  frequency  of  micturition;  a  .sense  of 
weight  or  dull  pain  in  the  perineum;  diminished  projectile  force  of  the  stream 
of  urine;  there  is  often  a  tendency  to  sexual  excitement  and  premature  emis- 

*  Schiitz's  method,  as  set  forth  by  R.  W.  Taylor  in  his  work  upon  "  Venereal  Diseases." 


Treatment  of  Acute  Gonorrhea  985 

sion.  In  prostatorrhea  a  milky  discharge  gathers  in  the  urethra  during  sleep 
and  flows  during  muscular  effort  or  while  the  patient  is  at  stool.  The  linen 
is  stained  but  slightly  and  the  lips  of  the  meatus  are  not  glued  together  on 
waking.  There  is  a  history  of  masturbation  or  sexual  excess.  The  condition 
is  not  aggravated  particularly  by  alcohol  or  sexual  intercour.se.  In  chronic 
anterior  urethritis  there  is  a  discharge  from  the  meatus  or  sticking  to- 
gether of  the  lips  in  the  morning.  In  chronic  posterior  urethritis 
there  is  no  discharge  of  pus  from  the  meatus.  If  the  three-glass  test  is 
made,  it  will  be  found  that  in  a  case  of  chronic  anterior  urethritis  only 
the  first  portion  will  be  cloudy  and  show  shreds;  if  he  suffers  from  pos- 
terior urethritis  of  not  very  long  standing,  both  portions  will  be  a  little  clouded, 
the  first  containing  clap  shreds,  the  last  hook-shaped  shreds.  In  a  very 
chronic  case  neither  sample  will  be  cloudy,  but  the  first  portion  will  contain 
shreds.  In  gleet  the  rigidity  of  the  urethra  causes  the  retention  of  small 
quantities  of  urine  after  each  act  of  micturition,  back  of  the  thickened  areas. 
This  retained  urine  decomposes  and  adds  to  inflammation.  Indulgence  in 
alcohol,  sexual  excitement,  or  sexual  intercourse  aggravates  the  condition. 

Treatment  of  Acute  Gonorrhea. — General  Care. — Wash  the  hands  after 
touching  the  parts  and  dry  them  on  an  individual  towel,  which  is  not  used 
upon  the  face.  Wear  a  suspensory  bandage.  Avoid  violent  exercise,  espe- 
ciallv  bicycle  riding,  and  also  wet.  Moderate  e.xercise  is  allowable.  The 
patient  must  not  only  refrain  from  sexual  intercourse,  but  must  not  permit 
himself  to  indulge  in  se.xual  excitement,  and  must  not  drink  a  drop  of  liquor, 
malt,  spirituous,  or  alcoholic.  At  least  twice  a  day  wash  the  penis  in  a  cup 
of  warm  water  containing  oj  of  salt.  If  the  foreskin  is  long,  catch  the  dis- 
charge on  a  bit  of  absorbent  cotton  caught  under  the  prepuce  and  change  it 
at  each  act  of  micturition.  If  the  foreskin  is  short,  cut  a  small  opening  in  a 
square  piece  of  old  linen,  sHp  the  linen  over  the  glans,  catch  it  back  of  corona, 
and  bring  the  ends  forward  with  the  prepuce.  If  the  glans  is  completely 
naked,  pin  an  old  stocking  foot  upon  the  undershirt,  put  absorbent  cotton  in 
the  toe,  and  place  the  penis  within  this  bag.  Never  tie  or  fasten  any  material 
about  the  penis.  The  patient  should  drink  freely  of  plain  water,  of  water 
containing  a  little  bicarbonate  of  sodium,  or  of  alkaline  mineral  water  (\'ichy 
or  Apollinaris).  He  should  obtain  one  bowel  movement  every  day.  I  am 
accustomed  to  direct  the  patient,  in  accordance  with  Guiteras's  rule  (Begg, 
in  "Phila.  Med.  Jour.,"  June  7,  1902),  to  avoid  tea,  much  coft'ee,  pickles, 
spices,  condiments,  rhubarb,  tomatoes,  and  asparagus.  Guiteras  permits 
the  moderate  use  of  claret. 

Abortive  treatment  may  be  tried  if  the  case  is  seen  early.  The  writer 
formerlv  believed  that  by  cleansing  the  urethra  several  times  a  day  with  per- 
oxid  of  hydrogen,  following  the  hydrogen  by  the  injection  of  oil  of  cinnamon 
and  benzoinol,  many  cases  of  gonorrhea  could  be  quickly  aborted.  Further 
observations  confirmed  by  bacterial  investigation  have  shown  that  he  was  in 
error.  True  gonorrhea  cannot  be  aborted  by  the  above-mentioned  plan. 
Other  abortive  methods  are  the  use  of  hot  retro-injections  of  corrosive  subli- 
mate solution  (i  :  20,000),  two  pints  being  run  through  the  urethra  once  a 
dav;  strong  injections  of  nitrate  of  silver  or  of  tannin;  scraping  the  meatus 
or  the  urethra  adjacent  with  cotton,  and  injecting  15  drops  of  a  3  per  cent. 
solution  of  nitrate  of  silver.     If  in  seventy-two  hours  the  symptoms  are  not 


986 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


greatly  improved,  abortive  treatment  should  be  abandoned.  Recent  studies 
render  it  almost  certain  that  there  is  no  real  abortive  treatment.  Abortive 
treatment,  to  be  efficient,  would  have  to  be  carried  out  before  the  gonococci 
penetrated  the  epithelial  cells;  in  other  words,  would  need  to  be  instituted 
before  the  symptoms  of  the  disease  appear.     Janet  says  that  we  must  alter 

our  conception  as  to  what  constitutes 
abortive  treatment,  and  he  doubts  if 
a  case  of  true  gonorrhea  was  ever  really 
aborted.*  The  method  of  irrigation 
with  solutions  of  permanganate  of  po- 
tassium is  really  a  prophylactic  treat- 
ment. Janet  applies  his  treatment  as 
evidences  of  trouble  present  themselves, 
and  before  acute  symptoms  appear, 
and  claims  that  in  most  persons  tlie 
disease  can  be  arrested  in  from  eight 
to  twelve  days.  The  same  plan  of 
treatment  is  useful  in  a  well-developed 
case. 

Irrigation  can  be  used  in  an  incipi- 
ent or  in  a  well-developed  case.  Janet's 
method  is  as  follows:  An  irrigator  is 
filled  with  a  warm  solution  of  perman- 
ganate of  potassium  (i  :  4000).  The 
patient  after  emptying  his  bladder  is 
seated  upon  a  chair  and  his  sacrum 
rests  upon  the  extreme  front  edge  of 
the  chair  (Valentine).  The  reservoir 
is  joined  to  a  glass  nozzle  by  a  rubber 
tube.  The  nozzle  is  introduced  into 
the  meatus,  and  the  fluid  is  permitted 
to  run  gradually  at  first,  with  full 
force  later.  In  anterior  trouble  the 
fluid  is  allowed  to  run  out  of  the 
meatus  by  the  side  of  the  nozzle. 
The   anterior   urethra   is   always  irri- 

Fig- 573--Valentine's  urethral  and  intravesi-    gated     first,     the     reservoir    being     tWO 
cal  irrigator :    a.  Board  with   attacliments  to  be     ^      .      i  ^i  i      • 

screwed  to  wall;   c,  open  collar;    d,   pulley;   .,    ^ect  above  the  chair. 

cord ;  /,  ring  to  suspend  percolator ;  ^,  brass  rod ;  In  posterior  urethritis,  after  the  an- 

h,  percolator;  i,  rubber  tube;/,  ring  for  fourth   ^gj-j^j.  urethra  has  been  irrigated,  the 

finger;  ;^,  flange  to  graduate  pressure;  /,  shield  ;  .       .  .       ,     ^ 

;«,  ring  to  suspend  shield ;«,  nozzle  attached.       rcscrvoir  IS    raised   from  SIX  to  sevcn 

feet  above  the  bed,  the  meatus  is  held 
tight  about  the  nozzle,  and  the  fluid  overcomes  the  force  of  the  compressor 
muscles  of  the  urethra  and  the  bladder  sphincter  and  enters  the  bladder. 
If  the  muscles  do  not  quickly  relax,  continue  the  hydrostatic  pressure  for 
several  minutes,  when  relaxation  will  usually  occur;  but  if  it  does  not  do  so, 
tell  the  patient  to  breathe  slowly  and  deeply,  and  to  make  efforts  at  urina- 
tion (Valentine).     When  the  bladder  is  full  the  tube  is  withdrawn  and  the 

*  Ann.  d.  mal.  d.  org.  gen.-urin.,  1896,  p.  1031. 


Treatment  of  Acute   Gonorrhea 


9S7 


patient  micturates.  This  procedure  is  practised  once  or  twice  a  day  for  five 
or  six  days,  or  even  longer,  and  the  strength  of  the  solution  is  gradually 
increased  up  to  i  :  1000.  It  has  been  claimed  that  after  one  or  two  weeks 
of  this  treatment  gonococci  permanently  disappear  in  the  majority  of  cases. 
Fig.  573  shows  the  irrigator  devised  by  Ferd.  C.  Valentine.  Valentine,  of 
New  York,*  has  constructed  the  following  table,  which  is  of  use  to  a 
practitioner  who  wishes  to  employ  irrigations  with  permanganate  of  potas- 
sium in  the  treatment  of  acute  gonorrhea: 


First   day,   first  visit. 

First  day,  7  r.  m. 

Second  day,  9  A.  M. 

Second  day,  7  v.  M. 

Third  day,  9  A.  M. 

Third  day,  7  i'.  M. 

Fourth  day,  9  A 


M. 


M, 


Fourth  day,  7  P. 

Fifth  day.  Noon. 

Sixth  day.  Noon. 

Seventh  day,  Noon. 

Eighth  day,  9  A.  M. 

Eighth  day,  7  p.  M. 

Ninth  day,  9  A.  M. 

Ninth  day,  7  P.  M. 

Tenth  day,  9  A.  M. 

Tenth  day,  7  p.  M. 


Anterior  irrigation 

Anterior  " 

Anterior  " 

Anterior  " 

Intravesical  " 

Anterior  " 

Intravesical  " 

Intravesical  " 

Anterior  " 

Intravesical  " 

Intravesical  " 

Intravesical  " 

Intravesical  " 

Anterior  " 

Intravesical  " 

Anterior  " 

Intravesical  " 

Anterior  " 

Intravesical  " 

Anterior  " 

Intravesical  " 

Anterior  " 

Intravesical  " 

Anterior  " 


:  3C00 
:  .4000 
30CO 
4OCO 
6000 
5000 
5000 
5000 
2000 
5000 
5000 
5000 
5000 
3000 
5000 
20C0 
4000 
1000 
4000 
1000 
4000 
1000 
5000 
500 


For  full  directions  regarding  this  method  see  \'alentine's  excellent  book, 
"The  Irrigation  Treatment  of  Gonorrhea."  If  a  stricture  exists,  it  is  not 
advisable  to  employ  this  treatment.  Excellent  results  can  be  obtained  by 
irrigations  with  fluid  containing  silver  nitrate  (i  :  12,000  to  i  :  8000). 

When  a  patient  is  treated  by  irrigation,  after  the  entire  subsidence  of 
acute  symptoms,  a  thin,  colorless  discharge  may  persist.  This  can  be  cured 
by  the  use  of  astringents.  Two  or  three  times  a  day  an  astringent  is  injected 
by  means  of  a  half-ounce  syringe.  Dalton's  formula  is  very  useful:  Zinc 
oxid  and  lead  acetate,  of  each,  h  gr.  to  3  gr. ;  tincture  of  catechu,  from  ii\,x  to 
n\^xxx;  glycerin,  from  3ss  to  5j;  and  water  to  5J. 

Many  writers  oppose  the  irrigation  treatment,  claiming  that  it  increases 
the  liability  to  complications,  especially  prostatic  infiltration,  and  enhances 
the  danger  of  recurrence.  I  believe  in  the  method.  I  do  not  think  it  shortens 
the  duration  of  the  disease,  but  do  believe  that  it  mitigates  its  intensity,  makes 
the  patient  much  more  comfortable,  and  quickly  causes  the  discharge  to 
become  mucopurulent.  That  it  increases  complications  and  the  danger  of 
reinfection  is  very  doubtful.  Much  of  the  trouble  which  has  followed  its 
use  has  been  due  to  raising  the  reservoir  to  too  great  a  height. 

Irritative  gonorrhea  will  subside  in  a  few  days.  The  above  directions 
should  be  followed,  and  the  anterior  urethra  should  be  washed  out  several 
times  daily  with  peroxid  of  hydrogen,  or  irrigated  once  a  day  with  a  hot  solu- 
*  "The  Irrigation  Treatment  of  Gonorrhea." 


988  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

tion  of  permanganate  of  potassium  (i  :  4000).  In  catarrhal  gonorrhea,  at 
once  order  injections  (i  grain  to  the  ounce  of  sulphate  of  zinc;  or  zinci  sulphas 
gr.  viij,  plumbi  acetas  gr.  xv,  water  5viij;  or  gr.  v  of  sulphocarbolate  of  zinc 
to  oj  of  water;  or  White's  prescription  of  Sj  each  of  acetate  of  zinc  and  tannic 
acid,  oiij  of  boric  acid,  5vj  of  liq.  hydrogen,  peroxid.).  For  injecting  use  a 
blunt-pointed  hard-rubber  syringe  of  a  capacity  of  three  or  four  drams.  Let 
the  patient  urinate  and  then  sit  on  a  chair,  his  buttocks  hanging  over  the 
edge;  throw  a  syringeful  of  the  solution  into  the  urethra  and  let  it  run  out  at 
once  and  throw  in  another  syringeful  and  hold  it  in  from  three  to  five  minutes. 

In  ordinary  acute  gonorrhea  the  old  rule  was  to  order  balsams.  The 
common  custom  is  to  give  two  capsules  three  times  a  day,  each  capsule  con- 
taining 5  grains  of  salol,  5  grains  of  oleoresin  of  cubebs,  10  grains  of  balsam 
of  copaiba,  and  i  grain  of  pepsin.  Clinical  observation  indicates  that  the 
balsams  are  of  distinct  value  in  gonorrhea.  When  used  early,  the  discharge 
tends  to  become  mucopurulent  and  the  acute  symptoms  subside  (S.  Behr- 
mann,  in  "  Dermatologisches  Centralblatt,"  Berlin,  Nov.  and  Dec,  1901). 
Many  practitioners  will  not  use  balsams  until  the  third  week.  Bacteriological 
studies  indicate  that  copaiba,  when  eliminated  in  the  urine,  has  a  certain 
amount  of  power  in  inhibiting  the  growth  of  gonococci,  but  that  cubebs  and 
sandal  have  not  such  power.  Yet  sandal  is  more  useful  than  copaiba  as  a 
remedy.  Salol  is  distinctly  germicidal,  hence  it  is  given  with  the  balsams. 
In  a  case  treated  with  balsams  an  astringent  injection  is  usually  employed. 
The  injection  is  used  two  or  three  times  a  day,  immediately  after  micturition. 
As  the  inflammation  subsides  increase  the  strength  of  the  injection.  A  good 
plan  is  to  order  an  eight-ounce  bottle  and  eight  half-grain  powders  of  sulphate 
of  zinc.  Direct  the  patient  to  fill  the  bottle  with  water,  in  which  one  powder 
is  dissolved;  when  this  is  used  dissolve  two  powders  in  a  bottleful  of  water, 
and  so  progressively  increase  the  strength.  When  the  discharge  ceases  stop 
the  injections  gradually.  Whenever  a  syringeful  is  taken  from  the  bottle  a 
syringeful  of  water  is  put  into  the  bottle,  and  thus  pure  water  is  soon  obtained, 
at  which  point  injection  is  discontinued.  If  an  astringent  injection  causes 
much  pain,  use  a  sedative  injection — 3ij  of  boric  acid,  gr.  viij  of  aqueous 
extract  of  opium,  and  ,^viij  of  liquor  plumbi  subacetatis  dilutus. 

Argonin,  which  is  a  combination  of  albumin,  silver,  and  an  alkali,  is  highly 
recommended  by  some  authors  as  a  local  remedy  for  gonorrhea  (Schaffer, 
Guthiel).  A  solution  of  this  material  is  non-irritant,  the  silver  is  not  pre- 
cipitated by  chlorids,  and  the  agent  destroys  gonococci.  It  is  used  by  injec- 
tion or  irrigation.  If  used  by  irrigation,  employ  a  i  :  500  solution  twice  a 
day.  If  used  as  an  injection,  employ  a  i  :  200  solution  six  or  eight  times  a 
day.  When  the  discharge  is  found  free  from  gonococci  and  remains  free  for 
three  days,  stop  the  argonin  and  use  an  astringent  injection. 

Protargol,  metallic  silver  combined  with  a  proteid,  is  a  yellow  powder  solu- 
ble in  water,  the  .solution  not  being  acted  on  by  light.  It  is  a  non-irritant 
germicide.  Neisser,  after  demonstrating  the  presence  of  the  gonococcus, 
administers  protargol  by  injection,  the  first  injections  being  of  a  strength  of 
0.25  per  cent.,  the  .strength  being  gradually  increased  to  0.5  per  cent.,  and 
finally  to  i  per  cent.  In  the  beginning  he  orders  three  injections  a  day, 
each  injection  being  retained  from  fifteen  to  thirty  minutes;  after  several 
days,  when  the  symptoms  improve  he  gives  only  one  or  two  injections  a  day. 


Treatment  of  Acute   Gonorrhea  989 

and  these  are  continued  for  ten  days  after  gonococci  disappear  from  the  dis- 
charge. After  protargol  is  abandoned  an  astringent  injection  should  be  used 
for  a  time.  Some  surgeons  use  a  i  :  1000  solution  of  protargol,  and  irrigate 
the  anterior  urethra  and  flush  the  bladder  twice  a  day.  The  most  powerful 
and  useful  of  the  silver  salts  is  argyrol,  or  silver  vitellin.  This  salt  was 
discovered  by  A.  C.  Barnes  and  H.  Hiller  ("Aled.  Record,"  May  24, 
1902).  It  is  an  extremely  soluble  preparation,  contains  30  per  cent,  of 
silver,  does  not  coagulate  albumin,  and  is  not  precipitated  by  chlorids. 
When  injected  into  the  urethra  it  enters  deeply  into  the  mucous  mem- 
brane and  is  powerful  in  destroying  gonococci.  (See  "A  Clinical  Study  of 
a  New  Silver  Salt  in  the  Treatment  of  Gonorrhea,"  by  H.  M.  Christian,  in 
"Med.  Record,"  vol.  l.xii,  1902.)  In  most  cases  gonococci  disappear  within 
two  weeks.  The  injection  used  at  first  may  be  of  a  strength  of  2  per  cent. 
The  drug  should  be  retained  in  the  urethra  four  or  five  minutes,  and  three  or 
four  injections  should  be  given  each  day.  The  strength  of  the  injection  can 
be  gradually  increased  to  5  per  cent,  or  even  more.  Picric  acid  has  been 
highly  commended  as  an  injection.  The  strength  of  solution  is  i  :  200,  and 
it  is  to  be  retained  in  the  urethra  three  or  four  minutes  (de  Brun's  method). 

Methylene-blue  internally  is  occasionally  of  service  in  gonorrhea.  A 
capsule  containing  gr.  ij  of  the  drug  is  given  three  times  a  day.  It  makes  the 
urine  greenish-blue  and  occasionally  induces  strangury.  Urotropin  renders 
the  urine  sterile.     Salicylate  of  sodium  may  be  of  value  late  in  the  case. 

Christian's  plan  of  treating  acute  gonorrhea  is  very  useful.  It  is  as  fol- 
lows: Two  solutions  are  used  during  the  first  ten  days.  Three  times  a  day 
a  solution  of  permanganate  of  potash  is  injected  (gr.  ^  of  permanganate  of 
potash  in  8  ounces  of  water),  six  syringefuls  being  used  at  each  seance.  After 
a  washing  with  permanganate  protargol  is  injected  (gr.  x  of  protargol  to  .siv 
of  water)  and  retained  ten  minutes.  At  the  end  of  four  days  the  strength 
of  the  protargol  is  increased  to  gr.  xx  in  siv  and  the  strength  of  the  perman- 
ganate to  I  :  4000.  During  the  third  week  abandon  the  above-mentioned 
solutions,  put  the  patient  on  balsams,  and  use  an  astringent  injection.  Chris- 
tian uses  gr.  X  of  sulphate  of  zinc,  gr.  ij  of  subcarbonate  of  bismuth,  2  ounces 
of  solution  of  hydrastis,  and  4  ounces  of  water.  Cure  is  obtained  in  six  or 
seven  weeks. 

Ardor  nrincc  is  relieved  by  urinating  while  the  penis  is  immersed  in  hot 
water  and  by  administering  an  alkaline  diuretic.  Chordee  requires  a  bowel- 
movement  in  the  evening,  and  sleeping  in  a  cool  room,  under  light  covers, 
and  on  a  hard  mattress;  bromid  is  given  several  times  daily,  and  a  consider- 
able dose  is  given  at  night;  it  may  be  necessary  to  use  suppositories  of  opium 
and  camphor  or  to  give  hyoscin.  Balanitis  requires  frequent  washing  with 
warm  water,  drying  with  cotton,  and  dusting  with  borated  talc  or  with  boric 
acid  and  subnitrate  of  bismuth  (i  :  6).  Bala>w posthitis  requires  soaking  in 
hot  water,  applications  of  lead-water  and  laudanum,  and  injections  of  black 
wash  under  the  prepuce  until  edema  of  the  foreskin  subsides,  and  then  clean- 
liness and  the  application  of  a  drying  powder.  Phimosis  requires  soaking 
the  penis  in  hot  water,  injections  of  hot  water  beneath  the  foreskin,  followed 
by  black  wash,  and  the  use  of  lead-water  and  laudanum  externally.  If  this 
fails,  circumcision  must  be  performed.  If  parapliimosis  occurs,  grasp  the 
head  of  the  penis  with  the  left  hand,  squeeze  the  blood  out,  and  try  to  push 


990  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

the  head  back  while  with  the  right  hand  the  penis  is  puhed  upon,  as  if  the 
surgeon  intended  to  hft  the  individual  by  the  organ.  If  this  fails,  cut  the 
collar  on  the  dorsum  with  scissors;  or,  what  is  better,  for  it  gives  free  expo- 
sure, incise  each  side  of  the  prepuce  between  the  middle  of  the  dorsum  and 
the  frenum.  Bubo  requires  the  application  of  iodin,  ichthyol,  or  blue  oint- 
ment, the  use  of  a  spica  bandage,  and  rest.  If  a  bubo  suppurates,  it  must  be 
opened  or  aspirated.  Acute  posterior  iirethritis  is  treated  by  rest,  and  if  the 
symptoms  are  severe,  by  rest  in  bed.  If  the  balsams  do  not  irritate,  they  are 
»iven;  if  they  do,  they  are  withdrawn.  Urotropin  or  salol  is  given  and  the 
patient  is  placed  upon  a  milk-diet  with  orders  to  drink  largely  of  flaxseed  tea. 
Alkahne  fluids  do  harm  by  favoring  ammoniacal  decomposition  of  the  urine. 
Injections  and  irrigations  are  abandoned.  Pain  and  vesical  spasm  are  con- 
trolled by  suppositories  of  opium  and  belladonna.  If  retention  of  urine 
occurs,  have  the  patient  urinate  while  in  a  hot  bath;  if  this  fails,  use  a  soft 
catheter.  Acute  vesiculitis  is  treated  as  is  acute  prostatitis.  Chronic  vesicu- 
litis is  considered  on  page  1005.  Pyelitis  is  treated  by  rest  in  bed,  hot  baths, 
wet  cupping  of  the  loin,  or  milk-diet,  the  use  of  diuretics,  the  taking  of  a  large 
quantity  of  bland  Hquid,  and  the  administration  of  salol  or  urotropin.  Fol- 
liculitis is  treated  by  rest  and  the  application  of  a  hot-water  bag  to  the  peri- 
neum (if  that  be  the  part  involved).  If  pus  forms,  evacuate  by  incision. 
Later  the  follicle  may  be  dissected  out  or  destroyed  by  cauterization.  If 
the  folHcle  opens  into  the  urethra  it  may  be  cauterized  through  an  endoscope. 
Peri-urethritis  is  treated  by  rest  and  hot  applications.  If  pus  forms,  an  inci- 
sion must  be  made.  If  the  abscess  is  permitted  to  break  into  the  urethra, 
rest  and  hot  fomentations  may  be  used,  but  at  the  first  sign  of  urinary  ex- 
travasation make  an  external  incision.  Cowperitis  is  treated  in  the  same 
way  as  peri-urethritis.  Gonorrheal  rheumatism  is  considered  on  page  485. 
Acute  prostatitis  and  cystitis  require  confinement  to  bed,  a  milk-diet,  the  use 
of  diuretics,  hot  apphcations  to  the  perineum  and  hypogastrium,  sup- 
positories of  opium,  and  belladonna  or  ichthyol,  leeching  the  perineum, 
the  discontinuance  of  balsams  and  injections,  and  the  administration  of 
urotropin  or  salol.  Abscess  of  the  prostate  requires  instant  incision.  In 
retention  of  urine  the  patient  should  try  to  pass  the  urine  while  in  a  hot  bath; 
if  this  fails,  a  soft  catheter  is  used.  After  reheving  the  bladder  put  the  patient 
to  bed  and  apply  hot  sand-bags  as  for  acute  prostatitis.  Chronic  prostatitis 
requires  cold  hip-baths,  cold-water  enemata,  deep  urethral  injections,  plain 
diet,  avoidance  of  alcohol  and  over-exertion,  counter-irritation  of  the  peri- 
neum, and  the  relief  of  .stricture  or  phimosis.  Great  benefit  is  occasionally 
derived  from  passing  a  soft  bougie  covered  with  blue  ointment  or  with  a  10 
per  cent,  ointment  of  protargol.  If  epididymitis  arises,  put  the  patient  to 
bed,  abandon  injections,  shave  the  hair  from  the  groin,  leech  over  the  cord, 
elevate  the  testicles,  and  apply  an  ice-bag.  Give  a  cathartic,  a  fever  mixture, 
and  suitable  doses  of  bromid  of  potassium  and  morphin.  The  application 
twice  a  day  of  20  drops  of  guaiacol  in  3]  of  cosmolin  or  olive  oil  gives  great 
relief.  When  swelling  lingers,  after  tenderness  subsides  strap  the  testicle 
with  adhesive  plaster.  A  lingering  case  is  benefited  by  the  internal  use  of 
iodid  of  potassium  and  the  local  application  of  ichthyol.  In  gonorrheal 
ophthalmia  secure  a  watch-crystal  over  the  unaffected  eye,  put  the  patient 
in  a  darkened  room,  rub  the  infected  conjunctival  .sac  with  cotton  soaked  in  a 


Treatment  of  Chronic  Gonorrhea 


991 


2  per  cent,  solution  of  silver  nitrate,  wash  out  the  affected  eye  often  with  hot 
boric-acid  solution,  keep  the  pupil  dilated  with  atropin,  leech  the  temple, 
give  purgatives,  and  employ  hot  mustard  foot-baths.  Always  send  for  an 
ophthalmologist. 

When  is  Gonorrhea  Cured? — When  actual  discharge  ceases,  a  patient 
considers  himself  cured  and  yet  he  may  have  residuals  of  infection  which  are 
liable  at  any  time  to  awaken  into  activity  and  produce  anew  an  acute  condi- 
tion. Gonococci  are  frequently  retained  in  the  urethral  glands  and  folhcles 
or  in  areas  surrounded  by  indurated  mucous  membrane.  A  man  is  considered 
to  be  well  when  shreds  and  pus  disappear  from  the  urine,  when  an  examination 
of  expressed  mucus  on  three  successive  days  fails  to  find  gonococci,  and  when 
there  has  been  no  discharge  for  ten  days.  Furthermore,  we  must  be  sure 
that  the  prostate,  Cowper's  glands,  and  the  seminal  vesicles  are  free  from 
disease. 

Treatment  of  Chronic  Gonorrhea  and  of  Chronic  Urethritis  follow- 
ing Gonorrhea. — The  first  thing  to  do  is  to  determine  the  cause  of  the  pro- 
longation of  the  discharge.     Valentine's  list  of  causes  should  be  borne  in 


Fig.  574. — Bougie-a-boule. 


mind  ("Med.  Record,"  June  29,  1901).  They  are  as  follows:  (i)  Lack  of 
treatment;  (2)  misdirected  treatment;  (3)  insufficient  treatment;  (4)  over- 
treatment;  (5)  infraction  of  dietetic  or  hygienic  regulations;  (6)  constitu- 
tional disturbances;  (7)  congenital  or  acquired  deformities  and  compHca- 
tions;  (8)  involvement  of  the  urethral  adnexa;  (g)  marital  reinfection.  In 
a  case  in  which  a  discharge  persists  or  recurs,  the  symptoms  and  general 
condition  must  be  closely  studied,  the  discharge  must  be  examined  micro- 
scopically, the  condition  of  the  urine  must  be  determined,  and  the  urethra 
must  be  explored. 

Exploration  of  the  urethra  is  inaugurated  by  inspection  and  external  pal- 
pation. Palpation  detects  induration,  peri-urethritis,  follicular  abscess  or 
inflammation,  Cowperitis,  etc.  The  prostate  and  seminal  vesicles  are  ex- 
amined by  a  finger  in  the  rectum.  The  interior  of  the  urethra  is  explored 
with  a  soft  bougie-a-boule  (Fig.  574).  On  withdrawing  this  instrument  the 
shoulder  catches  in  any  contracture.  It  is  to  be  borne  in  mind  that  a  large 
steel  sound  can  often  be  introduced  with  ease  when  the  bougic-a-boule  makes 
evident  that  a  contracture  exists.  The  emergence  of  the  instrument  is  arrested 
by  a  patch  of  thickening,  a  granular  area,  a  zone  of  epithelial  j)roliferation, 


992 


Diseases  and  Injuries  of  the  Genito-urinaiy  Organs 


a  papilloma,   or  a  stricture.     In  fact,  anything  which  lessens  the  urethral 
caliber  interferes  with  the  withdrawal  of  the  bougie-a-boule.     It  does  not  do 

to  conclude   that  stricture 


exists  simply  because 
some  lessening  of  caliber 
is  appreciated.  The 
bougie-a-boule  finds  its 
chief  use  in  exploring  the 
^^^_^  ,  anterior     urethra.     If    in- 

-=J~\W  troduced  into  the  deep 
urethra  its  emergence  will 
l>e  normally  checked  as 
its  shoulder  comes  against 
the  posterior  layer  of  the 
triangular  ligament. 

In  most  cases  the 
diagnosis  is  only  certainly 
-=^.  determined  by  the  use  of 
the  urethroscope.  This 
instrument  has  been  per- 
fected of  recent  years  and 
is  now  an  absolutely  es- 
sential  part   of  an   arma- 


Fig.  575. — Valentine's  urethroscope. 


mentarium.     I  use  Valentine's  instrument  and  find  it  most  satisfactory  (Figs. 

hi 


Fig.  576. — Valentine's  urethroscopic  tube. 

575-578).      The  anterior  and  posterior  urethra  can  be  thoroughly  examined 
with  the  utmost  ease.     Before  inserting  a  urethroscopic  tube  place  the  patient 


Fig.  577. — Valentine's  obturator. 

recumbent  and  cleanse  the  foreskin,  glans,  and  anterior  urethra  as  directed 
in  the  secti(jn  on  Cystoscopy.     Insert  a  tube  which  readily  passes  the  meatus, 


9\ 


Fig.  578. — Valentine's  light  carrier. 


first  cleansing  the  tube  anrl  (jljturator  l)\-  burning  alcohol  upon  them.     Carry 
the  tube  to  the  anterior  layer  of  the   triangular   h'gament.     Withdraw   the 


Chronic  Urethral   Discharcres 


993 


obturator  and  insert  the  Hght.  Turn  on  the  hght,  mop  the  urethra  with  bits 
of  cotton  wrapped  on  a  stick,  and  slowly  withdraw  the  tube,  examining  the 
urethra  as  its  walls  fall  together  back  of  the  retracting  tube.  x\fter  with- 
drawal of  the  tube  irrigate  the  anterior  urethra.  To  examine  the  deep  urethra, 
carry  the  instrument  through  the  prostatic  urethra.  After  the  examination 
give  an  intravesical  irrigation. 

When  the  cause  of  a  discharge  is  once  determined,  rational  treatment  can 
be  instituted,  and  to  determine  the  cause  the  electric  urethroscope  is  indispen- 
sable. x\n  erosion  of  the  mucous  membrane  or  a  granular  patch  requires 
touching  from  time  to  time  with  a  solution  of  silver  nitrate  (i  or  2  per  cent.). 
These   apphcations   are   made   through   the   tube   of   the   urethroscope.     A 


Fig;.  5S2. — Obeilaiider's  anteroposterior  dilator. 


stricture  or  an  infiltration  is  treated  by  gradual  dilatation.  This  combines 
pressure  and  massage.  If  the  caliber  of  the  urethra  is  less  than  No.  21  of  the 
French  scale,  conical  steel  sounds  are  used  twice  a  week.  If  there  is  much 
hyperesthesia  they  are  retained  but  a  brief  time;  but  as  hyperesthesia  dimin- 
ishes the  period  of  retention  is  lengthened,  until  an  instrument  can  be  kept 
in  place  without  causing  severe  suffering  for  ten  or  fifteen  minutes.  It  is 
not  desirable  to  use  cocain,  as  it  is  distinctly  dangerous,  obtunds  die  sen- 
sibihty  so  that  undue  violence  may  be  used,  and  increases  the  post-operative 
inflammation.  Before  and  after  using  an  instrument  the  urethra  must  be 
cleansed  as  previously  directed  (page  982). 

When  the  urethra  becomes  tolerant  to  instrumentation,  a  special  dilator 
6-, 


994  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

is  employed  to  act  particularly  on  the  area  of  disease.  If  in  the  beginning  of 
treatment  the  caliber  of  the  urethra  is  equal  to  or  greater  than  No.  21  of  the 
French  scale,  it  is  rarely  necessary  to  precede  the  dilator  by  the  use  of  conical 
sounds.  Figs.  579,  580,  581,  and  582  show  various  dilators.  Most  dilators 
should  be  inserted  in  a  sterile  rubber  cover  before  being  used,  otherwise  they 

will  cut,  tear,  or  pinch 
~^  the  urethra.  Koll- 
mann's  dilator  will  not 
injure  the  mucous 
membrane  and  can  be 
used  without  a  cover 
^-      .      ,-  „         •     ,    ^      •  (FiS-  S70)-     A  dilator 

Fig.  583.— kollmann  s  gland  syringe.  ^      °     j  /  7/ 

should  be  lubricated 
with  lubrichondrin  or  synol  soap.  If  a  two-bladed  dilator  is  used  at  first, 
a  four-bladed  dilator  must  be  subsequently  employed. 

A  dilator  is  cleansed  by  scrubbing  its  blades  with  soap  and  water,  sticking 
them  in  alcohol,  withdrawing,  and  burning  the  alcohol  retained  in  the  in- 
strument. 

The  following  rules  are  of  the  first  importance  (Ferd.  C.  \'alentine,  in 
"Med.  Record,"  June  29,  1901): 

1.  The  first  dilatation  must  stop  at  that  point  at  which  the  first  resistance 
to  further  dilatation  is  felt  by  the  operator's  fingers  turning  the  screw  that 
separates  the  blades. 

2.  Dilatations,  if  done  by  a  novice,  must  in  the  beginning  of  treatment 
be  repeated  no  oftener  than  every  three  or  four  days. 

3.  Each  dilatation,  in  point  of  time,  must  reach  no  greater  duration  than 
two  minutes  over  that  of  the  preceding  session. 

4.  No  dilatation  must  exceed  one-half  number  Chariere  above  the  number 
attained  at  the  next  prior  seance,  regardless  of  any  lack  of  resistance  that  may 
be  present. 

As  a  rule,  glandular  and  follicular  infiltrations  are  cured  by  the  use  of 
the  dilator.  If  they  are  not,  they  must  be  treated  through  the  tube  of  the 
urethroscope.  The  interior  of  a  follicle  may  be  cauterized  with  an  electric 
wire  or  subjected  to  electrolysis,  or  touched  with  a  3  per  cent,  solution  of 
silver  nitrate.  A  thickened  crypt,  or  gland,  or  follicle,  or  an  area  of  indura- 
tion, may  be  slit  with  a  knife.  A  polyp  can  be  removed  with  a  snare,  the 
cautery,  or  special  forceps.  In  a  chronic  inflammation  of  the  urethra,  'in 
which  the  inflammation  is  superficial  and  in  which  the  glands  are  not  in- 
volved, irrigations,  urethral  and  intravesical,  con.stitute  the  best  treatment. 
(See  Valentine's  treati.se  on  "  The  Irrigation  Treatment  of  Gonorrhea,  its 
Local  Complications  and  Sequels.") 

In  any  lingering  case  of  gonorrhea  examine  the  urine,  and  direct  suitable 
treatment  for  oxaluria,  lithemia,  or  phosphaturia,  if  any  one  of  these  condi- 
tions exists.  Such  morljid  states  of  the  urine  are  occasionally  re.sponsible  for 
great  prolongation  (;f  the  inflammation.  In  some  cases  a  di.scharge  is  kept 
up  by  inflammation  of  the  seminal  vesicles  (page  1005). 

Gonorrhea  of  the  anus  and  rectum  occasionally,  though  very  rarely, 
occurs.  It  may  result  from  pederasty,  or  in  a  woman  from  a  flow  of  infectious 
material  from  the  genitalia  to  the  anus.  It  causes  severe  burning  pain,  aggra- 
vated by  defecation.     The  parts  are  red,  swollen,  and  tender.     The  discharge 


Stricture  of  the  Uretlira  995 

is  profuse,  being  at  first  cream  white,  and  then  thicker  and  greenish.  The 
diagnosis  rests  upon  the  history  and  the  finding  of  gonococci  in  the  discharge. 
The  disease  rarely  extends  above  the  anus. 

Treatment. — If  the  anus  only  is  involved  spray  several  times  daily  with 
pero-xid  of  hydrogen,  wash  with  salt  solution,  irrigate  with  permanganate  of 
potash  (i  :  4000),  dust  with  talc  powder,  and  interpose  a  piece  of  iodoform 
gauze  between  the  inflamed  surfaces.  An  ulcer,  a  fissure,  or  an  excoriation 
is  touched  with  lunar  caustic.  If  the  rectum  becomes  involved,  secure  a 
daily  bowel  movement  and  irrigate  the  rectum  twice  a  day  with  boracic-acid 
solution  or  permanganate  of  potash  (i  :  4000). 

Gonorrhea  of  the  Mouth.— This  is  a  very  uncommon  malady.  It 
occurs  in  infants  more  often  than  in  older  people.  Infection  in  infants  may 
take  place  during  birth  if  the  mother  has  gonorrhea.  The  symptoms  are 
those  of  violent  stomatitis.  The  diagnosis  is  suggested  by  the  condition  of  the 
mother  and  is  proved  by  finding  gonococci  in  the  discharges  from  the  mouth. 

Treatment. — Wash  the  mouth  frequently  wath  boracic  acid  and  listerine 
(gr.  xlviij  to  5viij),  and  swab  the  disea.sed  areas  at  intervals  with  a  10  per 
cent,  solution  of  argyrol. 

Gonorrhea  of  the  Nose.— It  is  alleged  that  this  condition  can  arise, 
but  an  absolutely  authentic  case  does  not  seem  to  be  on  record. 

Gonorrhea  of  the  female  may  affect  the  vulva,  the  vagina,  the  ure- 
thra, or  the  uterus.     The  danger  is  the  development  of  metritis  or  salpingitis. 

The  treatment  for  vulvitis  is  to  place  the  patient  upon  a  low  diet  and  put 
her  at  rest  with  the  pelvis  elevated;  every  two  or  three  hours  spray  the  parts 
with  peroxid  of  hydrogen,  dry  them  with  absorbent  cotton,  and  dust  them 
with  equal  parts  of  starch  and  oxid  of  zinc.  In  severe  cases  purge,  use  hot 
baths,  apply  lead-water  and  laudanum  locally  or  paint  the  vulva  with  silver 
solution  (gr.  xl  to  oj),  and  leech  the  groins.  If  the  vulvovaginal  gland  sup- 
purates, open  it. 

For  vaginitis  follow  the  same  general  directions.  Wash  out  the  vagina 
every  two  hours,  first  with  Oj  of  hot  solution  of  bicarbonate  of  sodium,  next 
with  Oj  of  hot  water,  and  finally  with  Oj  of  astringent  solution  (a  teaspoonful 
of  lead  acetate,  a  teaspoonful  of  zinc  sulphate,  a  teaspoonful  of  alum,  or  four 
teaspoonfuls  of  tannin  to  the  pint  of  hot  water)  (White).  As  the  attack 
subsides,  use  vaginal  suppositories,  each  containing  gr.  v  of  tannic  acid.  In 
some  cases  apply  solutions  of  silver  nitrate  (i  :  200)  or  of  argyrol  (10  per  cent.), 
and  insert  tampons  moistened  with  boroglycerid  and  ichthyol  (8  per  cent.) 
(Le  Blonde).  Metritis  must  be  prevented,  and  it  is  a  wise  precaution  to  apply 
from  time  to  time,  iodin  or  a  10  per  cent,  solution  of  argyrol  to  the  cervical  canal. 

For  urethritis  use  astringent  injections  locally  and  copaiba  and  cubebs 
by  the  mouth.  In  chronic  cases  use  strong  solutions  of  silver  nitrate.  The 
urethra  and  bladder  may  be  irrigated  with  silver  nitrate  (i  :  8000). 

For  uterine  gonorrhea  observe  the  same  general  management.  Swab 
out  the  uterus  with  tincture  of  iodin:  use  tampons  of  iodoform  gauze  and 
injections  of  peroxid  of  hvdrogen. 

Stricture  of  the  urethra,  or  narrowing  of  the  urethral  cahber,  is 
divided  into  inflammatory,  spasmodic,  and  organic.  The  so-called  inflam- 
matory or  congestive  stricture  is  not  a  stricture,  but  is  an  inflammatorv  swell- 
ing of  the  mucous  membrane. 


996  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Spasmodic  stricture  does  not  exist  alone,  but  complicates  organic  stricture, 
a  hvperesthetic  urethra,  or  an  inflamed  bladder. 

Organic  stricture  is  a  fibrous  narrowing  of  the  urethra,  due,  as  a  rule,  to 
chronic  gonorrheal  inflammation  or  to  traumatism.  True  organic  stricture 
is  very  rare  in  children,  but  can  occur.  Abbe  reported  a  case  of  impassable 
stricture  in  the  deep  urethra  of  a  male  child  two  and  one-half  years  of  age, 
due  to  urethral  gonorrhea.  There  were  also  two  strictures  of  the  anterior 
urethra.  External  urethrotomy  was  performed.  Traumatic  strictures  occur 
in  the  bulbous  or  membranous  urethra,  and  are  due  generally  to  force  applied 
to  the  perineum,  the  urethra  being  squeezed  between  the  subpubic  ligament 
and  the  vulnerating  body.  Strictures  resulting  from  gonorrheal  inflamma- 
tion occur  in  the  penile,  bulbous,  or  membranous  urethra.  Stricture  never 
forms  in  the  prostatic  urethra  except  as  a  result  of  traumatism.  Recent 
non-traumatic  strictures  are  soft  and  are  easily  distended.  Old  strictures 
and  traumatic  strictures  are  \ery  dense.  A  resilient  stricture  is  one  which 
contracts  quickly  after  dilatation.  The  nearer  a  stricture  is  to  the  meatus, 
the  more  fibrous  it  is. 

A  congenital  stricture  is  congenital  narrowness  of  a  portion  of  the  urethra, 
usually  the  portion  near  the  meatus.  The  more  fibrous  a  stricture  is,  the 
more  it  narrows  the  urethra  and  the  less  dilatable  it  is.  A  stricture  may  be 
annular  (forming  a  ring  around  the  urethra),  tubular  (surrounding  the  ure- 
thra for  a  considerable  distance),  or  bridle  (when  a  band  crosses  the  urethra 
from  wall  to  wall).  A  stricture  of  large  caliber  will  admit  an  instrument 
larger  than  a  No.  15  French  sound.  A  stricture  of  small  caliber  will  not 
admit  a  Xo.  15  French  sound.  An  impermeable  stricture  will  not  admit  the 
passage  of  any  instrument.  Impermeable  is  more  or  less  a  relative  term. 
A  stricture  may  be  impermeable  when  an  anesthetic  is  not  used,  and  perme- 
able when  the  patient  is  anesthetized,  or  may  be  impermeable  to  one  surgeon, 
but  permeable  to  another.  Impermeability  is  often  a  temporary  condition 
due  to  inflammatory  edema  about  an  organic  stricture. 

Symptoms  and  Results  of  Stricture. — There  is  usually  a  history  of 
repeated  attacks  of  urethritis.  A  chronic  discharge  may  exist,  the  amount 
of  which  is  yariah)le.  There  is  a  feeling  of  weight  in  the  perineum,  soreness 
of  the  back,  and  frequency  of  micturition.  Hypochondriacal  tendencies 
are  usual.  In  a  deep  stricture  there  is  difficulty  in  starting  the  stream  in 
micturition.  In  mo.st  cases  the  stream  is  small,  twisted,  and  forked.  There 
is  often  interruption  or  "stammering"  of  the  stream,  and  it  dribbles  long 
after  the  conclusion  of  the  act,  so  that  the  penis  must  be  "milked"  before  it 
is  returned  within  the  clothing.  The  urethra  back  of  the  stricture  dilates, 
a  pouch  forms,  drops  of  urine  collect  and  decornpose,  and  a  chronic  inflam- 
mation results  in  the  mucous  membrane  or  the  parts  adjacent,  which  inflam- 
mation may  go  on  to  ulceration  or  to  peri-urethral  abscess.  A  urinary  fistula 
results  from  the  opening  externally  of  a  peri-urethral  abscess.  Retention 
of  urine  may  occur,  not  from  actual  obliteration  of  the  tube  by  the  growth 
of  the  stricture,  but  by  closure  of  the  lumen  of  the  urethra  by  muscular  spasm 
and  by  edematous  swelling  in  the  neighborhood  of  the  stricture.  Edematous 
swelling  may  be  due  to  cold,  wet,  venereal  excitement,  the  use  of  alcohol, 
overexertion,  etc.  Spasm  of  the  muscles  results,  and  contact  of  the  urine 
increases  the  spasm,  and  spasm  plus  edema  of  the  mucous  membrane  closes 


Treatment  of  Stricture 


997 


the  urethra.  Spasm  may  exist  in  the  urethra  itself  and  in  the  muscles  of  the 
neck  of  the  bladder,  but  is  only  a  temporary  condition.  In  old  strictures 
the  bladder  is  hypertrophied  and  often  fasciculated,  and  is  very  liable  to 
cystitis.  The  diagnosis  of  stricture  and  of  its  location  is  made  by  the  use 
of  exploratory  bougies.  In  this  examination  the  author 
follows  to  a  great  extent  the  plan  of  Ramon  Guiteras, 
which  is  as  follows:  *  Have  the  patient  pass  urine  into 
two  glasses.  Examine  the  urine  for  clap-shreds.  Cloudiness 
in  the  first  glass  shows  that  urethral  dis- 
charge exists.  Cloudiness  in  the  second  glass 
points  to  cystitis.  The  patient  is  placed  re- 
cumbent with  his  shoulders  elevated,  and  the 
urethra  is  washed  out  with  warm  salt  solution 
or  boracic  acid.  Bulbous  sounds  are  inserted 
beginning  with  No.  15  French.  If  this  passes 
with  ease,  take  a  larger  size  and  note  where 
strictures  are  situated  by  the  catch  on  with- 
drawal. If  No.  15  does  not  pass,  use  a 
smaller  size.  Remember  that  the  posterior 
layer  of  the  triangular  ligament  catches  a 
bulbous  instrument  on  withdrawal.  If  the 
meatus  is  too  small  to  permit  of  exploration, 
divide  it  with  a  curved  bistoury,  cutting  from 
within  outward.  After  cutting  the  meatus 
bleeding  is  arrested  with  styptic  cotton,  and 
a  piece  of  absorbent  cotton  is  tucked  into 
the  cut.  After  each  act  of  micturition  the 
patient  inserts  a  fresh  bit  of  cotton,  and  after 
three  days  the  urethral  examination  is  pro- 
ceeded with. 

Treatment. — A  stricture  of  large  caliber 
in  the  deep  urethra  requires  gradual  dilata- 
tion. A  steel  bougie  is  introduced  every 
fifth  day,  the  size  being  gradually  increased. 
Never  anoint  a  bougie  with  cosmolin,  as  it 
may  become  a  nucleus  for  a  stone  in  the 
bladder;  use  oil,  glycerin,  synol  soap,  or 
„    lubrichondrin.      Before    passing    an    instru- 

Fig.  584.  .  .  ^  ^      . 

— Syme's  mcut  the  patient  urinates  and  his  urethra 
staff.  is  washed  out  with  salt  solution  or  boracic 
acid  solution.  Glans,  meatus, and  urethra  are 
cleansed  as  directed  on  page  982.  The  sound  is  ren- 
dered sterile  by  boiling  before  using.  Gradual  dilata- 
tion can  be  effected  by  the  use  of  the  dilator  of  Ober- 
lander,  the  tube  being  distended  to  the  extent  of  three 
millimeters  every  fifth  day.     If  after  dilatation  there 

is  urethral  spasm,  pain,  or  very  frequent  micturition,  suspend  the  treatment 
for  a  number  of  days  and  order  each  night  a  hot  hip-bath  and  a  dose  of  pare- 

*  Med.  Record,  Nov.   14,  1896. 


Fig.  5S5. — Maisoniieuve's 
urethrotome. 


998 


Diseases  and  Injuries  of  the  Genito-urinaiy  Organs 


goric.  In  effecting  gradual  dilatation  by  sounds  the  instrument  should  be  intro- 
duced every  fifth  day.  During  the  treatment  the  patient  should  not  use  alcohol, 
should  refrain  from  sexual  excitement,  should  avoid  cold 
and  damp,  and  should  take  internally  capsules  containing 
boric  acid  and  salol.  It  is  rarely  necessary  to  dilate 
above  No.  32  French.  After  the  surgeon  finishes  treat- 
ment he  teaches  the  patient  to  use  an  instrument  and 
directs  him  to  pass  it  once  a  month.  Strictures  in  the 
pendulous  urethra,  if  soft,  are  treated  by  gradual  dila- 
tation; if  fibrous  and  contractile,  by  internal  urethrotomy. 
In  performing  internal  urethrotomy  prepare  the  patient 
carefully;  for  several  days  before  the  operation  give  salol 
and  boric  acid  by  the  mouth,  and  wash  out 
the  bladder  repeatedly  with  boric-acid  solu- 
tion. Be  thoroughly  aseptic.  Anesthetize 
the  patient.  Before  cutting  irrigate  the 
urethra  with  warm  normal  salt  solution, 
and  after  cutting  irrigate  again  and  tie  in 
IP       III  a  rubber  catheter.     These  precautions  will 

prevent  urethral  fever.  In  cutting,  insert 
Gross's  urethrotome  (Fig.  587)  back  of  the 
stricture,  spring  out  the  blade,  cut  the 
stricture  on  the  roof  of  the  urethra,  close 
the  blade,  withdraw  the  instrument,  and 
pa.ss  a  full-sized  bougie. 

Stricture  of  the  meatus  requires  incision 
with  a  knife  and  the  use  of  a  meatus  bougie 
until  heahng  is  complete.  Strictures  of 
small  caliber  in  front  of  the  membranous 
urethra  require  gradual  dilatation  and,  if 
this  fails,  internal  urethrotomy  or  divulsion. 
Internal  urethrotomy  can  be  performed  with 
the  urethrotome  of  Maisonneuve  (Fig.  585). 
This  instrument  is  shaped  like  a  sound,  has 
a  groove  upon  its  surface,  and  into  this 
groove  a  shaft  carrying  a  triangular  knife 
can  be  inserted.  The  staff  is  screwed  to  a  guide,  the  guide  is 
carried  into  the  bladder  and  the  staff  follows  it.  The  point  of 
the  staff  is  carried  to  the  prostatic  urethra  and  the  guide  curls 
up  in  the  bladder.  The  penis  is  held  upon  the  stretch,  the 
blade  is  in.serted  and  jmshed  down  through  the  stricture.  This 
instrument  cuts  the  stricture,  but  not  the  healthy  urethra.  For 
divulsion  the  patient  is  {prepared  as  for  internal  urethrotomy. 
The  divulsor  of  Gross,  or  of  Sir  Henry  Thorap.son,  or  of  Gouley 
(Figs.  586,  588,  589)  is  introduced,  the  blades  are  .separated,  the 
instrument  is  withdrawn,  a  large  bougie  is  pas.sed,  and  a  catheter  is 
tied  in  the  bladder.  Strictures  of  small  cah'ber  in  the  deep  urethra 
require  gradual  dilatation;  if  this  fails,  employ  external  urethrotomy. 
In    strictures    of    the  deep    urethra,  if   only  a  filiform   bougie   can    be   in- 


Fig. 


586. — Gross's   ure- 
thral dilator. 


Fig.  5S7.— 
S.  W.  Gross's 
explo  ra  tory 
urethrotome. 


Urethral  Fe\-er 


999 


troduced,  the  bougie  may  be  left  in  place,  and  in  a  day  or  two  another 
can  be  sHpped  in  beside  it,  until  in  a  few  days  the  channel  becomes 
permeable  to  a  metal  bougie.  A  tunnelled  catheter  can  be  shpped  over 
the  fihform  bougie,  both  be  withdrawn,  and  a  metal  bougie  passed.  A 
tunnelled  and  grooved  staff  can  be  carried  in  over  the  bougie  and  external 
urethrotomy  be  performed.  Thompson's  dilator  can  be  carried  in  over  the 
filiform  and  the  stricture  be  divulsed.  Fort's  method  of  electrolysis  is  said 
to  be  of  value,  but  I  have  had  no  personal  experience  with  it.  Fort  treats 
stricture  by  linear  elec- 
trolysis. His  instrument 
looks  hke  a  whip,  and  it 
has  a  platinum  blade  pro- 
jecting from  about  the 
center.  The  blade  is  con- 
nected with  the  negative 

pole  of  a  galvanic  battery  and  the  positive  pole  is  placed  over  the  pubes. 
The  guide  carrying  the  blade  is  inserted  into  the  urethra,  and  when 
the  blade  comes  against  the  stricture  the  current  is  turned  on  and  the 
platinum  passes  rapidly  through  the  constriction.  The  current  is  turned 
off  and  the  instrument  is  carried  onward  until  it  strikes  another  stricture, 
when  the  current  is  again  turned  on,  and  so  on.  The  necessary  current- 
strength  is  lo  to  15  ma.  The  operation  requires  twenty  to  thirty  seconds  and 
causes  but  little  pain.     After  its  performance  a  sound  is  passed  (a  No.  22 


Fig.  58S. — Thompson's  divulsor. 


Fig.  589.— Gouley's  divulsor. 


of  the  French  scale).  The  patient  need  not  be  confined  to  bed  after  this 
operation.  By  Fort's  method  we  act  purely  upon  the  diseased  tissue.  In 
impassable  stricture  of  the  deep  urethra  perform  external  jjerineal  urethrotomy 
without  a  guide  (the  operation  of  Wheelhouse). 

If  a  perineal  fistula  exists,  dilate,  divulse,  or  cut  the  stricture;  retain  a 
catheter  in  the  bladder  for  forty -eight  hours.  After  this  period  dilate  every 
few  days  with  a  metal  instrument.  Every  morning  and  evening  draw  the 
urine  with  a  soft  catheter,  introduce  boric-acid  solution  into  the  bladder, 
remove  the  catheter,  and  let  the  man  empty  his  bladder  naturally.  A  portion 
will  flow  from  the  fistula  and  a  part  from  the  meatus.  Day  by  day  the  quan- 
tity which  comes  from  the  fistula  lessens,  and  finally  the  abnormal  opening 
heals. 

Urethral  Fever. — x\ny  operation  upon  the  urethra  may  be  followed 
by  a  chill  owing  to  shock  (urethral  shock),  and  this  may  be  followed  by  a 
nervous  fever.  Urethral  fever  proper  is  sapremia  following  a  urethral 
operation.     This   condition   is   due   to   absorption  of   toxic   elements  which 


looo         Diseases  and  Injuries  of  the  Genito-urinary  Organs 

mav  be  in  the  urine,  may  have  been  in  the  urethra,  or  may  have  been 
introduced  from  without.  It  usually  follows  the  first  urinary  act  after  opera- 
tion. It  begins  with  a  violent  chill  and  presents  the  characteristics  of  a  septic 
fever.  It  is  accompanied  by  a  marked  tendency  to  urinary  suppression, 
and  may  eventuate  in  septicemia  or  pyemia.  Urethral  fever  can  be  pre- 
vented by  rigid  antisepsis.  If  this  fever  should  arise,  a  catheter  must  be  tied 
in  the  bladder,  the  bladder  and  urethra  must  be  repeatedly  irrigated  with 
aseptic  or  antiseptic  fluids,  and  the  patient  must  be  given  urinary  antiseptics 
and  stimulants  by  the  mouth. 

Urinary  Fever. — Sir  Benjamin  Brodie  pointed  out  that  the  with- 
drawal of  residual  urine  in  a  case  of  enlarged  prostate  may  be  followed  by 
very  serious  symptoms.  The  condition  is  spoken  of  as  urinary  fever,  and 
is  said  by  many  to  be  due  to  the  sudden  and  complete  emptying  of  a  bladder 
which  has  become  accustomed  to  retaining  permanently  a  considerable 
quantity  of  urine.  Modern  studies  prove  that  urinary  fever  is  due  to  infection 
of  the  bladder  and  kidneys,  and  not  simply  to  the  sudden  withdrawal  of  all  of 
the  urine  from  the  bladder,  although  such  a  procedure  leads  to  vesical  con- 
gestion and  probably  favors  infection.  The  bacteria  most  often  found  are 
pyogenic  cocci,  colon  bacilli,  and  micro-organisms  which  cause  putrefaction 
and  decomposition  of  urea. 

The  condition  does  not  arise  promptly,  suddenly,  and  violently,  as  does 
urethral  fever,  but  begins  rather  insidiously  after  several  days.  Mr.  C. 
Mansell  Moulhn  thus  describes  the  condition:  * 

"  So  far  as  the  broader  features  are  concerned,  the  symptoms  that  present 
themselves  in  these  cases  are  remarkably  uniform.  They  do  not  begin  at 
once.  Nearly  always  some  few  days  elapse  before  there  is  anything  to  excite 
suspicion.  Then  the  urine  becomes  cloudy,  though  it  may  still  retain  its 
acid  reaction.  A  small  quantity  of  albumin,  more  than  can  be  accounted 
for  bv  the  amount  of  pus  that  is  present,  makes  its  appearance.  Under  the 
microscope  there  are  a  few  hyahne  casts,  perhaps  a  blood-corpuscle  or  two, 
numerous  pus-corpuscles,  and  myriads  of  bacteria.  The  specific  gravity  is 
lower  than  it  ought  to  be,  and  is  lower  than  it  was  before  the  catheter  was 
used.  The  total  amount  passed  in  the  twenty-four  hours  may  either  increase 
until  it  is  as  much  as  seven  or  eight  pints,  or  diminish  until  it  scarcely  reaches 
twenty  ounces.  There  is  seldom  any  definite  rigor,  but  there  may  be 
numerous  slight  chills.  The  pulse  grows  more  rapid  and  feeble.  The 
tongue  becomes  red  and  dry.  There  is  complete  anorexia.  Delirium  sets 
in  at  night,  and  in  a  considerable  proportion  of  cases  the  symptoms  rapidly 
grow  worse  and  worse  until,  at  the  end  of  a  few  days,  the  patient  sinks  into 
a  semi-comatose  condition  from  which  he  seldom  rallies.  Post-mortem 
there  are  all  the  signs  of  recent  acute  cystitis  and  pyelonephritis.  The  mu- 
cous membrane  lining  the  pelvis  and  calices  of  the  kidneys,  the  ureters, 
and  the  bladder  is  swollen  and  stained  by  old  and  recent  hemorrhages,  and 
here  and  there  a  thin  layer  of  pus  is  adherent  to  it.  The  pelvis  and  the 
ureters  are  dilated,  the  apices  of  the  pyramids  are  eaten  away,  the  cortex  is 
shrunken  and  hard,  the  capsule  is  adherent,  and  in  places  between  the 
tubules  are  minute  collections  of  pus  differing  in  shape  and  (jutline  accord- 
ing to  the  anatomical  arrangement." 

*  Lancet,  Sept.   lo,   1898. 


Wheelhouse's  Operation 


lOOI 


Treatment. — Aseptic  catheterization  is  necessary  if  we  would  avoid 
urinary  tever;  and  as  the  urethra  contains  some  of  the  causative  organisms, 
the  prepuce,  glans,  and  meatus  should  be  washed  with  soap  and  water  and 
irrigated  with  boric-acid  or  permanganate  of  potassium  solution,  and  the 
urethra  be  irrigated  with  boric-acid  solution  or  permanganate  of  potassium 
before  the  sterile  catheter  is  introduced  to  draw  the  urine. 

If  urinary  fever  arises,  it  may  be  possible  to  control  it  by  frequentlv  irri- 
gating the  bladder  with  warm  normal  salt  solution,  solution  of  nitrate  of 
silver  (i  :  8000),  or  boric-acid  solution,  and  by  administering  stimulants, 
diuretics,  diaphoretics,  sahne  cathartics,  and  nutritious  food.  In  severe  cases 
perform  suprapubic  cystotomy  for  drainage. 


Fig.  590. — Wheelhouse's  staff. 

Perineal  section  is  external  perineal  urethrotomy.  There  are  three 
methods — the  operation  of  Syme,  of  Wheelhouse,  and  of  Cock. 

Syme's  Operation. — This  operation  is  employed  if  a  stricture  is  very 
contractile,  if  dilatation  fails  to  cure,  or  if  urethral  instrumentation  invari- 
ably causes  pronounced  urethral  fever.  The  patient  is  anesthetized,  Syme's 
staff  (Fig.  584)  is  introduced,  and  the  surgeon  makes  an  incision  in  the  mid- 
line of  the  perineum  and  exposes  the  staff  just  above  the  shoulder  of  the 
instrument.  The  knife  is  carried  along  the  groove  and  divides  the  stricture. 
A  catheter  is  passed  into  the  bladder  from  the  meatus  and  is  retained  for 
several  days,  and  the  wound  is  dressed  antiseptically.  After  the  catheter  is 
removed  it  must  be  used  every  six  hours  until  the  urine  comes  entireh-  by 
the  meatus.  During  the  rest  of  the  patient's  life,  a  full-sized  sound  should 
be  passed  at  regular  intervals. 


Fig.  591. — Teale's  probe  gorget. 


Wheelhouse's  Operation. — This  operation  is  employed  for  the  treat- 
ment of  impermeable  stricture.  Wheelhouse's  staff  is  passed  into  the  urethra 
until  it  blocks  on  the  stricture.  The  perineum  is  incised  down  to  the  staff 
and  in  front  of  the  stricture.  The  edges  of  the  cut  urethra  are  held  apart 
with  forceps,  the  surgeon  seeks  for  the  opening  through  the  stricture,  passes 
a  fine  probe  through  it,  divides  the  stricture,  carries  into  the  bladder  from  the 
wound  an  instrument  known  as  a  probe  gorget  to  dilate  the  canal  and 
furnish  a  solid  flioor  to  facilitate  the  introduction  of  a  catheter.  With  the  gorget 
in  place  a  metal  catheter  is  carried  from  the  meatus  into  the  bladder.  The 
gorget  is  removed  and  the  catheter  is  tied  in  place.  After  three  or  four  davs  the 
catheter  is  removed  and  is  then  passed  frequently.     The  ])erineal  wound  is. 


I002         Diseases  and  Injuries  of  the  Genito- urinary  Organs 

of  course,  dressed  antiseptically.  Figs.  590  and  591  show  the  instruments 
for  Wheelhouse's  operation. 

Cock's  Operation. — This  operation  opens  the  urethra  back  of  the  stricture 
and  without  a  guide  and  reUeves  retention  of  urine.  The  surgeon  introduces 
into  the  rectum  the  index-finger  of  the  left  hand,  and  the  tip  of  the  finger  is 
rested  upon  the  apex  of  the  prostate  gland.  The  surgeon  incises  the  median 
line  of  the  perineum,  the  back  of  the  knife  being  toward  the  anus.  When 
the  point  of  the  knife  is  felt  to  be  near  the  finger  the  handle  is  lowered  slightly, 
the  blade  is  placed  a  little  oblique,  and  the  urethra  is  opened.  A  catheter  is 
passed  into  the  bladder  from  the  wound  and  retained  for  a  time,  and  the 
stricture  is  subsequently  treated. 

Epispadias  is  a  congenital  cleft  in  the  corpora  cavernosa,  the  roof  of 


Fig.  5<52. — Beck's  operation  for  hypospadias. 


the  urethra  being  completely  or  partly  absent.  In  complete  epispadias  there 
are  absence  of  the  pubic  arch  and  exstrophy  of  the  bladder. 

Partial  epispadias  may  sometimes  be  remedied  by  a  plastic  operation. 

Hypospadias  is  a  congenital  cleft  on  the  floor  of  the  urethra,  the  meatus 
opening  on  the  floor  at  some  point  between  the  scrotum  and  the  end  of  the 
glans  penis,  the  channel  in  front  of  the  meatus  being  a  gutter  and  not  a  tube. 

Hypospadias  of  the  glans  is  the  most  common  form.  In  this  condition 
the  urethra  has  no  floor,  as  it  passes  beneath  the  glans,  the  site  of  the  urethra 
is  indicated  by  a  groove,  and  the  foreskin  is  absent  below.  Partial  hypo- 
spadias requires  no  treatment  except  possibly  dilatation  or  incision  of  the 
meatus.  People  who  suffer  from  it  are  very  prone  to  develop  chronic  urethral 
inflammation.  In  hypospadias  of  the  penis  the  ill-developed  cord-Hke  corpus 
spongio.sum  draws  the  penis  to  the  scrotum.  In  this  variety  of  the  deformity 
the  penis  is  very  short. 


Chancroid  1003 

In  complete  hypospadias  the  opening  of  the  urethra  is  back  of  the  scrotum 
in  the  perineum,  the  penis  is  dwarfed  and  bound  down,  and  looks  not  unlike 
a  clitoris,  the  scrotum  is  divided  into  two  portions,  a  gap  existing  between 
them,  and  in  many  cases  the  testicles  have  not  descended.  Such  individuals 
are  occasionally  mistaken  for  females.  In  the  penile  complete  forms  of 
hypospadias  a  plastic  operation  should  be  performed  between  the  eighth  and 
tenth  years  of  age.  Such  an  operation  unfortunately  may  fail.  Hypospadias 
is  rare  in  women,  but  it  may  occur.  In  such  a  case  the  urethra  opens  into 
the  vagina.  Fig.  592  shows  the  ingenious  operation  successfully  practised 
by  Carl  Beck  for  penile  hypospadias. 

Chancroid  (soft  chancre;  the  local  venereal  sore)  is  an  ulcer,  usually  of 
venereal  origin.  The  name  chancroid  was  introduced  by  Clerc,  who  believed 
that  a  soft  sore  resulted  from  inoculating  a  person  already  syphilitic  with  the 
products  of  a  hard  sore.  He  further  held  that  when  a  soft  sore  arose  the 
syphilitic  poison  lost  its  infective  properties,  and  "  could  be  transmitted  as 
a  soft  sore  to  a  healthy  person,  and  not  cause  general  infection."  *  The 
chancroidal  ulcer  is  not  connected  with  the  syphilitic  poison,  but  is  developed 
by  inoculation  with  the  bacterium  of  Ducrey.  Until  recently  it  was  believed 
that  a  chancroid  was  not  produced  by  a  special  poison,  but  arose  after  in- 
oculation with  inflammatory  products  or  irritating  secretions.  It  seems  to 
have  been  proved,  however,  by  Krefting  and  Colombini  that  the  organism 
discovered  bv  Ducrey  in  1889  is  the  real  cause.  This  organism  is  grown 
on  a  medium  of  fresh  blood  and  bouillon  or  in  "  unmixed  human  blood." 
(See  Lincoln  Davis,  "  Observations  on  the  Distribution  and  Culture  of  the 
Chancroid  Bacillus."  Report  of  Research  Work,  1902-1903;  the  Division 
of  Surgery  of  the  Medical  School  of  Harvard  University.)  As  a  rule, 
chancroids  are  of  venereal  origin,  and  result  from  contact  with  other  chan- 
croids, pus,  mucopus,  or  areas  of  ulceration.  A  chancroid  appears  soon 
after  intercourse,  usually  within  five  days,  always  within  ten  days.  It 
is  first  manifested  by  a  pustule  which  ruptures  and  discloses  an  ulcer.  This 
ulcer  has  sharply  defined  and  undermined  margins;  it  looks  "punched  out"; 
the  base  is  gray  and  sloughy;  the  discharge  is  profuse,  purulent,  foul,  and 
auto-inoculable,  and  causes  fresh  chancroids  by  flowing  over  the  parts.  The 
area  around  a  chancroid  is  red  and  inflamed,  and  considerable  pain  is  apt 
to  be  complained  of.  The  original  chancroid  spreads  and  new  sores  appear. 
The  edge  of  a  chancroid  is  rarely  indurated  unless  caustics  have  been  used 
or  there  is  mixed  infection  with  syphilis.  Inflammatory  induration  fades 
gradually  into  the  tissues,  but  the  induration  of  a  hard  chancre  is  sharply 
defined.  Fournier  says  that  a  chancroid  may  have  a  hard  base  if  the  sore  is 
located  in  the  sulcus  back  of  the  glans,  on  a  lip  of  the  meatus,  or  on  the  lower 
border  of  the  prepuce  of  a  man  with  phimosis,  or  when  the  ulcer  is  inflamed. 
The  surgeon  should  always  ask  if  the  sore  has  been  cauterized  and  how  it 
has  been  treated.  When  a  chancroid  after  a  time  displays  marked  and 
sharply  outlined  induration  it  points  to  mixed  infection  of  chancroid  and 
syphilis.  Chancroids  are  not  followed  by  constitutional  symptoms,  but  are 
apt  to  be  accompanied  by  painful  inflammatory  buboes  which  are  prone  to 
suppurate.  In  hospital  practice  about  30  per  cent,  of  patients  develop  bu- 
boes. The  bubo  may  be  one-sided  or  bilateral.  The  adenitis  of  chancroid 
*  "Syphilis,"  by  Alfred  Cooper. 


I004         Diseases  and  Injuries  of  the  Genito-urinary  Organs 

is  due  in  the  majority  of  cases  to  the  absorption  of  toxins  and  pus  may  be 
free  from  bacteria.  Cases  have  been  reported  in  which  non-indurated  sores 
were  followed  by  syphiHs.  It  is  probable  that  a  mixed  infection  existed, 
and  that  induration  was  overlooked,  because  a  papular  initial  lesion  was 
underneath  the  chancroidal  ulcer.  When  inflammation  in  chancroids  is 
high  a  rapidly  destructive  ulceration  known  as  phagedena  may  arise,  but  this 
process  is  more  common  in  syphilitic  sores. 

Treatment. — Ordinary  cases  of  chancroid  are  treated  by  spraying  with 
peroxid  of  hydrogen,  drying  with  cotton,  touching  each  sore  first  with  pure 
carbolic  acid  and  then  with  pure  nitric  acid,  and  dressing  with  black  wash 
or  dusting  with  iodoform  or  with  calomel.  Every  few  hours  the  patient 
soaks  the  penis  in  hot  salt  water  (a  teaspoonful  of  salt  to  a  pint  of  water), 
sprays  the  sores  with  peroxid  of  hydrogen,  dries  with  cotton,  and  dresses  with 
black  wash  or  dusts  with  iodoform  or  with  calomel.  As  soon  as  granulation 
begins  the  sores  should  be  dressed  with  i  part  of  ointment  of  nitrate  of  mer- 
cury to  7  parts  of  cosmolin.  Mild  cases  do  well  without  cauterizing,  peroxid 
of  hydrogen  being  frequently  used  and  a  drying  powder  being  employed. 
In  chancroids  with  phimosis  sht  up  the  foreskin,  smear  the  raw  edges  of  the 
wound  with  pure  carbolic  acid,  and  treat  the  ulcers  by  cauterization.  A 
regular  circumcision  often  fails  because  of  infection  of  the  stitch-holes.  Phage- 
dena requires  the  internal  use  of  iron,  quinin,  and  milk-punch,  and  the  local 
use  of  powerful  caustics  (bromin  or  nitric  acid  or  even  the  actual  cautery). 
In  some  cases  continuous  antiseptic  irrigation  is  valuable.  When  a  bubo  first 
begins,  order  rest,  apply  iodin  or  an  ointment  of  belladonna  or  ichthyol,  and 
make  pressure  by  a  spica  bandage  of  the  groin.  Some  surgeons  advise  the 
injection  of  20-40  minims  of  a  solution  of  carbolic  acid  (gr.  x  to  the 
ounce),  but  I  have  never  seen  any  benefit  from  it.  Some  inject  a  i  per 
cent,  solution  of  bichlorid  of  mercury,  but  the  proceeding  causes  intense 
pain.  Welander  recommends  the  injection  of  a  i  per  cent,  solution  of  ben- 
zoate  of  mercury.  I  have  had  no  experience  with  this  method.  If  the 
bubo  persists,  even  though  it  does  not  suppurate,  it  should  be  completely 
excised.  If  pus  forms,  several  methods  of  treatment  are  open  to  us:  Aspi- 
ration, injection  with  a  solution  of  carbolic  acid,  squeezing  out  the  acid  and 
injecting  10  per  cent,  ointment  of  iodoform  and  glycerin,  and  sealing  the 
opening  with  collodion  (Scott  Helms).  Hayden  makes  a  puncture,  squeezes 
out  the  pus,  washes  out  the  cavity  with  peroxid  of  hydrogen  and  then  with  cor- 
rosive sublimate  solution,  injects  warm  iodoform  ointment,  and  dresses  with 
cold,  moist,  corrosive  sublimate  gauze  to  set  the  ointment.  Otis,  Fontain, 
Perry,  and  others  commend  this  plan.  We  have  often  found  it  to  succeed. 
If  the  above-mentioned  plan  fails,  if  it  is  not  used,  or  if  an  ulcer  or  sinus  exists, 
incise,  curet,  cauterize  with  pure  carbolic  acid,  cut  away  hopelessly  infiltrated 
skin,  and  pack  the  wound  with  iodoform  gauze.  In  some  ca.ses  it  will  be 
necessary  to  extirpate  fragments  of  gland. 

Phimosis  is  a  condition  of  the  prepuce  that  renders  retraction  over  the 
glans  impossible.  It  is  u.sually  congenital,  but  it  may  arise  from  inflamma- 
tion. Congenital  phimosis  causes  retention  of  sebaceous  matter,  which  de- 
composes and  lights  up  inflammation  and  the  prepuce  is  apt  to  grow  fast  to 
the  glans.  Congenital  phimosis  may  induce  irritability  of  the  bladder,  in- 
continence of  urine,  prolapse  of  the  rectum,  and  various  nervous  symptoms. 


Seminal  Vesiculitis  1005 

The  treatment  is  circumcision.  Asepticize  the  parts.  Grasp  the  foreskin 
and  the  mucous  membrane  with  two  forceps,  draw  the  prepuce  forward, 
catch  the  skin  (at  the  point  it  is  desired  to  cut)  hori- 
zontally between  the  arms  of  the  handle  of  a  pair 
of  scissors,  and  cut  off  the  redundant  prepuce.  Re- 
trench the  excess  of  mucous  membrane  by  cutting 
around  with  scissors  one-quarter  of  an  inch  from 
the  glans,  stitch  the  skin  to  the  mucous  membrane 
Fig-  593— Circum-      ^^.j^j^  catsfut,  and  dress  with  sterile  gauze  (Fig.  kqx). 

crsion    completed    (Es-  r-  j.  r    xl  •  ,^   ,      •  ?    oVO/_ 

march  and  Kowaizig).  rracture  01   trie  pcniS,  which  IS  a   laceration  of 

the  cavernous  bodies  with  extravasation  of  blood,  occurs 
occasionally  during  coition.  The  treatment  consists  of  cold  and  bandaging 
to  arrest  bleeding,  and  occasionally  incisions  to  let  out  clot. 

Gangrene  of  the  penis  arises  from  phagedena,  from  tying  constricting 
bands  around  the  organ,  from  fracture  with  excessive  hemorrhage,  and  from 
paraphimosis.     If  extensive,  it  requires  amputation. 

Cancer  of  the  penis  is  commonest  in  persons  with  phimosis.  In  a 
limited  epithelioma  of  the  foreskin  circumcision  is  performed  and  the  glands 
of  the  groin  are  removed ;  if  cancer  affects  the  glans,  amputation  of  the  penis 
and  removal  of  the  inguinal  glands  is  required. 

Amputation  of  the  Penis.— Ricord  advised  cutting  off  the  organ 
with  a  single  stroke  of  the  knife,  making  four  slits  in  the  mucous  membrane 
of  the  urethra,  and  stitching  each  of  these  flaps  to  the  skin.  Treves  splits 
the  skin  of  the  scrotum  along  the  raphe,  separates  the  halves  of  the  scrotum 
down  to  the  corpus  spongiosum,  passes  a  metal  catheter  down  to  the  triangular 
ligament,  inserts  a  knife  between  the  corpus  spongiosum  and  the  corpora 
cavernosa,  withdraws  the  catheter,  cuts  the  urethra  across,  detaches  the 
urethra  from  the  penis  back  to  the  triangular  ligament,  cuts  around  the  root 
of  the  penis,  divides  the  suspensory  ligament,  detaches  each  crus  from  the 
pubes,  slits  up  the  corpus  spongiosum  half  an  inch,  stitches  its  edges  to  the 
rear  end  of  the  scrotal  incision,  introduces  a  drainage-tube,  ligates  the  vessels, 
and  sutures  the  wound. 

Seminal  Vesiculitis. — Inflammation  of  the  seminal  vesicles  is  due 
to  the  extension  of  a  gonorrheal  inflammation,  a  pyogenic  process,  or  to 
tuberculosis. 

Acute  inflammation  is  made  evident  by  frequent  and  painful  micturition, 
pains  in  the  anus,  rectum,  and  perineum,  and  possibly  the  hip-joint,  back, 
and  thigh.  Defecation  and  micturition  are  excessively  painful.  Persistent 
erections  may  take  place,  and  in  some  cases  bloody  ejaculations  occur.  Rectal 
examination  detects  the  enlarged  and  tender  vesicles  external  to  the  lateral 
lobes  of  the  prostate  and  on  a  higher  level. 

Treatment. — Abandon  local  urethral  treatment,  and  treat  the  patient  as 
for  acute  prostatitis. 

Chronic  vesiculitis  may  result  from  the  acute  form  or  may  come  on  in- 
sidiously in  an  individual  with  gonorrhea.  It  is  one  of  the  causes  of  chronic 
urethral  discharge.  The  patient  suft'ers  from  imperative  and  frequent  de- 
mands to  micturate,  and  he  has  a  gleety  discharge  which  becomes  worse  and 
better,  but  does  not  disappear.  This  chronic  inflammation  is  believed  to 
persist  because  of  narrowing  of  the  duct,  and  consequent  incomplete  drainage 


ioo6         Diseases  and  Injuries  of  the  Genito-urinary  Organs 

of  the  vesicle.     In  chronic  seminal  vesiculitis  there  is  usually  sexual  weak- 
ness, nocturnal  emissions  occur,  and  the  semen  may  contain  blood. 

Treatment. — Treat  the  posterior  urethritis  by  ordinary  methods.  Use 
hot  rectal  enemata.  Milk  the  ducts  by  Fuller's  method  once  every  seven 
days.  During  massage  the  patient's  bladder  should  be  full.  He  leans 
over  a  chair-back,  the  knees  being  straight  and  the  body  at  a  right  angle 
to  the  thighs.  The  surgeon  covers  his  finger  with  a  rubber  stall  and  anoints 
it  with  oil  or  synol  soap,  and  introduces  it  into  the  rectum,  and  makes  pres- 
sure over  the  pubes  with  the  fist  of  the  other  hand.  The  finger  comes  in 
contact  with  the  lower  half  of  the  vesicle;  it  makes  firm  pressure  for  a 
moment,  and  is  then  drawn  slowly  toward  the  duct.  This  stroking  is 
repeated  several  times.  The  other  vesicle  is  treated  in  the  same  manner. 
This  maneuver  empties  the  vesicle  and  hastens  the  resolution  of  inflam- 
mation. After  the  completion  of  the  stripping  the  patient  should  micturate, 
and  the  bladder  and  urethra  should  be  irrigated. 

Tuberculosis  of  the  Seminal  Vesicles. — Primary  tuberculosis  is 
very  unusual.  As  a  rule  there  is  antecedent  tuberculosis  of  the  testicle 
or  prostate  gland.  About  50  per  cent,  of  the  cases  occur  in  individuals  under 
forty  years  of  age.  The  diseased  vesicle  is  at  first  nodular  and  indurated, 
but  later  undergoes  caseation  and  softening.  Finally  the  disease  passes 
through  the  capsule  and  invades  adjacent  structures.  Dreyer  collected  36 
cases  and  found  that  in  34  of  them  the  lungs  were  involved. 

Tuberculous  vesicuHtis  may  be  unilateral  or  bilateral.  In  unilateral 
tuberculous  epididymitis  the  corresponding  vesicle  is  apt  to  become  diseased. 
In  bilateral  disease  of  the  testicles  both  vesicles  are  liable  to  involvement. 
Peritoneal  tuberculosis  may  follow  tuberculous  vesiculitis.  In  very  unusual 
cases  spontaneous  cure  is  obtained  by  fibrous-tissue  formation.  On  palpa- 
tion a  tuberculous  vesicle  is  found  to  contain  here  and  there  hard  and  but 
slightly  tender  nodules. 

Treatment. — If  tuberculous  epididymitis  is  followed  by  tuberculous 
vesiculitis  it  is  justifiable  to  remove  the  vesicle  after  removing  the  tes- 
ticle, provided  the  prostate  and  other  parts  of  the  genito-urinary  tract  are 
free  from  disease  and  there  is  no  distant  lesion  of  tuberculosis.  If  both 
testicles  are  removed,  both  vesicles  can  be  extirpated.  If  a  vesicle  or  both 
vesicles  suffer  from  primary  tuberculosis,  an  operation  may  be  performed. 
Reported  cases  do  not  seem  to  favor  operation. 

Kraske,  Schede,  and  Rydygier  have  removed  the  vesicles  after  prehminary 
resection  of  the  sacrum.  Zuckerkandl,  Dittel,  and  Schede  have  employed 
the  perineal  rcjute.  Villeneuve  reached  them  by  way  of  the  inguinal  region. 
The  curved  perineal  incision  of  Zuckerkandl  is  the  method  usually  preferred. 
H.  H.  Young  makes  a  suprapubic  incision,  strips  the  peritoneum  from  the 
bladder,  and  reaches  the  ve.sicles  from  behind.  He  calls  it  the  suprapubic- 
retrocy.stic-extraperitoneal  method  (H.  H.  Young,  in  "Annals  of  Surgery," 
Nov.,  190J). 

Acute  Prostatitis. — Acute  inflammation  of  the  prcjstate  gland  may 
be  caused  by  inflammation  in  adjacent  structures,  the  use  of  instruments  or 
irritant  applications  in  the  deep  urethra,  injury  by  a  passing  or  impacted 
calculus,  various  infectious  diseases,  a  .stricture  of  the  urethra,  but  particularly 
by  gonorrhea.     The  gland  enlarges  greatly,  the  prostatic  fluid  exudes  mixed 


Chronic  Prostatitis  1007 

with  blood  and  pus,  and  the  gland-ducts  become  distended  with  pus.  A 
distinct  abscess  may  form.  The  oritices  of  the  ejaculatory  ducts  become 
distended  and  filled  with  pus,  and  the  seminal  vesicles  or  epididymis  may  also 
suffer.  An  abscess  is  liable  to  form  in  the  cellular  tissue  outside  of  the  pros- 
tate. 

Symptoms. — A  feeling  of  weight,  fulness  or  soreness  in  the  perineum;  a 
persistent  pain  at  the  neck  of  the  bladder;  frequent  micturition,  pain  being 
present  and  becoming  most  severe  as  the  last  drops  are  voided;  perineal 
tenderness;  painful  defecation;  and  bulging  of  anal  mucous  membrane.  If 
a  finger  is  introduced  into  the  rectum  it  causes  severe  pain  and  palpates  the 
enlarged  and  tender  gland,  unless  the  outlines  are  destroyed  by  periprostatitis, 
in  which  case  there  will  be  felt  a  large,  boggy,  tender  mass.  (See  Henry 
Morris  on  "  Injuries  and  Diseases  of  the  Genital  and  Urinary  Organs.") 
These  symptoms  are  accompanied  by  distinct  elevation  of  temperature. 
The  inflammation  may  abate  with  suppuration,  but  as  a  rule  pus  forms,  the 
temperature  becomes  characteristic,  the  pain  becomes  pulsatile,  micturition 
causes  agony,  the  inflammatory  mass  is  felt  per  rectum  to  be  softening;  and 
often  the  swollen  perineum  becomes  dusky  red.  Retention  of  urine  is  alm.ost 
certain  to  occur.  The  abscess  may  rupture  into  the  urethra  or  the  rectum, 
or  may  diffuse  in  the  periprostatic  cellular  tissue  and  subsequently  may 
open  in  the  perineum.  Spontaneous  evacuation  may  be  followed  by  recovery 
or  by  the  development  of  annoying  or  dangerous  complications. 

Treatment. — Keep  a  hot-water  bag  on  the  perineum  and  three  or  four 
times  a  day  use  rectal  injections  of  hot  water.  Place  the  patient  on  a  milk- 
diet.  Leech  the  perineum.  Give  suppositories  of  opium  and  belladonna, 
and  also  suppositories  of  ichthyol,  and  administer  urotropin  by  the  mouth. 
At  the  first  sign  of  suppuration  make  a  curved  perineal  incision.  Reten- 
tion of  urine  is  relieved  by  a  soft  catheter. 

Chronic  Prostatitis. — May  arise  from  stricture,  venereal  excess, 
chronic  cystitis,  or  stone  in  the  bladder,  but  gonorrhea  is  the  common  cause. 
The  prostate  is  usually,  but  not  always,  enlarged,  is  somewhat  softened,  and 
the  ducts  contain  pus  and  blood. 

Symptoms. — There  is  usually  a  mucopurulent  discharge  or  fluid  can  be 
obtained  by  massage  of  the  prostate.  There  is  a  feeling  of  weight  and  fulness 
in  the  perineum,  increased  frequency  of  micturition,  and  the  prostate  is  very 
sensitive  to  digital  pressure.  The  patients  are  neurotic,  frequently  suffer 
from  nocturnal  emissions,  and  have  but  feeble  power  of  erection.  The  pros- 
tatic urethra  is  extremely  hyperesthetic.  All  the  symptoms  are  aggravated 
by  worry,  sexual  excitement,  or  violent  exercise.  An  abscess  may  form  and 
rupture  into  the  urethra. 

Treatment. — Tonics  and  nutritious  food  are  essential.  Intravesical 
irrigations  with  nitrate  of  silver  solution  (i  :  8000)  do  good.  Massage  of 
the  prostate  is  u.seful.  Some  cases  are  benefited  by  touching  the  posterior 
urethra  through  a  urethroscope  tube  with  nitrate  of  silver  (3  grains  to  the 
ounce)  or  by  injecting  by  means  of  Ultzman's  syringe  a  few  drops  of  silver 
nitrate  solution  (5  grains  to  the  ounce).  Rectal  suppositories  of  ichthyol 
may  be  ordered.  Blistering  the  perineum  at  intervals  may  prove  of  service. 
At  intervals  of  three  or  four  days  a  full-sized  cold  steel  sound  should  be  gently 
introduced.     If  an  abscess  refuses  to  heal,  incise  the  perineum. 


I008  Diseases  and  Injuries  of  the  Genito-urinaiy  Organs 

Prostatorrhea. — Just  as  overaction  of  the  glands  of  the  urethra  con- 
stitutes urethrorrhea,  so  overaction  of  the  glandular  apparatus  of  the  prostate 
gland  constitutes  prostatorrhea.  Prostatorrhea  is  not  inflammatory,  although 
the  prostate  and  posterior  urethra  are  often  congested,  and  the  latter  region 
is  usually  hvperesthetic.  In  some  cases  urethrorrhea  exists  with  prostator- 
rhea. Prostatorrhea  is  produced  by  se.xuai  excess,  masturbation,  ungratified 
sexual  desire,  and  riding  a  bicycle  with  an  improper  seat.  The  condition 
is  usually  accompanied  by  marked  neurasthenia,  and  may  be  associated  with 
spermatorrhea  and  impotence. 

The  patient  notices  a  milky  or  gray  discharge  after  straining  at  stool 
(defecation-spermatorrhea),  after  violent  exercise,  sexual  excitement,  or  a 
bicycle  ride.  The  discharge  also  gathers  in  the  urethra  during  sleep.  Ex- 
amination of  the  discharge  shows  it  to  be  prostatic  fluid,  although  spermato- 
zoids  are  sometimes  found.  It  is  not  purulent  and  contains  amyloid  corpus- 
cles. The  meatus  is  not  glued  up  in  the  morning,  and  the  linen  is  very  slightly 
stained.  The  urine  is  clear  and  contains  small  comma-shaped  hooks  (Chris- 
tian). Sexual  excitement  and  alcohol  do  not  appreciably  aggravate  the  con- 
dition. The  bladder  is  irritable,  and  there  are  frequency  of  micturition  and 
often  some  pain  in  the  head  of  the  penis  at  the  termination  of  the  act.  Noc- 
turnal emissions  may  occur. 

Treatment. — The  patient  should  correct  bad  habits.  If  there  is  urethral 
hyperesthesia  or  prostatic  congestion,  irrigate  the  bladder  and  urethra  once  a 
day  with  a  solution  of  silver  nitrate  (i  :  4000),  and  every  fourth  or  fifth  day 
introduce  a  cold  sound.  In  some  cases  the  occasional  instillation  into  the 
prostatic  urethra  of  a  few  drops  of  a  i  per  cent,  solution  of  nitrate  of  silver 
does  good. 

For  the  irritable  bladder  give  hot  hip-baths  at  night.  The  following 
prescription  is  of  service:  gr.  xv  of  bromid  of  potassium,  h  dram  of  tincture 
of  hyoscyamus  in  ^  ounce  of  cinnamon-water,  three  times  a  day.  Hot  enemata 
are  of  service. 

After  the  hyperesthesia  of  the  urethra  has  abated,  and  nocturnal  emissions 
have  ceased,  the  neurasthenia  is  treated  by  cold  sponging  of  the  body  night 
and  morning,  the  continued  use  at  intervals  of  several  days  of  a  large-sized 
cold  sound,  irrigation  every  second  or  third  day  with  silver  nitrate  (i  :  4000), 
and  the  administration  of  strychnin  and  other  tonics. 

Hypertrophy  of  the  Prostate  Gland. — Enlargement  of  the  pros- 
tate gland  may  be  brought  about  by  different  forms  of  growth.  It  is,  as  a 
general  thing,  a  senile  change,  occurring  only  after  the  age  of  fifty,  and  being 
most  likely  to  arise  after  the  attainment  of  sixty  years.  It  is  very  rare  for 
enlargement  of  the  prostate  to  begin  long  before  the  age  of  fifty  or  after  the 
age  of  seventy.  According  to  Freyer,  t,T)  per  cent,  of  all  men  past  fifty-five 
years  of  age  present  some  enlargement  of  the  prostate. 

There  are  some  that  oppose  the  view  that  prostatic  enlargement  is  essen- 
tially a  senile  change.  For  instance,  Dr.  L.  Bolton  Bangs  ("Jour,  of 
Dermatol,  anrl  Ocn.-Urin.  Dis.,"  March,  1901)  !n;iinlains  that  the  change 
is  not  senile;  that  it  really  begins  early  in  life,  but  that  its  effects  do  not 
become  manifest  until  during  or  after  middle  age.  Undoubtedly,  the  enlarge- 
ment begins  long  before  it  occasions  .sufficient  obstruction  to  induce  symp- 
toms; and   the   growth   progres.ses  very  slowly.    .  Guyon   and   the    French 


Hypertroph}'  of  the  Prostate  Gland  1 009 

school  maintain  that  hypertrophy  of  the  prostate  gland  is  always  the  result 
of  arteriosclerosis,  affecting  not  only  the  prostate,  but  also  the  entire  urinary 
tract.  The  hypertrophy  that  ensues  affects  the  bladder-walls  notably,  as 
well  as  the  prostate,  because  of  distinct  growth.  Caspar  has  apparently 
demonstrated  that  Guyon's  view  is  not  correct.  He  has  shown  that  in  many 
cases  there  is  no  sclerosis  of  the  prostatic  arteries,  and  that  frequently  there 
are  no  sclerotic  changes  in  other  portions  of  the  urinary  tract.  Another 
important  point  made  by  Caspar  is  that  arteriosclerosis  tends  to  cause  degen- 
eration, and  not  hypertrophy. 

In  the  hypertrophied  prostate  there  is  an  excessive  production  of  fibrous 
tissue  and  of  ill-formed  glandular  tissue,  the  mass  constituting  a  fibro-adenoma. 
Fibro-adenoma  is  the  common  cause  of  enlargement  (W.  Bruce  Clarke). 
Again,  in  not  a  few  prostates  there  is  no  real  enlargement,  but  there  is  an 
indurated  fibrous  mass  producing  obstruction.  Albarran  and  Halle  ("An- 
nales  des  Maladies  des  Organes  Genito-Urinaires,"  1898,  vol.  xvi)  point  out 
that  in  an  enlargement  of  the  prostate  different  elements  may  usuallv  be 
recognized:  soft  hypertrophy  of  the  gland;  indurated  enlargement  of  the 
glandular  elements;  fibrous  enlargement;  circumscribed  tumor-masses; 
distinct  fibromata  or  myomata;  or  adenofibromyomata.  The  real  cause 
of  the  various  forms  of  prostatic  enlargement  is  not  known. 

All  the  lobes  may  be  enlarged  equally;  all  may  be  enlarged  unequally;  the 
enlarged  gland  may  surround  the  prostatic  urethra  like  a  horse-collar;  or 
one  lobe  only  may  be  enlarged.  Symmetrical  enlargement  of  the  entire  gland 
is  not  so  apt  to  produce  symptoms  as  is  a  non-symmetrical  enlargement. 
In  some  cases  the  chief  enlargement  is  into  the  bladder;  in  others,  into  the 
urethra.  An  enlarged  prostate  frequently  shows  a  circular  groove  about  it, 
due  to  the  constriction  exerted  by  the  rectovesical  fascia  at  the  vesical 
neck. 

The  bridge  of  prostate  which  joins  the  two  lateral  lobes  is  known  as  the 
"middle  lobe,"  and  a  comparatively  trivial  enlargement  of  the  middle  lobe 
may  cause  obstruction.  Prostatic  hypertrophy  causes  a  narrowdng  and 
lengthening  of  the  urethra,  and  gives  this  tube  a  tortuous  course.  The 
opening  of  the  urethra  into  the  bladder  is  usually  pushed  to  a  higher  level, 
and  there  forms  behind  it  a  pouch,  in  which  urine  collects.  The  urine  that 
gathers  in  this  pouch  is  known  as  residual  urine.  It  cannot  be  voluntarily 
expelled.  It  may,  therefore,  collect  in  large  quantity,  and  it  is  likely  to  de- 
compose, producing  cystitis.  The  mechanical  resistance  to  the  expelling  of 
the  urine  causes  hypertrophy  of  the  muscles  of  the  bladder,  and,  in  conse- 
quence, the  bladder  enlarges,  thickens,  and  becomes  fasciculated.  When 
this  takes  place,  micturition  becomes  very  difiicult  and  sometimes  impos- 
sible. Enlargement  of  the  middle  lobe  inevitably  blocks  the  flow^  of  urine  and 
causes  great  distention  of  the  bladder.  In  hypertrophy  of  the  prostate  gland, 
the  ureters  and  the  renal  pelves  and  calices  may  distend  and  surgical  kidney 
may  develop. 

It  is  useful  to  divide,  as  does  Horwitz,  persons  with  prostatic  hypertrophy 
into  three  groups:  (i)  those  in  w-hom  there  is  no  obstruction  or  in  whom  the 
urinary  symptoms  are  very  trivial;  (2)  those  in  whom  there  is  residual  urine 
and  disturbances  of  urinary  function,  who  depend  upon  the  catheter  for 
relief,  but  who  do  verv  well  bv  this  method;  and  (0  those  that  suffer  a  com- 
64  ■  ' 


loio         Diseases  and  Injuries  of  the  Genito-urinary  Organs 

plete  break-down  during  the  period  in  which  the  catheter  is  depended  upon 
(Orville  Horwitz,  in  "  Phila.  Med.  Jour.,"  Nov.  i6,  1901). 

Symptoms. — In  90  per  cent,  of  the  cases  there  is  very  trivial  inconveni- 
ence, the  patient  merely  being  annoyed  somewhat  by  episodes  of  nocturnal  fre- 
quency of  micturition.  The  stream  of  urine  is  slow  to  start  and  falls  feebly 
from  the  end  of  the  penis.  In  some  cases  there  is  interruption  of  the  stream 
(stammering).  The  last  drops  fall  entirely  without  control.  If  the  patient  be- 
comes chilled  or  worried,  or  indulges  inordinately  in  the  pleasures  of  the  table 
or  in  wine,  beer,  or  alcoholic  liquor,  nocturnal  frequency  of  micturition 
becomes  for  a  short  time  most  harassing.  In  10  per  cent,  of  all  cases  the 
bladder  cannot  be  emptied  entirely,  and  residual  urine  collects.  Frequency 
of  micturition  comes  on,  particularly  at  night ;  the  patient  has  to  get  up  often ; 
the  bladder  never  feels  empty;  and  cystitis  is  apt  to  arise.  The  urine,  at  first 
acid  and  clear,  becomes  neutral  and  cloudy,  and  finally  ammoniacal  and 
turbid,  and  contains  bacteria,  mucopus,  precipitates  of  phosphates,  and 
blood.  Above  the  pubes  there  is  aching  pain,  soon  spreading  to  the  peri- 
neum, which  pain  is  increased  when  the  bladder  is  distended  and  during 
micturition.  The  rectum  becomes  irritable,  and  piles  form  or  prolapse  of 
the  mucous  membrane  occurs,  because  of  straining  in  micturition.  Attacks 
of  retention  of  urine  may  occur.  Enlargement  of  the  lateral  lobes  can  be 
detected  bv  a  finger  in  the  rectum.  The  bladder  becomes  thin  and  distended, 
or  hypertrophied,  rigid,  and  fasciculated.  In  rare  cases  true  incontinence  is 
caused  by  the  median  lobe  growing  toward  the  neck  of  the  bladder  and  pre- 
venting closure.  The  health  breaks  down  because  of  pain,  restless  nights, 
indigestion,  and  disorder  of  the  bowels.  The  kidneys  may  become  involved 
(inflammation  of  the  pelves  or  calyces,  or  surgical  kidney),  and  suppression 
may  occur.  Septic  fever  may  arise.  Calculi  may  form  in  the  bladder. 
Death  is  due  to  exhaustion,  suppression  of  urine,  or  septic  cystitis.  A  foul 
catheter  is  the  usual  cause  of  septic  cystitis,  but  micro-organisms  sometimes 
enter  by  passing  along  the  urethral  mucous  membrane. 

A  patient  should  be  examined  by  rectal  touch,  by  a  sound,  and  by  a  cysto- 
scope,  if  possible;  the  amount  of  residual  urine  must  be  determined,  and  the 
condition  of  the  urine  is  carefully  studied.  After  an  examination  by  instru- 
ments the  patient  must  remain  in  bed  for  twenty-four  hours. 

Treatment. — Many  cases  can  be  treated  by  regular  and  cleanly  catheteri- 
zation and  a  careful  adherence  to  hygienic  rules.  Alexander  has  formulated 
several  sound  rules  as  to  when  catheterization  is  the  proper  treatment.  He 
says,  if  the  patient  is  intelligent  and  dexterous,  if  cystitis  is  not  severe,  if  the 
amount  of  residual  urine  is  not  very  large,  if  obstruction  is  not  great,  if  the 
bladder  retains  considerable  expulsive  power,  and  if  catheterization  is  easy 
and  painless,  rely  upon  this  .simple  plan  of  treatment.  Prevent  cystitis  by 
emptying  the  bladder  each  evening  with  a  coude  catheter.  If  there  is  trouble 
in  passing  the  catheter,  strengthen  the  instrument  by  inserting  a  filiform 
h)ougie  as  a  stylet  (Brinton).  It  is  very  seldom  that  a  metal  instrument  is 
used,  but  if  it  is  required  a  catheter  with  a  large  curve  is  employed. 
If  a  soft  semi-solid  instrument  can  be  i)asscd,  teach  the  patient  how  to 
clean  it,  how  to  use  it,  and  how  to  keep  it,  but  never  permit  the  patient 
to  use  a  metal  instrument  himself.  A  dirty  instrument  may  cause  fatal 
infection.     It    is    true    that    some    people    use    dirty  instruments  for  long 


Treatment  of  Hypertrophy  of  the  Prostate  Gland  loii 

periods  without  trouble,  but  in  most  cases  there  will  be  troul)le  if  it  is 
attempted.  It  is  absolutely  necessary  to  use  only  perfectly  aseptic  in- 
struments. Metal  instruments  are  sterilized  by  boiling  in  water.  Rubber 
catheters  can  be  cleansed  by  washing  with  soap  and  running  water  and  boil- 
ing. Woven  instruments  can  be  placed  in  a  glass  cylinder,  the  bottom  of  which 
is  like  a  sieve.  This  jar  is  placed  for  twenty-four  hours  in  a  vessel  which 
contains  formalin.  The  vapor  of  formalin  is  an  excellent  germicide,  and 
does  not  injure  the  catheter.  After  sterilization  the  instruments  are  kept 
ready  for  use  in  a  glass  cyhnder  which  contains  calcium  chlorid.*  Guyon 
scrubs  the  catheters  with  soap  and  water,  dries  them  outside  and  inside,  and 
places  them  in  a  sealed  jar,  and  exposes  them  to  the  vapor  of  sulphurous  acid 
for  forty-eight  hours.  If  there  are  three  ounces  of  residual  urine,  use  the 
catheter  only  at  night.  If  there  are  six  ounces,  use  it  night  and  morning.  If 
there  are  more  than  six  ounces  of  residual  urine,  add  one  more  catheterization 
a  day  for  every  additional  two  ounces  present  until  the  catheter  is  used  six 
times  in  the  twenty-four  hours.  It  should  never  be  u.sed  oftener  than  this. 
Gradual  dilatation  with  steel  sounds  is  of  benefit,  but  forcible  dilatation  is  not 
advisable.  The  sound  may  be  passed  once  a  week.  Tell  the  patient  to 
avoid  violent  exercise,  cold,  damp,  sexual  excitement,  and  the  use  of  alcohohc 
liquors;  prevent  constipation  and  indigestion,  and  direct  him  to  drink  milk 
and  plenty  of  water.  A  hot  hip-bath  at  night  adds  to  his  comfort.  Hot 
enemata  are  of  value.  If  a  large  quantity  of  residual  urine  exists,  or  if  cystitis 
begins,  wash  out  the  bladder  daily  with  boric-acid  solution,  or  normal  salt 
solution,  or  nitrate  of  silver  (from  i  :  10,000  to  i  :  2000),  and  give  urotropin 
or  salol  and  boric  acid  by  the  mouth  (Cystitis,  page  962).  In  some  severe 
cases,  if  a  large-sized  rubber  catheter  be  tied  in  the  bladder  for  a  few  days, 
great  relief  is  obtained.  Retention  of  urine  can  be  relieved  by  the  introduc- 
tion of  a  coude  catheter  strengthened  with  a  whalebone.  In  exceptional 
cases  a  silver  instrument  with  a  prostatic  cur\e  must  be  employed  or  aspiration 
must  be  practised.  .  Most  cases  can  be  kept  comfortable  by  catheterization, 
and  only  when  this  fails  should  an  operation  be  performed.  If  the  symptoms 
grow  constantly  worse,  if  the  suffering  becomes  severe,  if  the  patient  cannot 
urinate  without  the  use  of  an  instrument,  if  catheterization  is  painful  or  impos- 
sible, if  the  patient  is  too  careless  or  ignorant  to  trust  with  a  catheter,  if  only  a 
catheter  of  very  small  size  can  be  introduced,  if  attacks  of  obstinate  retention 
occur,  if  there  is  persistent  or  recurring  cystitis  or  hematuria,  if  there  are  signs 
of  beginning  infection  of  the  kidney,  if  the  residual  urine  gradually  increases  in 
amount,  the  bladder  should  be  opened.  Do  not  postpone  operation  until 
the  patient  becomes  really  ill.  Give  palliative  measures  a  reasonable  trial, 
and  if  they  fail,  operate. 

In  the  majority  of  cases  in  which  palliation  fails  the  operative  indication 
is  to  remove  an  obstructing  mass  and  depress  the  level  of  the  opening  from 
the  bladder  into  the  prostatic  urethra,  so  that  the  prostatic  pouch  is  abolished 
and  the  bladder  is  thoroughly  drained.  It  is  to  be  borne  in  mind  that  prosta- 
tectomy of  necessity  de.stroys  the  power  of  procreation. 

The  perineal  operation  is  as  safe  as  the  suprapubic,  or  safer,  and  can  be 
rapidly  performed.  In  this  operation  the  drainage  is  at  the  lowest  part  of 
the  bladder,  and  by  an  incision  of  the  prostate  gland  the  floor  of  the  urethra 
*  R.  W.  Frank,  iu  Berliner  klin,  Woch.,  No.  44,  1895. 


I0I2          Diseases  and  Injuries  of  the  Genito-urinar}^  Organs 

mav  be  lowered  to  the  level  of  the  floor  of  the  bladder  (Dandridge).  Simple 
incisicn  of  the  prostate  in  this  manner  is  known  as  prostatotomy.  The 
mortahty  is  small  and  the  rehef  is  often  great.  Prostatotomy  is  performed 
on  old  and  exhausted  patients  with  damaged  kidneys.  A  large  tube  should 
be  worn  during  the  healing  of  the  wound. 

The  suprapubic  operation  is  easier  than  the  perineal;  it  is  no  safer;  it 
gives  excellent  results  if  temporary  drainage  only  is  needed.  If  siphon  drain- 
age is  not  used,  the  opening  is  better  placed  in  the  perineal  operation,  unless 
permanent  drainage  is  required.  After  the  suprapubic  operation  the  floor 
of  the  urethra  cannot  be  brought  level  with  the  floor  of  the  bladder  by  a  simple 
incision  of  the  prostate;  it  can  only  be  brought  level  by  the  performance  of 
prostatectomy.  Suprapubic  prostatectomy  damages  the  sphincter  of  the 
bladder  and  is  often  followed  by  inability  to  expel  urine  (John  B.  Murphy, 
"Jour.  Amer.  Med.  Assoc,"  March  29,  1902).  The  ureters  may  be  damaged 
and  subsequently  become  obstructed  from  contraction.  It  is  most  useful 
when  the  hvpertrophy  is  very  large  and  intravesical.  It  is  the  operation  of 
choice  if  the  bladder  contains  a  stone.  It  is  not  a  suitable  method  if  the 
bladder  is  markedly  contracted  and  if  the  belly-waUs  are  thick.  After  a 
suprapubic  cystotomy  has  been  performed  for  drainage,  the  opening  may  be 
kept  permanently  patent  by  the  retention  of  a  tube  (Hunter  McGuire's  opera- 
tion). It  is  only  in  very  advanced  cases  or  in  cancer  that  permanent  supra- 
pubic drainage  is  employed. 

Suprapubic  Prostatectomy. — After  the  bladder  is  opened  the  mass  of 
prostate  is  enucleated  or  cut  away  with  scissors  or  with  cutting  forceps.  The 
bladder  is  drained  for  a  time  and  the  suprapubic  cut  is  then  allowed  to  heal. 
If  the  suprapubic  method  of  prostatectomy  is  employed,  it  is  wise  to  use  also 
a  perineal  cut,  in  order  to  control  hemorrhage  and  secure  good  drainage 
(Dandridge). 

McGill's  Operation:  The  bladder  is  opened  by  a  suprapubic  incision, 
the  edges  of  the  cut  bladder  are  sutured  to  the  abdominal  wound  by  catgut, 
and  the  interior  of  the  viscus  is  carefully  explored  with  the  finger  and  by  sight, 
an  electric  light  being  used  for  illumination.  If  a  sessile  growth  exists, 
the  mucous  membrane  is  incised  and  the  growth  enucleated  with  a  finger  or 
a  curet.  A  j:)edunculated  growth  is  cut  away  with  sharp-edged  forceps.  If 
a  mass  projects  into  the  bladder  an  incision  is  made  to  divide  it  into  two 
portions  and  each  half  is  enucleated.  Hemorrhage  is  arrested  by  irrigation 
with  hot  salt  solution  and  by  compression  with  gauze  pads.  In  some  cases  a 
tampon  must  be  inserted.  The  bladder  is  drained  for  several  days  or  a  num- 
ber of  days  by  a  siphon  (Fig.  561) .  As  a  matter  of  fact,  a  dense  fibrous  prostate 
cannot  be  enucleated  and  can  only  be  removed  by  scissors  or  cutting  forceps. 

Fuller's  Operation:  Open  the  bladder  above  the  pubes;  have  an  assistant 
push  the  gland  up  by  means  of  a  fist  in  the  perineum.  The  gland  can  be 
lifted  by  two  fingers  in  the  rectum  (Guiteras).  The  surgeon  makes  a  small 
incision  through  the  mucous  membrane  over  the  ])r().state,  enucleates  the 
gland  by  means  of  the  finger,  and  drains  through  an  incision  in  the  mem- 
branous urethra,  as  well  as  through  the  suprapubic  opening. 

Belfield's  Operation:  Belfield  performs  suprapubic  cystotomy,  makes  a 
perineal  cut  to  enable  the  finger  to  approach  the  prostate,  pushes  the  prostate 
up  toward  the  belly,  and  enucleates  it  from  within  the  bladder. 


Prostatectomy  1013 

Perineal  Prostatectomy. — Perineal  prostatectomy  is  less  bloody  than  supra- 
pubic prostatectomy.  The  sphincter  of  the  bladder  is  not  damaged,  the  entire 
prostate  can  be  brought  into  view  and  removed,  and  perfect  drainage  is  ob- 
tainable after  operation. 

NicolPs  Operation:  Perform  suprapubic  cystotomy.  Then  incise  the 
perineum  down  to  the  prostate,  split  the  capsule  of  the  prostate,  insert  two 
fingers  of  the  left  hand  into  the  bladder,  and  push  the  prostate  into  the 
perineum  so  as  to  bring  it  within  reach.  Enucleate  the  gland  from  the 
perineal  wound  without  damaging  the  mucous  membrane  of  the  floor  of  the 
bladder. 

Alexander's  Operation:  Alexander  makes  a  suprajnibic  incision  and  uses 
it  for  the  same  purpose  as  does  Nicoll,  but  he  also  opens  the  membranous 
urethra  on  a  grooved  staff.  After  enucleating  the  gland  he  inserts  a  drainage- 
tube  through  the  incision  in  the  membranous  urethra.  In  a  very  thin  subject  it 
may  not  be  necessary  to  perform  suprapubic  cystotomy.  Alexander  has 
brought  the  gland  into  an  accessible  position  in  the  perineal  wound  by  supra- 
pubic pressure  and  Guiteras  has  done  so  by  making  an  incision  in  the  linea 
alba  and  inserting  two  fingers  into  the  prevesical  space.  Syms  advocates 
opening  into  the  peritoneal  cavity,  inserting  the  hand,  and  pressing  the  pros- 
tate into  the  perineum  without  opening  the  bladder  above  the  pubes. 

Bryson's  Operation:  This  is  a  very  satisfactory  method.  The  bladder 
is  irrigated  and  filled  with  warm  salt  solution.  A  grooved  staff  is  intro- 
duced and  a  median  perineal  section  is  made  to  open  the  urethra  just  in 
front  of  the  apex  of  the  prostate  gland.  The  knife  is  pushed  back  in  the 
groove  of  the  staff  sufficiently  far  to  incise  the  ring  at  the  apex  of  the  pros- 
tate; the  forefinger  is  passed  into  the  prostatic  urethra  and  the  staff  is 
withdrawn.  Then,  a  short  tear  is  made  by  means  of  a  blunt  instrument  into 
the  mass  of  the  left  lobe  and  the  finger  is  introduced  and  enucleates  the  lobe. 
The  same  procedure  is  carried  out  on  the  right  lobe,  and  finally,  if  necessary,  on 
the  middle  lobe.  If  the  middle  lobe  requires  removal,  but  cannot  be  reached,  a 
.suprapubic  cut  is  made  into  the  cave  of  Retzius,  two  fingers  are  inserted,  and 
the  lobe  is  pushed  within  reach  of  the  finger  below.  A  large  perineal  tube  is 
introduced  for  drainage  and  bleeding  is  arrested  by  packing.  Horwitz  also 
introduces  a  catheter  and  ties  it  in  place. 

BottinVs  Gahanocaustic  Prostatotomy. — Bottini,  of  Padua,  in  1876  sug- 
gested cauterizing  the  prostate  by  means  of  a  special  instrument.  This 
instrument  is  shaped  like  a  catheter,  and  carries  a  platinum  l)lade  which  is 
heated  by  an  electric  current.  Bottini's  early  instrument  was  not  satisfactory 
and  the  operation  never  became  popular  until  Freudenberg  improved  the 
tools  in  1897. 

Bottini's  galvanocaustic  operation  is  performed  as  follows:  The  bladder 
should  be  emptied,  irrigated,  and  distended  with  air  and  the  posterior  urethra 
must  be  anesthetized  by  instillation  of  cocain  or  eucain.  The  current  is  tried 
to  see  how  many  seconds  it  requires  to  heat  the  blade  sufficiently.  The  cur- 
rent is  broken,  the  instrument  is  introduced,  the  cooling  current  is  set  in 
motion,  and  one  assi-stant  watches  this  and  nothing  else.  Turn  on  the  cur- 
rent. Wait  the  required  number  of  seconds  for  the  blade  to  become  red  hot 
(twelve  to  fifteen  seconds),  turn  the  screw  at  the  handle,  and  burn  a  groove 
in  the  prostate.     A  groove  should  be  burned  toward  the  rectum,  one  to  the 


I0I4         Diseases  and  Injuries  of  the  Genito-urinaiy  Organs 


side,  and,  if  it  is  thouglit  desirable,  one  to  the  opposite  side.  No  groove  should 
be  burned  toward  the  pubes.  When  a  groove  has  been  burned,  return  the 
blade  into  its  sheath,  increasing  the  current  while  doing  so  in  order  to  keep 


Fig.  594. — Young's  modification  of  Freudenberg's  instrument  for  prostatotomy  by  galvanocautery. 

the  blade  from  adhering  to  the  tissue,  then  shut  off  the  current.  After  with- 
drawing the  instrument  it  is  not  necessary  to  introduce  and  retain  a  catheter. 
The  patient  is  confined  to  bed  only  twenty-four  hours,  there  is  rarely  bleeding 


\   / 


Fig.  595.— Incisions  of  tlie  middle  lobe  (Young). 

or  fever,  and  the  results  are  good.  The  scars  contract  and  the  gland  atrophies. 
During  the  period  of  healing  a  steel  sound  should  be  passed  from  time  to 
time  (Bangs).  It  is  alleged  that  fibrous  stricture  of  the  neck  of  the  bladder 
may  follow  in  some  cases.* 


Fig.  596. — Differetit  incisions  of  prostate  gland  in  Bottiiii's  operation  (after  Young). 

Bottini's  operation  is  the  procedure  to  be  selected  for  a  sclerotic  prostate, 
and  for  hypertrophy  in  a  feeble  and  aged  individual  with  damaged  kidneys. 
It  is  not  probable  that  the  cautery  operation  will  replace  prostatectomy.     The 

*  For  description  of  this  operation,  see  Freudenberg,  in  Berliner  klin.  Woch.,  No.  46, 
1897;  and  Willy  Meyer,  in  Med.  Record  of  March  5,  1898,  and  May  12,  1900. 


Castration  and  Vasectomy 


lOI 


Incising  the  middle  lobe  (Young). 


Cystitis  ceases,  and  desire  to  urinate 


best  instrument  is  Young's  modification  of  Freudenberg's  apparatus  (Fig. 
594).    Figs.  595  and  596  show  various  methods  of  making  the  cuts  as  advised 
by  Hugh  H.  Young.     When  there  is  a  distinct  and  pedunculated  median  lobe 
the    ordinary  operation    fails    entirely; 
but  as  Young  shows  (Figs.  595,  597), 
if  an  oblique  cut  is  made  on  each  side 
across  the  base,  this  lobe  will  drop  out 
of  the  way  and  quickly  atrophy. 

Castration  and  Vasectomy. — In  1893 
J.  William  White  introduced  the  opera- 
tion of  bilateral  orchidectomy.  He 
proved  that  removal  of  the  testicles 
causes  a  rapid  shrinking  in  an  enlarged 
prostate.  Much  of  this  shrinking  may 
be  due  to  diminution  of  congestion  and 
edema,  but  true  atrophy  undoubtedly 
occurs.  Very  remarkable  results  have 
been  recorded.  In  some  cases  the  pa- 
tients become  absolutely  comfortable 
and  dispense  entirely  with  the  catheter, 
frequently  becomes  less  marked.  Unilateral  orchidectomy  has  been  employed, 
but  it  is  not  satisfactory.  Bilateral  division  or  exsection  of  the  vas  deferens 
(vasectomy)  may  be  employed  instead  of  orchidectomy.  This  operation  was 
suggested  by  Mears.  It  is  slower  in  its  results,  but  just  as  certain.  In  spite 
of  the  great  simplicity  of  orchidectomy  the  mortality  has  been  considerable 
(from  II  to  18  per  cent.).  In  several  instances  mental  disturbance  has  fol- 
lowed the  operation,  but  there  is  no  real  evidence  that  it  was  due  to  this 
special  form  of  operation  and  would  not  with  certainty  have  followed  any 
other.  Castration  is  now  very  seldom  performed,  as  vasectomy  is  just  as 
useful.  Vasectom}-  is  ^•alueless  in  cases  of  fibroid  prostate,  does  some  good 
in  adenoma,  but  is  most  valuable  when  the  prostate  is  generally  hyper- 
trophied  and  prone  to  great  congestion  causing  violent  symptoms. 

Other  Methods. — Among  other  operations  which  have  been  suggested  are 
ligation  of  the  spermatic  cord ;  ligation  of  the  vascular  elements  of  the  cord ; 
resection  of  all  the  cord  elements  except  the  vas  and  its  artery  and  vein  (an- 
gioneurectomy) ;  parenchymatous  injections  of  cocain  into  the  testicles;  and 
hgation  of  both  internal  iliac  arteries. 

Results. — The  relative  merits  of  these  various  operations  alluded  to  above 
are  in  dispute.  It  is  certain  that  ver}-  many  cases  of  prostatic  hypertrophy 
can  be  kept  comfortable  by  aseptic  catheterism.  If  this  procedure  fails  or 
for  other  reasons  must  be  abandoned,  a  careful  study  of  the  case  should  be 
made  before  selecting  a  special  operation.  The  Bottini  operation  is  coming 
into  extensive  use.  Some  would  apply  it  to  almost  any  sort  of  case,  and  claim 
that  the  operation  is  practically  free  from  danger.  Meyer  uses  it  for  any  case 
of  uncomplicated  hypertrophy;  but  if  the  prostate  is  very  large  ligates  the 
vasa  deferentia  some  weeks  before  cauterizing  the  prostate,  in  order  to  lessen 
the  danger  of  thrombosis. 

A  more  conservative  view  is  that  of  Eugene  Fuller,  who  doubts  the  per- 


ioi6         Diseases  and  Injuries  of  the  Genito-urinary  Organs 

manence  of  the  resuhs  of  the  Bottini  operation,  fears  that  stenosis  of  the  vesical 
neck  may  follow,  and  would  restrict  the  operation  to  uncomplicated  cases, 
not  of  a  grave  character  and  in  which  the  bladder  has  not  been  seriously 
damaged.  It  is  the  operation  of  choice  if  the  prostate  is  fibrous;  Horwitz 
prefers  it  if  the  patient  is  old,  debilitated,  or  the  victim  of  kidney  disease. 
Some  residual  urine  remains.  In  over  lo  per  cent,  of  cases  no  benefit  follows. 
Vasectomy  is  used  for  an  engorged  and  generally  enlarged  prostate.  It  may  do 
great  good  and  mav  fail  completely.  If  the  urine  is  extremely  foul,  some  opera- 
tion permitting  drainage  is  advisable.  In  an  adenomatous  prostate  in  which 
enucleation  is  easy  we  should  prefer  the  perineal  method.  In  other  cases  in 
which  it  is  probable  enucleation  will  be  hard,  in  cases  of  uncertain  diagnosis, 
in  cases  in  which  a  calculus  may  exist,  and  in  cases  in  which  the  middle 
lobe  is  at  fault,  do  a  suprapubic  operation,  although  sometimes  a  perineal 
incision  may  be  made,  and  a  cut  be  made  in  the  prostate  to  bring  the  floor 
of  the  urethra  level  with  the  trigone. 

In  old  men  with  great  obstruction,  and  with  serious  disease  of  the  bladder 
and  involvement  of  the  kidneys,  permanent  suprapubic  drainage  is  some- 
times the  most  useful  procedure. 

The  mortality  from  Bottini's  operation  is  over  5  per  cent.  Horwitz  col- 
lected 888  operations:  84.3  per  cent,  were  cured  or  improved;  10  per  cent, 
were  not  improved;  and  5.7  per  cent,  died  ("Phila.  Med.  Jour.,"  Nov.  16, 
1901).     Young  had  3  deaths  in  41  operations. 

Vasectomy  done  early  gives  a  mortality  of  from  3  to  5  per  cent.  If  per- 
formed later  the  mortality  is  10  to  15  per  cent. 

The  mortality  of  prostatectomy  is  variously  estimated.  Freudenberg 
collected  753  cases:  622  were  cured,  44  died,  and  87  were  not  improved. 

Guiteras  collected  152  cases  done  by  various  methods  ("Jour.  Amer.  Med. 
Assoc,"  Nov.  2,  1901).  Twenty-five  died.  Bangs  believes  that  the  mor- 
tality from  prostatectomy  should  not  be  above  8  per  cent.,  but  statistics  indi- 
cate that  it  is  from  10  to  15  per  cent,  in  most  hands.  W.  Bruce  Clarke  reports 
a  mortality  of  9  per  cent.  The  mortahty  of  the  suprapubic  operation  is 
higher  than  that  of  the  perineal  operation.  Belfield  estimates  the  former  at 
16  per  cent,  and  the  latter  at  9  per  cent. 

The  earlier  the  operation  is  performed,  the  safer  it  is. 

Malignant  Disease  of  the  Prostate  Gland.— Primary  mahgnant 

growths  of  the  prostate  are  not  very  frequently  encountered,  and  secondary 
growths  are  even  more  rare  than  are  primary  growths.  When  malignant  dis- 
ease does  occur,  it  is  almost  always  cancerous.  Secondary  cancer  of  the  pros- 
tate finds  its  most  usual  antecedent  in  cancer  of  the  rectum.  Epithelioma 
does  not  occur.  Scirrhus  occasionally  occurs;  but  the  most  frequent  form 
is  encephaloid.  Round-celled,  spindle-celled,  or  mixed-celled  sarcoma  may 
develop. 

Carcinoma  of  the  prostate  may  occur  at  an  earlier  age  than  ordinary 
hypertrophy  of  the  prostate.  The  latter  does  not  become  evident  until  after 
the  age  of  fifty;  but  carcinoma  of  the  prostate  may  begin  at  any  time  after 
the  age  of  forty,  and  sarcoma  of  the  prostate  may  commence  in  early  youth. 

At  first,  the  carcinomatous  growth  enlarges  slowly;  but  it  soon  begins  to 
grow  with  rapidity.  It  breaks  through  the  cap.sule  and  fungates  into  the 
bladder  or  into  the  urethra.     The  i;elvic,  the  inguinal,  and  the  femoral  glands 


Tuberculosis  of  the  Prostate  Gland  1017 

become  involved  early  in  the  course  of  the  disease.  It  is  not  usual  to  find 
great  obstruction  to  urination  or  to  the  passage  of  a  catheter  at  an  early  period, 
but  later  both  these  conditions  are  noted.  Early  in  the  case  there  is  pain  onlv 
when  obstruction  to  urination  occurs;  later,  the  pain  in  the  neck  of  the  blad- 
der may  be  severe,  and  there  may  also  be  pain  in  the  loin  and  in  the  sciatic 
nerves.  Hemorrhage  usually  occurs.  In  the  beginning  the  hemorrhage  is 
trivial  and  intermittent,  but  when  fungation  exists,  large  hemorrhages  gen- 
erally take  place.  The  blood  is  usually  mixed  with  urine,  but  there  is  some- 
times a  large  hemorrhage  without  micturition.  The  urine  is  not  likely  to 
contain  pus  or  any  quantity  of  mucus,  unless  the  bladder  is  involved  in  the 
growth. 

When  the  prostate  gland  is  felt  by  means  of  a  finger  in  the  patient's  rectum, 
it  is  found  to  be  of  stony  hardness  and  to  be  firmly  anchored  in  place.  Regi- 
nald Harrison  points  out  that  an  ordinary  hypertrophied  gland  is  not  so  firmly 
anchored  as  a  carcinomatous  gland;  that  the  bowel  moves  over  it  with  free- 
dom; and  that,  although  it  is  firm  to  the  touch,  it  is  not  of  stonv  hardness. 
The  patient  with  carcinoma  of  the  prostate  loses  flesh  rapidly  and  develops 
distinct  cachexia;  and  metastatic  deposits  are  likely  to  form  in  the  vertebral 
column,  in  the  kidneys,  and  in  other  organs  and  structures. 

In  making  a  diagnosis  Harrison  insists  upon  the  value  of  the  cystoscope. 
He  says  that  in  cancer  one  does  not  find  much  intravesical  projection,  and 
that  what  projection  there  is  is  uneven  and  irregular.  In  an  ordinary  adeno- 
matous prostate,  on  the  contrary,  the  surface  is  smooth  and  rounded  and 
projects  into  the  bladder. 

Treatment. — Radical  operation  is  out  of  the  question  in  these  cases. 
Permanent  suprapubic  drainage  is  made  in  most  instances,  and  usuallv  gives 
the  patient  great  relief.  (See  "Remarks  on  Cancer  of  the  Prostate,"  by 
Reginald  Harrison,  in  ''Brit.  Med.  Jour."  of  July  4,  1903.) 

Tuberculosis  of  the  Prostate  Gland. —Tuberculosis  of  the  pros- 
tate is  rarely  primary.  It  is  usually  secondary  to  tuberculosis  of  the  kidney 
or  of  the  epididymis.  In  the  majority  of  cases  of  tuberculosis  of  the  prostate 
the  lungs  are  involved  in  the  tuberculous  process  when  the  patient  is  first 
seen  by  the  surgeon.  The  disease  appears  particularly  between  the  ages  of 
twenty  and  thirty  years,  but  it  may  attack  elderly  men  and  even  the  aged. 
It  begins  by  the  formation  of  a  number  of  tuberculous  nodules  in  the  imme- 
diate neighborhood  of  the  prostatic  tubules.  These  nodules  caseate  and  run 
together,  forming  cavities  and,  eventually,  tuberculous  abscesses,  which  are 
prone  to  rupture  into  the  urethra.  In  very  rare  instances  a  large  tubercu- 
lous abscess  ruptures  through  the  perineum,  into  the  rectum,  or  into  the 
peritoneum. 

The  disease  occasionally  undergoes  spontaneous  cure,  through  hl^rous- 
tissue  formation  or  calcification.  The  tuberculous  process  is  liable  to  spread 
to  the  seminal  vesicles,  the  bladder,  the  ureters,  and  possibly  the  peritoneum; 
and  in  some  cases  it  inaugurates  thrombophlebitis  and  pyemia. 

Symptoms. — The  patient  suffers  with  pain  during  micturition;  there  is 
frequent  micturition ;  and  from  time  to  time  the  urine  contains  blood.  Attacks 
of  cystitis  take  place,  and  weakness  and  a  loss  of  flesh  are  greater  than  is 
commensurate  with  any  ordinary  inflammation.  Tuberculosis  of  the  prostate 
alone  is  said  not  to  cause  marked  hectic  fever;  but  wlien  adjacent  structures 


lOiS         Diseases  and  Injuries  of  the  Genito-urinary  Organs 

become  involved,  the  temperature  attains  a  high  level  and  becomes  charac- 
teristic. When  the  disease  has  advanced,  there  is  not  unusualh^  urinary  in- 
continence, on  account  of  the  involvement  of  the  circular  muscular  fibers 
about  the  neck  of  the  bladder.  Commonly,  there  is  a  mucopurulent  discharge, 
or  mucopurulent  matter  may  be  obtained  by  massaging  the  prostate.  This 
matter  may  contain  tubercle  bacilli,  and  in  some  cases  the  urine  also  contains 
these  bacilli.  Early  in  the  course  of  the  case  rectal  examination  detects  some 
enlargement  of  the  gland,  many  nodules,  and  tenderness;  later  in  the  disease 
it  finds  marked  enlargement  and  areas  of  softening. 

Treatment. — Early  in  the  case  Senn  recommends  parenchymatous  in- 
jections of  iodoform  emulsion,  the  punctures  being  made  through  the  peri- 
neum. If  these  fail,  operation  must  be  considered.  When  one  takes  into 
account  how  rare  primary  tuberculosis  of  the  prostate  is,  one  is  impressed 
with  the  infrequency  with  which  a  radical  operation  should  be  attempted. 
If  there  is  absolutely  no  evidence  that  any  adjacent  organ  is  involved  or  that 
any  distant  focus  of  disease  exists,  it  is  justifiable  to  perform  perineal  pros- 
tatectomy. As  a  rule,  however,  the  only  surgical  methods  that  are  employed 
consist  in  making  a  prerectal  curvilinear  incision,  exposing  the  prostate,  and 
curetting  caseous  foci.  If  an  abscess  forms,  it  should  be  evacuated  by  means 
of  a  perineal  incision  and  cavities  should  be  curetted  and  packed  with  iodo- 
form gauze. 

If  it  is  determined  that  no  operation  is  advisable,  one  should  look  to  the 
patient's  general  health,  administer  urotropin,  and  avoid  using  instruments 
as  much  as  possible;  because,  as  Sir  Henry  Thompson  has  shown,  instru- 
mentation irritates  the  prostate,  causes  a  great  deal  of  pain,  and  makes  the 
disease  worse  in  every  case. 

Retained  and  Malplaced  Testicle. — The  testicle  may  be  arrested 
in  its  passage  to  the  scrotum:  it  may  remain  in  the  lumbar  region;  it  may 
reach  the  internal  abdominal  ring;  it  may  lodge  in  the  inguinal  canal;  it  may 
emerge  from  the  external  ring,  but  fail  to  enter  the  scrotum;  or  it  may  pass 
into  unnatural  positions,  as  into  the  perineum  or  the  crural  canal.  It  may 
or  may  not  be  functionally  active.  A  retained  testicle  is  subject  to  attacks 
of  orchitis  and  may  become  sarcomatous.  In  80  per  cent,  of  cases  the  testicles 
have  descended  at  birth;  most  often  it  is  the  right  testicle  which  fails  to  de- 
scend. Sometimes  a  testicle  descends  after  being  retained  for  months  or  even 
years.  In  Keyes'  case  it  descended  in  the  thirtieth  year.  Late  descent 
u.sually  causes  hernia. 

Treatment. — If  one  testicle  is  undescended  one  year  after  birth,  and  the 
other  testicle  is  sound,  the  former  should  be  removed  if  it  is  found  impossible 
to  draw  the  gland  into  the  scrotum  and  fasten  it.  Always  try  to  get  a  retained 
gland  into  the  scrotum,  and  operate  before  the  age  of  puberty. 

Orchitis  is  inflammation  of  the  testicle.  ActUe  orchitis  may  be  due  to 
cold,  wet,  traumatism  or  epididymitis,  gout,  mumi)S,  rheumatism,  or  a  specific 
fever.  The  testicle  is  round,  swollen,  tender,  and  very  jjainful,  the  scrotum 
is  red  and  swollen,  the  tunica  vaginalis  is  filled  with  fluid,  and  there  is  fever. 
Chronic  orchitis  results  from  the  acute  form  or  from  a  chronic  urethral  in- 
flammation, and  is  almost  always  combined  with  epididymitis. 

The  treatment  of  the  (intle  form  consists  of  rest  in  bed,  and  a])plications  as 
for  epididymitis  (page  1020).  The  chronic  form  requires  the  removal  of  the 


Orchidectomy,  or  Castration  1019 

causative  lesion,  if  possible,  the  wearing  of  a  suspensory  bandage,  applications 
of  ichthyol  or  mercurial  ointment,  and  the  administration  of  iodid  of  potas- 
sium by  the  mouth.     Strapping  may  do  good.     Castration  may  be  required. 

Tuberculosis  of  the  testicle  may  be  primary,  but  in  most  instances 
is  secondary  to  tuberculosis  of  the  prostate,  bladder,  or  seminal  vesicles.  The 
disease  may  be  preceded  by  pulmonary  tuberculosis,  peritoneal  tuberculosis, 
or  tuberculous  disease  of  bones  or  joints;  and  primary  tuberculosis  of  the  tes- 
ticle may  be  followed  by  distant  tuberculous  lesions.  In  some  cases  involve- 
ment of  the  prostate  exists,  but  cannot  be  detected  (latent  tuberculosis  of  the 
prostate) ;  in  other  cases  the  prostate  is  in  a  state  of  subacute  inflammation. 
The  disease  begins  in  one  testicle,  but  in  the  vast  majority  of  cases  the  other 
testicle  becomes  involved  after  a  few  weeks  or  months.  If  but  one  epididy- 
mis is  involved  the  testicle  may  not  be  affected  for  weeks  or  months.  Van 
Bruns  says  that  in  40  per  cent,  of  such  cases  the  testicle  is  not  involved  for 
six  months;  in  18  per  cent.,  for  two  months  ("Archiv  f.  klin.  Chir.,"  B.  63, 
H.  4).  It  may  begin  in  either  the  epididymis  or  the  testicle.  As  a  rule  it 
begins  in  the  epididymis  and  attacks  the  testicle  later.  It  usually  comes  on 
gradually;  but  it  may  begin  acutely,  as  I  have  seen  in  two  instances  during 
the  progress  of  tuberculous  peritonitis.  The  disease  is  apt  to  follow  a  sHght 
injury  or  inflammation,  and  is  most  common  in  young  men,  but  may  arise 
at  any  age.  Nodules  form  most  commonly  in  the  epididymis,  but  some- 
times in  the  testicles  as  well.  These  nodules  .soften  and  run  together,  and 
the  cord  is  felt  to  be  enlarged.  After  a  time  the  skin  becomes  red  and 
adherent,  gives  way,  and  exposes  a  caseous  breaking-down  epididymis 
or  testicle.  Except  in  the  acute  cases,  the  testicle  is  only  slightly,  if  at  all, 
painful,  and  tenderness  is  trivial.  In  one-sixth  of  the  cases  a  small  hydro- 
cele forms.  In  a  questionable  case  the  tuberculin  test  should  be  employed. 
If  a  hydrocele  exists  the  fluid  should  be  withdrawn  by  tapping  and  cultures 
be  made  from  it. 

Treatment. — If  the  disease  is  limited  to  the  epididymis  or  the  epidermis 
and  vas,  resect  the  epididymis  (epididymectomy)  and  the  vas  deferens.  If 
the  testicle  is  diseased,  orchidectomy  is  performed.  It  was  long  believed  that 
orchidectomy  was  useless  if  the  vesicles  and  prostate  were  involved,  but 
Koenig  and  others  maintain  that  vesicular  and  prostatic  tuberculosis  improve 
after  removing  the  diseased  testicle  or  epididymis.  If  the  epididymis  of 
each  testicle  is  involved,  both  should  be  removed.  When  both  testicles  are 
diseased,  and  other  organs  and  structures  are  not  extensively  involved, 
double  orchidectomy  is  performed,  or,  better,  the  testicle  which  is  worse  is 
removed  and  the  diseased  portion  of  the  other  is  extirpated. 

In  association  with  and  after  operation  employ  antituberculous  remedies, 
order  a  nourishing  diet,  send  the  patient  to  a  good  climate,  and  insist  on  an 
open-air  life.  A  very  large  percentage  of  unilateral  cases  are  cured  by  opera- 
tion (over  40  per  cent.).     Some  bilateral  cases  are  also  cured. 

Orchidectomy,  or  Castration  (Excision  of  a  Testicle). — In  this 
operation  an  incision  is  made  over  the  cord,  commencing  just  outside  the 
external  ring  and  running  down  over  the  base  of  the  tumor.  Clamp  the  cord 
and  divide  it  near  to  the  ring,  remove  the  testicle,  ligate  the  spermatic  artery 
alone,  and  then  ligate  the  entire  thickness  of  the  cord.  The  cord  is  ligated 
with  chromic  gut.     The  skin   is  sutured  with  silkworm-<j;ut.     Drainage  is 


I020         Diseases  and  Injuries  of  the  Genito-urinaiy  Organs 

not  required.  It  is  often  advisable  to  remove  a  considerable  amount  of 
scrotal  skin. 

Epididymitis,  or  inflammation  of  the  epididymis,  is  usually  due  to 
inflammation  of  the  urethra.  It  is  apt  to  occur  in  the  stage  of  dechne  of  a 
gonorrhea,  and  is  announced  by  a  complete  cessation  of  the  discharge.  It 
mav  result  from  the  passage  of  a  urethral  instrument,  the  voiding  of  urine 
which  contains  fragments  of  calculi,  or  as  a  comphcation  of  prostatic  hyper- 
trophv.  Acute  epididymitis  is  characterized  by  swelling  about  the  testicle, 
pain  in  the  groin,  and  tenderness  over  the  posterior  part  of  the  testicle.  The 
pain  becomes  acute,  swelling  rapidly  increases,  and  the  constitution  sym- 
pathizes. The  sweUing  is  due  partly  to  engorgement  of  the  epididymis  and 
partlv  to  fluid  in  the  tunica  vaginalis  (acute  hydrocele).  Chronic  epididymitis 
is  usually  hnked  with  orchitis,  and  it  follows  an  acute  attack  or  a  chronic 
urethral  inflammation. 

Treatment  by  aseptic  puncture  with  a  tenotome,  if  fluctuation  is  marked, 
will  relieve  tension  and  pain.  Leeching  over  the  external  abdominal  ring, 
use  of  an  ice-bag,  elevation,  apphcation  of  guaiacol,  and  administration  of 
laxatives  and  opium  constitute  the  usual  treatment  in  the  acute  stage. 
Applications  of  guaiacol  over  the  cord,  epididymis,  and  testicle  quickly 
relieve  pain  and  distinctly  lessen  swelling.  Two  applications  a  day  should 
be  made  for  one  week.  At  each  appHcation  paint  the  scrotum  and  over  the 
external  ring  with  15  drops  of  guaiacol  in  i  dram  of  glycerin  or  oHve  oil. 
Strapping  is  employed  as  the  inflammation  subsides.  The  treatment  of  the 
chronic  form  is  the  same  as  that  for  chronic  orchitis. 

Strangulation  of  the  Cord  by  Axial  Rotation.— In  nearly  one- 
half  of  the  cases  the  testicle  is  undescended  or  only  partly  descended.  In  every 
case  there  is  a  long  mesorchium,  and  if  a  normal  testicle  is  normally  placed 
torsion  of  the  cord  wiH  hardly  occur  (Chas.  L.  Scudder,  "Annals  of  Surgery," 
Aug.,  1901).  The  twisting  may  be  toward  the  right  or  toward  the  left.  The 
svmptoms  arise  suddenly,  and  usually  during  exertion.  In  some  cases  a 
hernia  also  exists.  When  the  rotation  occurs,  the  testicle  swells,  hemorrhages 
take  place  into  it,  and  gangrene  may  occur.  If  the  cord  of  an  unde- 
scended or  partially  descended  testicle  twists,  swelling  and  tenderness  are 
noted  in  the  abdomen  or  the  groin.  If  the  swollen  testicle  is  in  the 
scrotum,  the  gland  feels  nodular  and  the  epididymis  is  anterior.  The  symp- 
toms are  sudden  pain,  vomiting,  moderate  shock,  and  a  swelling  in  the  groin 
or  a  swollen  testicle  in  the  scrotum.  The  swelling  receives  no  impulse  on 
coughing.  The  symptoms  resemble  those  of  strangulated  hernia,  but  are 
less  violent,  and  the  bowels  are  not  obstructed. 

Treatment. — An  incision  should  be  made,  and  if  the  twisting  was  recent 
and  the  testicle  is  not  gangrenous,  untwist  and  fasten  the  testicle  to  the  scrotum 
by  a  catgut  stitch.  If  the  testicle  is  gangrenous,  remove  it.  Scudder  tells 
us  that  in  88  per  cent,  of  cases  the  testicle  is  found  to  be  gangrenous.  Ac- 
cording to  Scudder,  there  are  32  cases  on  record;  31  were  operated  upon  and 
I  was  not,  ?jut  all  recovered;  in  3  the  testicle  sloughed  and  in  2  it  atrophied 
("Annals  of  Surgery,"  Aug.,  1901). 

Vaginal  hydrocele  (chronic  hydrocele)  (Fig.  598,  e)  is  a  collection  of 
fluid  in  the  tunica  vaginalis  testis.  An  enlargement  of  the  testis  may  cause 
it,  but  in  most  instances  the  cause  is  unknown  and  no  signs  of  inflammation 


Encysted  Hydrocele  of  the  Cord 


I02I 


exist.  The  fluid  is  albuminous,  but  it  does  not  coagulate  spontaneously;  it 
is  thin,  straw-colored,  and  may  contain  crystals  of  cholesterin.  The  testicle 
is  at  the  lower  and  back  part  of  the  sac.  The  pyriform  mass  fluctuates,  is 
translucent,  grows  from  below  upward,  and  the  introduction  of  an  exploring- 
needle  permits  the  yellow  fluid  to  flow  out. 

Treatment. — Simply  tapping  the  sac  with  a  trocar  is  only  palhative; 
air  must  run  in  as  fluid  runs  out,  and  suppuration  may  occur,  which  will  be 
dangerous  without  drainage.  Never  tap  a  rigid  sac.  The  injection  of  irri- 
tants should  be  abandoned,  as  it  exposes  the  patient  to  serious  danger  because 
of  inflammation  occurring  without  provision  for  drainage.  Hearn  incises 
the  sac,  dries  its  anterior  with  bits  of  gauze,  swabs  it  out  with  pure  carboHc 
acid,  packs  it  with  iodoform  gauze,  and  dresses  it  anti.septically.  The  packing 
is  removed  in  twenty-four  hours  and  the  wound  is  allowed  to  close.  In 
most  cases  I  prefer  this  method.  If  the  sac  is  rigid  and  will  not  collapse, 
either  stitch  it  to  the  skin  and  pack  it  or  excise  a  large  portion  of  its  parietal 
layer  and  insert  a  drainage-tube  (\'olkmann's  operation).  It  has  recently 
been  proposed  to  tap  the  sac  with  a  trocar  and  cannula,  to  leave  the  can- 
nula in  place  as  a  drain  for  some  days,  and  to  dress  antiseptically. 


Fig.  59S. — Varieties  of  hydrocele  ;    a.  Congenital ;    b,  infantile  ;  c,  funicular;  d,  encysted  ;  e,  vaginal. 


Longuet's  operation  is  easy  and  successful.  It  is  called  extraserous 
transposition  of  the  testicle.  It  was  introduced  by  Longuet  in  1898  ("  Progres 
Med.,"  Sept.  21,  1901).  A  local  anesthetic  is  injected  and  an  incision  two 
inches  in  length  is  made.  The  testicle  is  pulled  out.  The  serous  and  all 
the  other  coats  except  the  skin  fall  together  behind  and  make  a  sheath  for 
the  cord.  One  catgut  suture  will  hold  them  behind  the  cord.  A  bed  is 
made  for  the  testicle  beneath  the  inner  edge  of  the  skin  wound,  by  tearing  with 
the  fingers.  The  testicle  is  rotated  on  its  long  axis  and  inserted  into  this 
cavitv.  The  testicle  rests  against  the  scrotal  septum,  and  in  front  of  the  gland 
is  the  cord  covered  with  tunic.     The  skin  is  sutured  and  the  wound  is  dres.sed. 

Congenital  hydrocele  (Fig.  598,  a)  is  hydrocele  through  an  unclosed 
funicular  process  into  the  tunica  vaginalis.  If  the  pelvis  is  raised,  the  fluid 
runs  back  into  the  peritoneal  cavity,  from  which  it  originally  came.  The 
treatment  is  the  application  of  a  truss  to  obliterate  the  funicular  process. 

Infantile  hydrocele  (Fig.  598,  h)  is  a  collection  of  fluid  in  a  funicular 
process  and  the  tunica  vaginalis,  the  funicular  process  being  closed  above, 
but  not  below.  The  treatment  is  to  puncture  the  sac  and  to  scarify  the  sac- 
wall  with  a  needle. 

Encysted  Hydrocele  of  the  Cord  (Fig.  59S,  </).— In  this  variety 
the  funicular  process  is  obliterated  above  and  below,  but  it  is  patent  between 


I022         Diseases  and  Injuries  of  the  Genito-urinaiy  Organs 

these  two  points,  and  fluid  cohects.  The  treatment  is  the  same  as  that  for 
infantile  hydrocele.     If  this  fails,  incise  and  pack. 

Funicular  Hydrocele  (Fig.  598,  c).— The  funicular  process  is  closed 
below,  but  is  open  above.  Raising  the  pelvis  causes  the  fluid  to  trickle  back 
into  the  peritoneal  cavity.     The  treatment  is  the  application  of  a  truss. 

Encysted  hydroceles  of  the  testicles  and  0}  the  epididymis  may  occur.  Dif- 
fused hydrocele  of  the  cord  is  simply  edema  of  the  cord.  Hydrocele  of  a  hernia 
is  the  distention  of  a  hernial  sac  with  peritoneal  fluid. 

Hematocele. — Vaginal  hematocele  is  blood  in  the  tunica  vaginalis,  the 
result  of  traumatism,  a  tumor,  or  the  tapping  of  a  hydrocele.  There  is  a 
pyriform  tumor,  which  fluctuates,  but  which  gradually  becomes  firmer;  the 
scrotum  is  livid,  and  the  testicle  is  below  and  posterior  to  the  tumor.  The 
encysted  form  of  hematocele  of  the  cord  is  a  hydrocele  of  the  cord  into  which 
bleeding  has  occurred.  The  diffused  form  is  due  to  extravasation  of  blood 
into  the  cellular  substance  of  the  cord.  Encysted  hematocele  of  the  testicle  is 
due  to  effusion  of  blood  into  an  encysted  hydrocele  of  the  testicle.  Paren- 
chymatous hematocele  is  extravasation  of  blood  into  the  substance  of  the 
testicle. 

The  treatment  of  a  recent  case  of  vaginal  hematocele  is  to  put  the  patient 
to  bed,  support  the  scrotum,  and  apply  an  ice-bag  over  the  testicle.  If  the 
swelling  does  not  soon  abate,  incise,  irrigate,  and  pack. 

Varicocele  is  varicose  enlargement  of  the  veins  of  the  venous  plexus 
of  the  spermatic  cord.  The  veins  are  thickened,  lengthened,  dilated,  and 
convoluted.  The  assigned  causes  are  straining,  cough,  constipation,  and  an 
occupation  requiring  prolonged  standing.  Some  believe  ungratified  sexual 
desire  is  a  cause.  Hereditary  predisposition  is  probable.  There  are  more 
left-sided  than  right-sided  varicoceles,  because  the  right  spermatic  vein  has 
valves  and  empties  into  the  vena  cava  at  an  acute  angle,  but  the  left  spermatic 
vein  has  no  valves  (Brinton)  and  empties  into  the  left  renal  vein  at  a  right 
angle.  Varicocele  is  a  very  common  condition.  The  elder  Senn  found  it 
in  21  per  cent,  of  10,000  recruits.  An  irregular  swelling  exists  in  the  scrotum 
and  extends  up  the  cord.  This  swelling  feels  like  "a  bag  of  earth-worms"; 
it  exhibits  a  slight  impulse  on  coughing;  the  scrotal  skin  and  cremaster  mus- 
cle are  attenuated;  the  testicle  lies  at  the  bottom  of  the  swelling  and  is  softer 
and  smaller  than  normal;  the  swelling  diminishes  on  lying  down  and  increases 
on  standing  or  on  making  pressure  over  the  external  ring.  The  scrotum  is 
pendulous  and  the  scrotal  skin  frequently  contains  varicose  veins.  The 
testicle  may  be  soft  and  shrunken.  There  is  usually  some  discomfort,  aching, 
or  dragging  in  the  testicle  or  the  groin,  and  even  neuralgic  pain  in  the  cord. 
There  may  be  no  discomfort  of  any  sort.  A  large  varicocele  may  be  free  from 
discomfort  and  a  small  varicocele  may  produce  much  annoyance,  or  vice 
versd.  There  is  sometimes  mental  depression  and  hypochondria.  As  a 
man  reaches  middle  age  a  varicocele  usually  cea.ses  to  give  trouble. 

Treatment. — In  treating  varicocele,  reassure  the  patient:  tell  him  there 
is  no  real  danger  of  impotence;  order  cold  shower-baths,  correct  constipation 
and  indigestion,  give  occasional  tonics,  and  order  the  ])atient  to  wear  a  sus- 
pensory bandage.  If  the  testicle  becomes  much  atrophied,  if  the  pain  and 
the  dragging  are  annoying,  or  if  the  minfl  is  much  (Jepressed,  operate  (page 
330)- 


Classification 


1023 


XXXVII.   AMPUTATIONS. 

An  amputation  is  the  cutting  off  of  a  limb  or  a  portion  of  a  limb.  Re- 
moval of  a  limb  or  a  portion  of  a  limb  at  a  joint  is  known  as  "  disarticulation." 
Amputation  may  be  necessary  because  of  the  existence  of  severe  injurv,  of 
gangrene,  of  tumors,  of  intractable  disease  of  bones  or  joints,  of  ulcers  which 
will  not  heal,  of  traumatic  aneurysm,  etc.  A  re-amputation  may  be  required 
because  of  the  existence  of  a  defect  or  disease  in  the  stump. 

Classification. — Amputations  are  classified  as  follows  :  (i)  As  to 
time  of  operation  after  the  injur\-:  a  primary  amputation  is  performed  soon 
after  the  occurrence  of  the  accident — as  soon  as  the  sufferer  reacts  from  shock, 
and  before  he  develops  fever;  a  secondary  amputation  is  performed  some 
time  after  the  accident,   suppuration  having  supervened   (Stokes) ;  and  an 


Fig-  599- — Esmarch's  elastic  bandage. 


Fig.  600. — Application  of  tourniquet. 


intermediate  amputation  is  performed  during  the  existence  of  fever,  but  before 
the  development  of  suppuration.  (2)  As  to  the  situation,  where  the  bone  is 
divided  or  according  to  which  joint  is  cut  through.  (3)  As  to  the  form  and 
situation  of  the  flap. 

In  performing  an  amputation  maintain  rigid  asepsis;  completely  remove 
the  hopelessly  damaged  portion;  sacrifice  as  little  of  the  sound  tissue  as  possi- 
ble; pre\ent  hemorrhage  during  the  amputation,  and  carefully  arrest  it  after 
the  operation;  have  enough  sound  tissue  in  the  flap  to  cover  the  bone,  and 
enough  skin  to  cover  the  muscles;  and  secure  drainage  at  a  dependent  point. 

Hemorrhage  may  be  prevented  by  the  elastic  bandage  of  Esmarch  (Fig. 
599).  Ordinarily  we  can  apply  this  bandage  from  the  periphery  to  well  above 
the  line  of  the  prospective  incision,  encircle  the  limb  with  an  elastic  band  (not 
the  thin  tube  shown  in  the  cut  ),  and  remove  the  bandage.  The  bandage 
and  band,  asepticized  Ijefore  using,  are  applied  to  the  liml),  which  has 
been  carefully  sterilized.     After  the  band  has  been  a])])lieti  the  limb  .should 


I024 


Amputations 


not  freely  or  forcibly  be  moved,  because  of  the  danger  of  tearing  muscles  which 
are  firmly  fixed  b}-  the  compressing  band.  When  elastic  compression  is  used 
in  an  operation  the  surgeon  should  be  very  careful  to  tie  every  visible  vessel. 
The  paralysis  of  the  small  vessels  induced  by  pressure  often  prevents  bleed- 
ing, and  unless  their  mouths  be  found  and  the  vessels  be  tied  reactionary 
hemorrhage  will  occur.  Reactionary  hemorrhage  is  the  great  danger  after 
the  use  of  the  Esmarch  bandage,  and  paralysis  or  sloughing  may  also  follow 


Fig.  6oi. — Petit's  spiral  tourniquet. 


Fig.  602.— Charriere's  tourniquet. 


its  employment.  If  there  be  an  area  of  suppuration  or  of  gangrene  or  an 
extra -osseous  malignant  growth,  do  not  apply  the  bandage  as  directed  above. 
One  bandage  can  be  applied  from  the  periphery  to  near  the  lower  border 
of  the  area  of  growth  or  infection,  and  another,  from  near  the  upper  border 
of  this  area,  up  the  Hmb.  If  the  bandages  are  applied  in  this  manner  the 
contents  of  the  diseased  area  (tumor-cells  and  fluid  or  septic  products) 
are  not  squeezed  into  the  circulation.     In  cases  like  the  above  many  surgeons 


Fig.  603. — Catlin,  knife,  and  saws  for  amputation. 


hold  the  extremity  in  a  vertical  position  for  five  minutes,  Hghtly  stroking  it 
toward  the  body  with  the  hand,  and  at  once  apply  the  constricting  band. 
As  a  matter  of  fact,  this  plan  satisfactorily  empties  the  limb  of  blood,  and  it 
is  nf)t  nece.s.sary  in  any  case  to  force  the  blood  out  by  elastic  compression. 
Some  .surgeons  prefer  the  tourniquet.  Figs.  601  and  602  show  two  forms  of 
tourniquet.  To  apply  Petit's  tourniquet,  place  the  plates  in  contact,  apply 
a  small,  firm  compress  over  the  artery  and  a  broad  thick  compress  over  the 
outer  surface  of  the  limb,  buckle  the  tapes  around  the  hmb  so  that  the  plate 


Methods  of  Amputating 


1025 


Fig.  604. — Amputation  of  arm   b 
the  circular  method  (Druitt  1. 


is  over  the  broad  pad,  and  tighten  the  tourniquet  by  separating  the  plates 
with  the  screw  (Fig.  600).  When  a  tourniquet  is  appHed  to  arrest  bleeding 
during  transportation,  bandage  the  limb,  sew  the  compress  pad  to  a  bandage, 
and  place  the  plates  of  the  instrument  over  the  pad.  Signorini's  horseshoe 
tourniquet  may  be  used  upon  the  brachial  artery.  In  hip-joint  and  shoulder- 
joint  disarticulations  Wyeth's  pins  are  passed,  and  after  the  limb  is  emptied 
of  blood  the  band  is  fastened  above  them.  These  pins  prevent  the  bands 
from  shpping. 

The  instruments  and  appliances  required  for  amputation  are   Esmarch's 
apparatus  or  tourniquet,  amputating   knives,  a   bone-knife,  scalpels,  saws,  a 

lion-jawed  forceps,  bone-cutting  forceps,  a  peri- 
osteum-elevator, retractors  of  linen,  dissecting, 
hemostatic,  and  toothed  forceps,  a  tenaculum,  an 
aneurysm-needle,  a  probe,  scissors,  needles,  liga- 
tures, sutures  of  silkworm-gut,  dressings,  band- 
ages, and  solutions.  A  retractor  has  two  tails 
for  the  thigh  and  arm  and  three  tails  for  the  leg 
and  forearm:  it  is  made  by  taking  a  piece  of 
muslin  eight  inches  wide  and  twelve  inches  long 
and  cutting  tails  on  one  side  eight  inches  in  length. 

Methods  of  Amputating.— Transverse  Circular  Method  (Figs.  604 
and  605) . — This  is  the  oldest  method  of  amputating.  The  common  circular  in- 
cision is  at  a  right  angle  to  the 
axis  of  the  limb.  Kocher  con- 
siders also  as  a  circular  incision 
an  oblique  cut  around  the  limb 
if  the  line  of  the  incision  ''  con- 
tinues in  one  direction  "  (Koch- 
er's  "Text-Book  of  Operative 
Surgery,"  translated  by  Harold 
J.  Stiles) .  This  method  is  called 
the  oblique  circular  amputation. 
A  racket  incision  is  formed  b}- 
adding  a  longitudinal  cut  to  a 
transverse  circular  cut.  If  the 
edges  are  rounded,  the  lanceolate 
incision  is  formed.  Rectangular 
flaps  are  formed  when  two 
longitudinal  incisions  are  added 
to  a  transverse  circular  cut.  If 
the  corners  of  a  rectangular  flap 
are  trimmed,  rounded  flaps  are 
formed.  The  three  last-men- 
tioned plans  are  considered 
under  the  head  of  the  Modified 
Circular  Amputation  (page 
1026). 

The   surgeon  should   stand 
to  the   right   of  the   limb   and 
65 


Fig.  605. — The  steps  of  a  transverse  circular  amputa- 
tion (Kocher). 

use   a    long   amputating    knife    which    cuts 


I026 


Amputations 


from  heel  to  point  (Fig.  604).  After  an  assistant  has  retracted  the 
skin  the  operator  divides  the  soft  parts  by  a  series  of  circular  cuts. 
He  does  not  cut  at  once  to  the  bone,  but  divides  the  skin  and  subcutaneous 
tissues.  At  the  retracted  edge  of  the  first  cut  the  superficial  muscles  are 
divided,  and  after  these  muscles  retract  the  deep  muscles  are  divided.  The 
periosteum  is  incised  with  a  bone-knife  and  pushed  up  with  an  elevator,  and 
after  the  application  of  the  retractors  the  bone  is  then  sawed,  the  saw  start- 
ing from  heel  to  point.     A  periosteal  flap  can  be  made  to  cover  the  end  of  the 


Fig.  606. — Circular  amputation  ;  dissecting  up  the  skin-flap  (Esmarch). 

bone,  but  it  is  unnecessary.  In  this  amputation  is  formed  a  cone  whose  apex 
is  the  bone  and  whose  base  is  the  skin-edge.  Figure  605,  from  Kocher, 
shows  the  steps  of  the  operation  and  the  shape  of  the  resulting  stump.  In 
one  form  of  circular  amputation  {amputation  a  la  manchette)  the  retracted 
skin  is  cut  by  a  circular  sweep  of  the  knife,  a  cuff  of  skin  and  subcutaneous 
tissue  is  freed  and  turned  up,  and  the  muscles  are  cut  circularly  at  the  edge 
of  the  turned-up  cut  (Fig.  606).  The  pure  circular  amputation  is  performed 
on  the  arm  and  the  thigh;  the  amputation  a  la  manchette  is  performed 
chiefly  through  the  wrist  and  the  lower  forearm. 


Fig.  607. — Modified  circular  amputation  ;  skin-flaps  and  circular  cut  through  muscles  (Esmarch). 


If  there  is  more  sound  skin  upon  one  side  of  the  extremity  than  upon  the 
other,  the  transverse  circular  incision  sacrifices  more  of  the  limb  than  is  neces- 
.sary  and  the  oblique  circular  is  preferable.  An  objection  to  the  tran.sverse 
circular  incision  is  that  the  cicatrix  lies  directly  at  the  end  of  the  stump  and 
is  liable  to  cause  pain  when  subjected  to  pres.sure. 

Modified  Circular  Method. — In  this  operation  the  circular  skin-cut 
may  be  modified  by  making  a  vertical  incision  to  join  the  first  wound,  the 


Flap  Method  of  Amputating 


1027 


muscles  being  cut  by  a  circular  sweep  (racket  incision)  or  by  making  two 
vertical  skin-incisions  (rectangular  flaps).  The  lanceolate  incision  is  made 
by  rounding  the  edges  of  the  flaps  which  result  from  a  racket  incision. 
Liston's  modification  consists  in  dissecting  up  two  short  semilunar  integu- 
mentary flaps  and  in  dividing  the  muscles  circularly  (Fig.  607).  This  is 
known  as  the  "  mixed  method. "  The  modified  circular  can  be  used  upon 
the  thigh,  the  leg,  the  arm,  and  the  forearm. 

Oblique  Circular  Method  (Elliptical  Method). — Mark  the  upper  and 
lower  ends  of  the  incision  as  shown  in  Fig.  608.  The  lowest  incision  is 
at  a  right  angle  to  the  cutaneous 
surface;  the  highest  incision  is  parallel 
to  the  cutaneous  surface  (Kocher). 
The  skin  and  fascia  are  divided  so 
that  an  oblique  incision  to  the  muscles 
surrounds  the  limb.  The  distal  ellip- 
tical portion  of  skin  is  picked  up  and 
drawn  toward  the  body  and  the  mus- 
cles are  divided  to  the  bone,  the  knife 
being  held  transversely  (Fig.  608). 
Kocher  points  out  that  this  flap  in- 
creases in  thickness  toward  the  bone. 
The  rest  of  the  muscles  are  divided 
on  a  level  with  and  in  the  direction 
of  the  skin-edge.  The  periosteum  is 
cut  transversely  and  is  treated  as  in 
the  transverse  circular  operation.  The 
flap  of  muscle  and  integument  is 
brought  over  the  wound.  This 
method  stands  midway  between  the 
circular  operation  and  the  operation 
by  a  single  flap,  and  is  employed 
particularly  in  certain  disarticulations. 

Racket  Method.— (If  flaps  are 
rounded,  is  known  as  the  "oval"  or 
"lanceolate"  incision.)  In  an  oval 
amputation  the  incision  through  the 
skin  and  subcutaneous  tissue  is  an 
oval  with  a  pointed  end  or  a  triangle ; 
and  the  other  parts  down  to  the  bone 
are  cut  from  without  inward.  When 
a  longitudinal  incision  down  to  the 
bone  (Fig.  618,  a,  b)  extends  from  the  point  of  the  oval,  the  operation 
is  called  the  "racket"  amputation.  If  the  longitudinal  cut  ioins  a  circular 
cut,  the  operation  is  known  as  a  "T"  amputation.  The  oval  or  racket 
operation  is  performed  at  the  metacarpophalangeal,  metatarsophalangeal, 
and  shoulder-joints;  the  T  operation  may  be  performed  at  the  hip- joint. 

Flap  Method. — A  flap  may  be  composed  of  skin  only  or  of  both  skiu 
and  muscle,  but  the  skin-flap  must  always  be  longer  than  the  muscle-flap,  so 
that  the  latter  will  be  covered  by  it.  A  flap  containing  much  muscle  heals 
badly,  but  the  best  flap  has  a  moderate  amount  of  muscle  (enough  skin  to 


Fig.  60S. 


■The  early  steps  of  an  oblique  circular 

amputalioii  (Kocher). 


1028 


Amputations 


cover  the  muscle  and  enough  muscle  to  cover  the  bone) .     Flaps  may  be  single 

or  double.  Double  flaps  may  be  lateral  or 
antero- posterior,  square  or  \J -shaped,  equal  or 
tinequal,  and  they  may  be  cut  by  transfixion 
(Fig.  609),  by  cutting  from  without  inward, 
by  dissection,  or  by  cutting  the  skin  from 
without    inward    and   the    muscles   bv   trans- 


Fig.  609. — Amputation  of  the  thigh  by 
transfixion  (Gross). 


Fig.  610. — Amputation  of 
tlie  finger. 


fixion. 

Completion    of    an    Amputation. — 

When  an  amputation  is  completed,  tie  the 
main  vessels,  pull  down  the  nerves  and  cut 
them  high  up,  smooth  the  flaps,  take  off  the 
constricting  band,  and  after  arresting  hemor- 
rhage apply  sutures.  In  some  cases  the  deep 
parts  are  stitched  with  a  continuous  catgut 
suture  and  the  superficial  parts  are  closed  with  silkworm-gut;  in  other  cases 
the  deep  parts  are  not  stitched  at  all,  the  skin  alone  being  sutured  with 
silkworm-gut.  Drainage-tubes  should  be  used  e.xcept  in  amputations  of  the 
fingers  and  toes. 

Special  Amputations. 

Fingers  and  Hand. — In  amputating  the  thumb  and  index-finger  save 
every  possible  scrap  of  tissue.  In  either  of  the  fingers,  if  it  be  necessary  to 
amputate  above  the  middle  of  the  middle  phalanx, 
the  attachment  of  the  flexor  tendons  will  be  cut  off 
and  the  finger  will  be  hable  to  project  directly  back- 
ward, so  that  it  is  better  with  these  fingers  either  to 
disarticulate  at  the  metacarpal  joints  or  to  stitch  the 
flexor  tendons  to  the  periosteum.  The  flexor  tendons 
have  fibrous  sheaths  extending  from  the  proximal  end  of  the  distal  phalanx 

to  the  metacarpophalangeal  articulations,  these 
sheaths  being  thin  and  collapsible  opposite  the 
joints,  but  being  thick  and  rigid  opposite  the 
shafts  of  the  bone.  The  fibrous  sheath  is  known 
as  the  theca,  and  when  it  is  cut  in  an  amputation 
it  should  be  clo.sed,  otherwise  it  may  carry  infec- 
tion to  the  palm  of  the  hand.  The  theca  does 
not  exist  over  the  distal  phalanx,  and  it  is  not 
distinctly  visible  over  the  joint  between  the 
distal  and  middle  phalanges.  To  effect  closure 
over  the  shaft  of  a  bone,  strip  up  the  periosteum 
and  pass  catgut  sutures  vertically  through  the 
Fig.  6ii.-The  line  of  the  joints  t^g^a  and  the  periosteum  (Treves).     In  ampu- 

in  the  flexed  position  of  the  finger :    ^      .  ..^  11, 1  1  t-^  1 

a,  Extensor  longus  digitorum ;  b,  t^tion  of  the  fingers  and  the  thumb  an  Esmarch 
interossei  and  lumbricais;  c,  ex-  bandage  is  unnecessary,  though  pressure  may  be 
tensor  longus  digitorum  and  inter-  ^^^^  ^         ^^e  arteries  at  the  wrist.     Only  two 

esse; ;  ^,  interossei  and  lumbricais ;  it  /^i  •  1 

/,  flexor  subiimis ;  e,  flexor  pro-  o^"  thfce  ligatures  are  nccessary.  Close  with  a 
fundus  (Kocher).  vcry  few  sutures,  so  as  to  favor  drainage  between 

the  threads. 
The  distal  phalanx  is  be.st  removed  by  a  long  |)ahnar  llap  (Fig.  6io,  A). 


Disarticulation  at  the  Wrist-joint 


1029 


The  palmar  flap  (a)  is  marked  out  by  cutting  through  the  .skin  and  subcu- 
taneous tissue.  The  incisions  are  next  carried  to  the  bone,  the  flap  is  dis- 
sected from  the  bone,  the  finger  is  strongly  flexed,  a  transverse  incision  (b)  is 
carried  across  the  dorsum  on  a  level  with  the  base  of  the  third  phalanx,  the 
soft  parts  are  pushed  back,  the  joint  is  opened,  the  lateral  ligaments  are  cut 
from  within  outward,  the  third  phalanx  is  forcibly  extended,  and  the  remain- 
ing structures  are  cut  from  below  upward.  Fig.  611  shows  the  lines  of  the 
joints  when  the  finger  is  flexed.  The  middle  phalanx  can  be  removed  by 
the  same  method  (c,  Fig.  610).  The  proximal  phalanx  can  be  removed  by  a 
long  palmar  flap  or  by  a  long  palmar  and  a  short  dorsal  flap  (d,  e,  Fig.  610). 

Disarticulation  at  a  metacarpophalangeal  joint  is  best  performed 

by  the  oval  method.     The  incision  upon  the  dorsum  (a)  is  begun  .just  above 
the  head  of   the  metacarpal   bone, 
is  carried  down  to  beyond  the  base 
of  the    phalanx,   and   involves  the 
skin  only  (Figs.  612  and  613).  One 


Fig.  612. — A,  Disarticulation  of  a  metacarpo- 
phalangeal joint ;  c,  amputation  of  a  finger 
with  the  metacarpal  bone. 


Fig.  613. — Disarticulation  of  the  little  finger 
and  index  finger.  Disarticulation  of  the  ring 
finger  with  its  metacarpal  bone.  Disarticula- 
tion of  the  thumb  with  its  metacarpal  bone 
(Kocher). 


incision  sweeps  around  the  finger  at  the  level  of  the  web,  going  only  through 
the  skin  (b);  the  finger  is  extended  and  the  palmar  cut  is  carried  to  the 
bone;  each  lateral  incision  is  carried  to  the  bone  while  the  finger  is  bent  in 
the  opposite  direction,  the  flaps  are  dissected  back  to  the  joint,  the  finger 
is  strongly  extended,  the  joint  is  opened  from  the  palmar  side,  and  dis- 
articulation is  effected.  Cutting  off  the  head  of  the  metacarpal  bone 
improves  the  appearance  of  the  stump  but  weakens  the  hand,  hence  in  a 
workingman  it  must  not  be  done  unnecessarily.  If  it  is  necessary  to  remove 
a  metacarpal  bone,  the  incision  (c)  is  made  from  the  carpometacarpal  joint. 

Amputation  of  the  thumb  through  its  distal  or  proximal  phalanx  is 
performed  identically  as  is  an  amputation  of  a  finger.  Amputation  of  the 
thumb,  with  a  portion  or  the  whole  of  its  metacarpal  bone,  is  performed  by 
the  oval  or  racket  incision  (Fig.  613). 

Disarticulation  atthe  wrist=joint  can  be  done  by  the  oblique  circu- 
lar method  (Fig.  615)  or  by  a  double  flap.  In  the  double-flap  amputation  a 
dorsal  flap  is  made  by  carrying  a  semilunar  skin-incision  between  the  stA'loid 
processes;  the  skin  is  lifted,  the  wrist  is  forcibly  flexed,  the  joint  is  opened 


I030 


Amputations 


Fig.  614. — Modified  circular  amputation 
of  the  forearm  (Bryant). 


by  a  transverse  cut,  and  a  long  semilunar  palmar  flap  which  includes  only  the 
skin  and  fascia  is  made  by  dissection.     Kocher  prefers  to  amputate  by   an 

oblique  incision.     The  lower  end  of  this  in- 
cision is  about  the  middle  of  the  palm  and 
the  upper  end  is  in  the  line  of  the  wrist-joint 
(Fig.  615).     The  hand  is  strongly  flexed,  the 
extensor  tendons  are  divided,  the  posterior 
ligament  of  the  joint  is  incised,  and  incisions 
below  the  styloid  processes  divide  the  lateral  ligaments  and  certain  tendons. 
The  flexor  tendons  are  separated  from  the   bone  and  are  divided  so  as  to 
remain  in  the  palmar  flap. 

Amputation  through  the  forearm  may  be  eftected  by  the  circular 
method  (Fig.  615),  the  modified  circular,  or  the  flap  operation.  The  modified 
circular  is  an  excellent  plan.  A  semilunar  dorsal  skin-flap  and  a  semilunar 
skin-flap  on  the  flexor  surface  are  made.     The  flaps  are  raised,  the  muscles  are 


Fig.   615. — Disarticulation   of  the   middle  finger.      Disarticulation   at   the   wrist-joint, 
through  the  forearm  by  the  oblique  circular  method  (Kocher). 


Amputation 


cut  circularly  (Fig.  614),  the  interosseous  space  is  cleared  with  the  knife,  a 
three-tailed  retractor  is  applied,  the  periosteum  is  pushed  up,  and  the  bones 
are  sawn  half  an  inch  above  the  flap.  In  sawing  the  bones,  start  the  saw 
upon  the  radius,  draw  it  from  heel  to  point,  make  a  furrow  on  the  radius  and 


Fig.  616.— Disarticulation  of  the  elbow-joint  by  the  oblique  circular  method  (Kocher). 


ulna,  and  saw  both  bones  at  the  same  time.     After  sawing,  cut  away  any 
irregular  edge  with  bone-pliers.     In  the  lower  third  Teale's  amputation  may 


Disarticulation  at  the  Slioulder-joint 


1031 


be  done,  the  dorsal  flap  being  the  long  one.  In  Teale's  amputation  rectan- 
gular flaps  are  made.  The  long  flap  is  equal  in  width  and  length  to  one- 
half  the  circumference  of  the  limb  at  the  point  where  it  is  to  be  sawn.  The 
short  flap  is  equal  in  width  to  the  long  flap,  but  is  only  one-fourth  its  length. 
The  two  longitudinal  cuts  are  at  first  taken  only  through  the  skin,  but  the 
two  transverse  cuts  go  at  once  to  the  bone.  The  flaps  are  dissected  up 
from  the  interosseous  membrane  and  the  bone.  In  the  middle  or  the  upper 
third  of  a  fleshy  arm  two  semilunar  skin-flaps  can  be  cut  from  without 
inward,  and  the  muscle  can  be  cut  by  transfixion. 

Disarticulation  at  the  elbow=joint  can  be  done  by  the  elliptical 
method  or  by  a  long  anterior  and  short  posterior  flap.  In  Kocher's  oblique 
operation  the  incision  begins  anteriorly  over  the  joint-line  and  ends  poste- 
riorly a  hand's  breadth  below  the  summit  of  the  olecranon  (Fig.  616).  A  pos- 
terior flap  which  contains  the  integument,  insertion  of  the  triceps,  the  an- 
coneus, and  periosteum  is  dissected  up  until  the  posterior  surface  of  the 


Fig.  617. — Use  of  Wyeth's  pins  in  amputation  at  the  shoulder-joint.     The  acromion  is  marked  by  a 

black  line  (Keen). 


humerus  is  reached.  The  joint  is  opened  anteriorly  by  a  transverse  incision 
and  the  radiohumeral  articulation  is  opened  from  without  inward  (Kocher) .  In 
the  double  flap  operation  the  forearm  is  partly  flexed  and  a  skin-cut  marks 
out  a  long  anterior  flap,  the  knife  being  entered  opposite  the  external  condyle 
and  being  withdrawn  one  inch  below  the  internal  condyle.  The  muscles, 
which  are  bunched  forward,  are  cut  by  transfixion.  A  posterior  semilunar 
flap  is  made,  which  separates  the  attachments  of  the  radius,  the  ulna  is  cleared, 
and  the  triceps  is  cut  at  its  insertion  (Bell).  Gross  advocated  sawing  through 
the  olecranon  and  the  inner  trochlear  surface. 

Amputation  of  the  arm  is  best  performed  by  marking  out  with  a  knife 
two  equal  semilunar  anteroposterior  flaps,  the  first  cut  being  carried  through 
the  skin  alone,  the  muscles  being  then  transfixed  with  a  long  knife.  Teale's 
method  is  shown  in  Fig.  26S.  The  circular  or  the  modified  circular  ampu- 
tation may  be  performed. 

Disarticulation  at  the  Shoulder=joint. — In  this  operation  Wyeth's 
pins  are  passed  to  hold  the  Esmarch  band  in  place.  The  anterior  pin  is  entered 
at  the  middle  of  the  lower  margin  of  the  anterior  axillarv  fold,  and  emerges 


10^2 


Amputations 


one  inch  within  the  tip  of  the  acromion.  The  posterior  pin  is  entered  at  a 
corresponding  point  on  the  posterior  axillary  fold,  and 
emerges  more  posteriorly  than  the  first  pin  and  an  inch 
within  the  tip  of  the  acromion.  After  the  extremity  has 
been  drained  of  blood  by  the  Esmarch  bandage  or  by 
stroking  and  a  vertical  position  the  Esmarch  band  is  ap- 
plied above  the  pins  (Fig.  617). 

Larrey's  Operation. — In  this  method  of  shoulder-joint 
disarticulation  the  limb  is  held  from  the  side  and  an  incision 
is  made  down  to  the  bone,  the  incision  beginning  just  below 
and  in  front  of  the  acromion  and  running  vertically  for  four 
inches  down  the  outer  surface  of  the  arm  (Fig.  618,  a  &). 
From  the  center  of  this  incision  an  oval  incision  {c  d,  c  e)  is 
carried  around  the  arm,  the  inner  aspect  of  the  oval  reaching 
as  low  as  the  lower  end  of  the  vertical  cut.  The  oval  incision  at  first  in- 
volves only  the  skin  and  subcutaneous  tissues.  The  anterior  structures 
are  divided  close  to  the  bone,  and  the  posterior  structures  are  next  cut.  To 
disarticulate,  cut  the  capsule  transversely  upon  the  head  of  the  bone;  while 
the  arm  is  rotated  outward  cut  the  subscapularis,  ancK  while  the  arm  is  ro- 
tated inward  cut  the  supraspinatus  and  infraspinatus  and  the  teres  minor. 
Cut  away  any  tissue  holding  the  humerus  to  the  body,  hanging  nerves, 
capsule-fragments,  and  tissue-shreds,  and  sew  up  the  wound  vertically. 
Bell  advises  an  oval  incision  with  a  racket  handle.  Spence  used  an  anterior 
racket   incision. 

Kocher's  Operation. — Kocher  makes  an  anterior  lanceolate  incision 
(Fig.  619).  The  incision  begins  over  the  clavicle  just  external  to  the 
coracoid   process   of   the   scapula,  and    is   carried   downward,  dividing,   as 


Fig.  61S. — Ampu 
tation  at  the  shoul 
der-joint :  a,  b,  c,  d. 
e,  Larrey's  opera 
tion;  f.g,  Dupuy- 
tren's  operation. 


Fig.  619. — Disarticulation  at  the  slioulder-joint 
by  Kocher's  method  (Kocher). 


Fig.  620. — Removal   of  the  entire    upper    ex- 
tremity (Kocher). 


it  advances,  the  anterior  fibers  of  the  deltoid  muscle.  "Bleeding  vessels  and 
the  cephalic  vein  are  ligatured.  In  the  upper  part  of  the  wound  the  ac- 
romial branches  of  the  acromiothoracic  artery  are  also  ligatured.    The  knife 


Amputation  of  the  Entire  Upper  Extremity 


1033 


is  carried  down  to  the  bone  at  the  edge  of  the  deUoid  (only  the  upper  fitjers  of 
which  have  been  divided).  The  capsule  is  divided  over  the  lesser  tuberosity 
and  the  bicipital  groove.  The  periosteum,  the  insertions  of  the  subscapularis, 
pectoralis  major,  latissimus  dorsi,  and  teres  major  are  detached  along  with 
the  capsule.  The  capsule,  along  with  the  insertions  of  the  supraspinatus, 
infraspinatus,  and  teres  minor  muscles,  is  also  detached  from  the  upper  part 
of  the  head  and  from  the  great  tuberosity.  The  head  of  the  humerus  can 
now  be  protruded  from  the  wound.  In  cutting  down  over  the  surgical  neck 
it  may  be  necessary  to  ligature  the  circumflex  arteries;  in  any  case  the  ante- 
rior must  be  tied.  The  racket  incision  is  now  completed  by  dividing  the 
skin  circularly  at  the  level  of  the  axillary  folds.  The  vessels  and  nerves  are 
then  easily  isolated,  the  former  being  ligatured  and  the  latter  divided" 
(Kocher's  "  Text-Book  of  Operative  Surger}-,"  translated  by  Harold  J.  Stiles). 
Kocher  cautions  us  to  avoid  the  circumflex  nerve  which  supplies  the  deltoid, 
as  the  deltoid  is  the  muscle  of  the  stump. 

Dupuytren's  Operation. — In  Dupuytren's  shoulder-joint  disarticulation 
a  U-shaped  flap  is  marked  out  by  a  skin -incision  (Fig.  618,  /,  ^).  If  the  ampu- 
tation is  to  be  at  the  right  shoulder,  the  arm  is  carried  across  the  chest;  the 
knife  is  entered  at  the  root  of  the  acromion,  follows  the  margin  of  the  deltoid, 
and  is  withdrawn  at  the  coracoid  process,  the  arm  being  gradually  abducted 
and  pulled  off  from  the  chest.  If  the  left  shoulder  is  to  be  amputated,  the 
procedure  is  reversed  (Treves).  The  knife  next  cuts  through  the  deltoid 
and  raises  a  flap  composed  of  this  muscle,  the  shoulder-joint  is  exposed,  and 
disarticulation  is  effected  as  in  Larrey's  method.  The  knife  is  passed  down 
back  of  the  bone  and  a  short  internal  flap  is  cut. 

Lisfranc's  amputation  is  by  transfixion  with  the  formation  of  an  ante- 
rior and  a  posterior  flap,  and  can  be  performed  very  rapidly,  but  only  a  most 
skilful  surgeon  should  attempt  it. 

Amputation  of  the  Entire  Upper  Extremity.— Berger's  Ampu- 
tation.— This  operation  is  an  amputation  above  the  shoulder-joint.  By  it 
are  removed  the  arm,  the  scapula,  and  a  portion  of 
or  the  entire  clavicle.  It  is  occasionally  employed 
in  cases  of  malignant  disease  and  of  severe  injury. 
The  operation  is  attended  with  profuse  hemorrhage, 
,and  as  a  preliminary  the  subclavian  vessels  should 
be  ligated.  The  incisions  must  be  varied  according 
to  the  necessities  of  the  case.  In  this  operation 
Berger  divides  the  clavicle  at  the  junction  of  its  outer 
and  middle  thirds,  and  resects  the  middle  third  of 
the  bone;  ligates  and  divides  the  subclavian  vessels; 
cuts  the  anterior  flap;  divides  the  brachial  ple.xus; 
marks  out  the  posterior  flap;  and  completes  the  oper- 
ation by  dividing  the  structures  which  hold  the 
shoulder-blade  to  the  chest.  It  is  in  this  last  step 
that  bleeding  is  profuse.  Fig.  621  shows  Berger's 
incision  for  the  operation.  Fig.  620  shows  Kocher's 
incisions. 

The  usual  procedure  of  tying  the  third  part  of  the  subclavian  artery  as  a 
preliminary  measure  possesses  certain  disadvantages.     The  artery   is  very 


Fii;.    621.— Removal     of    the 
whole  upper  extremity. 


I034 


Amputations 


Fig.  622. — Ampu- 
tation of  the  toes 
with  and  without 
the  metatarsal 
bones. 


deeply  situated  at  this  point,  is  in  close  relation  with  the  pleura,  and  is 
covered  to  a  considerable  extent  by  the  vein;  and  the 
phrenic  nerve  is  very  near.  Le  Conte  maintains  that  one 
of  two  courses  may  be  taken:  The  veins  may  be  severed 
first,  and  afterward  the  artery  may  be  exposed  and  tied. 
When  this  is  done,  the  amount  of  blood  remaining  in  the 
arm  is  lost.  The  procedure  that  he  selects  as  the  best, 
however,  is  to  expose  the  axillary  artery  as  high  up  as 
possible,  and  place  a  temporary  ligature  around  it;  then 
elevate  the  arm,  empty  it  of  blood,  place  a  permanent  hga- 
ture  around  the  third  part  of  the  subclavian  artery,  and 
divide  the  artery  in  this  portion  of  its  course  (Robert  G. 
Le  Conte,  "Annals  of  Surgery,"  Oct.,  1902). 

Amputation  of  the  Toes  and  the  Foot.— Only  in 

the  great  toe  is  partial  amputation  performed,  and  it  is 
effected  by  the  formation  of  a  long  plantar  flap,  just  as  a 
long  palmar  flap  is  formed  from  the  finger.  Amputation 
at  the  metatarsophalangeal  joints  is  performed  by  an  oval 

or  racket  incision  (Fig.  622,  c).     Amputation   of  a  toe  with   removal  of  its 

metatarsal  bone  is  shown  in  Fig.  622,  a  b  and  d  e. 

Disarticulation   at   the  Tarsometatarsal  Articulation.— Lis- 

franc's  Operation  (after  Treves). — In  order  to  amputate  the  right  foot  by  this 
method  begin  an  incision  on  the  outer  border  of  the  foot, 
behind  the  tubercle  of  the  fifth  metatarsal  bone;  carry 
the  incision  forward  one  inch  and  sweep  it  across  the 
foot  half  an  inch  below  the  tarsometatarsal  articulations; 
bring  the  incision  to  the  inner  edge  of  the  foot,  half  an 
inch  in  front  of  the  articulation  of  the  tarsus  with  the 
first  metatarsal  bone,  and  carry  the  cut  straight  along 
the  inner  margin  of  the  foot  until  it  reaches  a  point 
three-fourths  of  an  inch  above  the  articulation  of  the 
metatarsal  bone  of  the  great  toe.  A  very  short  semilunar 
dorsal  skin-flap  is  thus  formed.  Fig.  628  shows  the  flaps 
as  cut  by  Kocher.  After  the  skin-flap  is  dissected  back 
for  a  quarter  of  an  inch  the  tendons  are  divided,  and 
the  flap,  which  now  contains  all  the  soft  parts,  is  dis- 
sected back  to  above  the  joint.  A  long  plantar  flap  is  cut, 
reaching  from  the  origin  of  the  first  flap  to  the  necks  of 

the  metatarsal  bones.  The  skin-flap  is  dissected  up  until  the  hollow  behind 
the  heads  of  the  metatarsal  bones  is  reached,  when,  with  the  toes  in  extension, 
the  tendons  are  cut  across  and  a  flap  composed  of  all  the  soft  parts  is  dissected 
up  to  above  the  tarsometatarsal  joint.  Figs.  623  and  628  show  the  line  of  Lis- 
franc  at  the  tarsometatarsal  articulation.  The  joint  is  opened  from  the  outer 
side  according  to  the  following  rule:  in  separating  the  fifth  metatarsal  direct  the 
edge  of  the  knife  toward  the  distal  end  of  the  first  metatarsal;  in  separating  the 
fourth  metatarsal  direct  the  knife  toward  the  middle  of  the  first  metatarsal;  in 
separating  the  third  metatarsal  carry  the  knife  almost  directly  across.  The 
separation  is  facilitated  by  bending  down  the  front  of  the  foot,  and  at  the 
same  time  the  tendons  of  the  peroneus  brevis  and  tertius  are  divided.     Open 


Fig.  623. —  Lines  in 
amputations  of  the  foot 
(Gross). 


Disarticulation  at  the  Tarsometatarsal  Articulatioi 


1035 


the  joint  between  the  first  metatarsal  and  the  inner  cuneiform  Ijtjne,  turning 
the  knife  toward  the  middle  of  the  shaft  of  the  fifth  metatarsal,  and  at  the 
same  time  divide  the  tibialis  anticus  muscle.  Treves  says  that  in  disarticula- 
tion of  the  second  metatarsal  the  knife  is  to  be  held  as  a  trocar,  it  is  to  be 
thrust  between  the  base  of  the  first  and  second  metatarsal  bones  until  the 
point  strikes  bone  (Fig.  624),  and  is  then  to  be  raised  to  a  perpendicular  and 


Fig.  624. — Lisfranc's  amputation — first  step 
in  disarticulating  the  second  metatarsal  bone 
(Guerin). 


Fig.  625.— Lisfranc's  amputation — second 
step  in  disarticulating  the  second  metatarsal 
bone  (Guerin). 


the  cut  is  to  be  made  toward  the  external  malleolus  to  sever  the  ligament  of 
Lisfranc  (Fig.  625).  Divide  any  remaining  ligaments,  and  also  the  tendon 
of  the  peroneus  longus  muscle.  The  skin-incisions  in  the  left  foot  are  begun 
on  the  inner  side,  and  in  disarticulating  the  tarsal  joint  of  the  great  toe  is  first 
opened.  Fig.  629  shows  the  parts  after  disarticulation  at  the  line  of  Lisfranc. 
Hey's  Operation. — In  Hey's  method  the  incision  is  practically  the  same 


Fig.   626. — Anterior    intertarsal       Fig.  627. — Chopart's  ahi-  Fig.    628. — Lisfranc's    ampu- 

disarticulalion  (Kocher).  pulation.  tation. 


as  that  for  Lisfranc's  amputation.     The  four  external  metatarsal  bones  are 
disarticulated,  but  the  first  metatarsal  is  removed  by  sawing  a  portion  of  the 


Amputations 


internal  cuneiform  bone.  Guerin  advised  sawing  all  the  bones  across.  Skey 
advised  the  division  of  the  head  of  the  second  metatarsal.  Fig.  623  shows 
the  line  of  Hev. 


d 

Fig.  629. — The  parts  after  Lisfranc's  amputa-         Fig.  630. — The   parts   after  amputation   by 
tion  (Bernard  and  Huette).  Chopart's  method  (Bernard  and  Huette). 

Anterior  Intertarsal  Disarticulation. — The  disarticulation  is  ef- 
fected between  the  three  cuneiform  bones  in  front  and  the  scaphoid  behind, 
and  the  cuboid  is  sawn  across.  The  incision  of  the  soft  parts  is  as  for  Lis- 
franc's amputation  (Fig.  626). 

Disarticulation  through  the  Middle  Tarsal  Joint.— Chopart's 
Operation  (Posterior  Intertarsal  Disarticulation). — Make  a  transverse  in- 
cision through  the  skin  of  the  instep,  two  inches  below  the  ankle-joint;  cut 
the  tendons  and  muscles,  expose  the  tarsus,  and  make  on  each  side  a  small 
longitudinal  incision  reaching  to  below  and  in  front  of  the  corresponding 
malleolus.  The  flap  thus  formed  is  retracted.  The  plantar  flap  is  made 
as  in  Lisfranc's  amputation.  The  flaps  as  made  by  Kocher  are  shown  in 
Fig.  627.  Open  the  astragaloscaphoid  joint,  then  the  calcaneocuboid 
joint,  and  disarticulate.  Fig.  623  and  Fig.  627  show  the  line  of  Chopart. 
Fig.  630  shows  the  parts  after  Chopart's  disarticulation.  In  amputation 
through  the  tarsus,  Forbes,  of  Toledo,  advises  making  flaps  as  in  Chopart's 
amputation,  disarticulating  the  scaphoid  from  the  cuneiform  bones,  and 
sawing  through  the  cuboid.     Fig.  623  shows  the  line  of  Forbes. 

Subastragaloid     Disarticulation. — A    circular    incision    is    carried 

around  the  foot  at  the  level 
of  the  middle  tarsal  joint  and 
a  racket  incision  is  added  to 
it  running  below  and  poste- 
rior to  the  tip  of  the  e.xternal 
malleolus  (Fig.  631).  "The 
joint  between  the  astragalus 
and  scaphoid  is  opened  upon 
the  dorsum,  without  open- 
ing the  calcaneocuboid  joint. 
A     narrow     knife    is     then 


Fig.  631. — Subastragaloid  disarticulation  (Kocher). 


passed  backward  and  slightly  upward  beneath  the  head  of  the  astragalus 
so  as  to  divide  the  strong  interosseous  ligament  between  it  and  the  os  calcis. 
The  soft  parts  are  then  dissected  off  the  os  calcis,  first  from  its  upper  surface, 
then  from  its  outer  and  under  surfaces,  and  lastly  from  its  inner  and  posterior 


Disarticulation  at  the  Ankle-joint 


1037 


surfaces.  The  greatest  difficulty  is  met  with  at  the  inner  side  in  clearing 
the  projecting  sustentaculum  tali"  (Kocher's  "Text-Book  of  Operative 
Surgery,"  translated  by  Harold  J.  Stiles). 

Disarticulation  at  the  Ankle=joint.— Syme's  Method.— The  foot 
is  held  at  a  right  angle  to  the  leg,  and  a  skin-incision  is  carried,  from  just 
below  the  external  malleolus,  straight  across  or  a  little  backward  across  the 
sole  to  a  corresponding  point  on  the  opposite  side.  Do  not  take  this  incision 
near  to  the  inner  malleolus,  as  to  do  so  will  endanger  the  posterior  tibial 
artery.  The  incision  is  carried  to  the  bone,  the  flap  being  pushed  back  and 
separated  from  the  bone  by  means  of  a  strong  knife  and  the  thumb-nail  until 
the  tuberosity  of  the  os  calcis  has  been  reached.  The  foot  is  now  extended 
and  a  transverse  cut  is  made  across  the  dorsum,  joining  the  two  ends  of  the 
first  incision;  the  ankle-joint  is  opened,  the  lateral  ligaments  are  cut,  disar- 
ticulation is  effected,  and  the  foot  is  finally  completely  remo\-ed  by  severing 
the  tendo  Achillis.  A  thin  piece  of  bone  including  both  malleoli  is  sawn 
from  the  tibia  and  fibula.  The  flap  is  perforated  posteriorly  to  secure  drain- 
age (Fig.  269). 

Pirogoff 's  Method. — Flex  the  foot  to  a  right  angle  with  the  leg.  "  ^Nlake 
an  incision  from  the  tip  of  the  internal  malleolus  across  the  sole,  a 
little  in  front  of  the  long  axis  of  the  tibia,  to  a  point  in  front  of  the 
apex  of  the  external  malleolus  down  upon  the  bone."*  Dissect  the 
flap  backward  from  the  calcaneum  for  a  quarter  of  an  inch,  but  do 
not  dissect  the  flap  from 
the  posterior  portion  of 
the  OS  calcis.  Join  the 
extremities  of  the  first  in- 
cision by  another  cut 
which  reaches  to  the 
bone,  and  which  is  "  half 
an  inch  in  front  of  the 
lower  extremity  of  the 
tibia"  (Bryant);  but  saw 
off  this  bony  projection 
obliquely  and  leave  it  ad- 
herent to  the  tissues.  The 
saw  is  used  after  disarticu- 
lation of  the  ankle-joint; 
it   is    passed   behind    the 

astragalus,  cutting  downward  and  forward,  sawing  the  os  calcis  obliquely, 
and  leaving  a  considerable  portion  in  place  in  the  flap.  The  lower  ends  of 
the  tibia  and  fibula  are  well  exposed  by  raising  the  anterior  flap  slightl\- ;  the 
sawing  is  begun  anteriorly  just  above  the  articular  surface,  and  is  completed 
half  an  inch  above  the  articular  surface  posteriorly.  The  lines  <7  and  h  (Fig. 
632)  show  the  sections  made  by  the  saw.  The  sawn  surface  of  the  os  calcis 
is  brought  into  contact  with  the  sawn  surfaces  of  the  tibia  and  fibula,  and  the 
flaps  are  sutured. 

Amputations  of  the  Leg. — The  so-called  "point  of  election"  is  at  the 

*"  Operative  Surgery,"  by  Joseph  D.  Bryant. 


Lines  of  section  of  the  os  calcis  and  the  bones  of  the 
leg  in  Pirogoff's  amputation. 


1038 


Amputations 


1 

:^ 

< 

^ 

1 

i:r 

\ 

/7 

t      \ 

i 

/• 

K 

"■$. 

k 

V 

■sA. 

1 

M 

Fig.  633. — Diagrammatic  representation 
of  amputation  of  the  leg  after  the  method 
of  Bier. 


upper  part  of  the  middle  third  of  the  leg.     Seventy  years  ago  Liston  advised 

surgeons  not  to  amputate  in  the  lower 
third  of  the  leg  because  of  the  scantiness 
of  the  soft  parts,  because  the  stump  is  apt 
to  ulcerate,  and  because  it  is  uncomfort- 
able in  an  artificial  leg.  These  views 
have  been  much  modified.  The  ampu- 
tation near  the  ankle  is  safer  than  the 
amputation  near  the  knee,  and  artificial 
legs  are  now  made  which  may  be  worn 
with  comfort.  In  amputations  of  the  leg 
by  the  long  anterior  flap,  cut  through  the 
skin,  dissect  up  the  anterior  muscles  with 
the  flap,  and  cut  all  the  posterior  tissues 
with  a  single  transverse  sweep.  Amputation  by  the  rectangular  flap,  Teale's 
method,  is  very  useful  (see  page  103 1).  The  long  flap  is  anterior,  and  is  in 
length  and  breadth  equal  to  one-half  the  circumference  of  the  limb.  The 
short  flap  is  one-fourth  the  length  of  the  long  flap.  The  flaps  are  dissected 
up,  the  bones  are  sawn,  the  long  flap  is  turned  upon  itself,  and  its  edges  are 
sutured  to  the  edges  of  the  short  flap. 

Bier  suggests  a  plan  (Fig.  633)  to  increase  the  supporting  power  of  the 
stump  after  a  leg-amputation.  After  the  wound  has  healed,  a  wedge-shaped 
piece  of  bone  is  removed  above  the  level  of  the  stump.  The  lower  extremity 
is  turned  forward  and  upward  through  an  arc  of  90  degrees,  and  unites  in  this 
position  (Zuckerkandl's  "Operative  Surgery").  Thus  the  medullary  cavity 
is  closed  and  the  skin  which  must  bear  pressure  is  healthy 
and  free  from  cicatrices;  and  as  the  muscles  are  still  at- 
tached to  the  bone,  they  do  not  undergo  atrophy. 

Sedillot's  leg-amputation  (Fig.  634)  is  by  a  long  ex- 
ternal flap.  A  longitudinal  incision  is  made  along  the  inner 
edge  of  the  tibia,  the  tissues  are  drawn  toward  the  fibula,  a 
knife  is  introduced  and  passed  to  the  outer  edge  of  the  tibia, 
just  touching  the  fibula,  and  is  brought  out  posteriorly,  thus 
transfixing  the  calf-muscles  and  cutting  an  external  flap.  A 
convex  incision  is  made  on  the  inner  side,  the  bones  are 
cleared  and  are  sawn  one  inch  above  the  flaps,  half  an  inch 
more  being  taken  from  the  fibula  than  from  the  tibia,  and 
the  tibia  being  bevelled  anteriorly. 

Modified  Circular  Amputation  of  the  Leg. — Cut  semi- 
lunar skin-flaps,  lay  them  back,  and  cut  circularly  to  the 
bone  at  the  edge  of  the  turned-up  flap.  Another  method  of 
modified  circular  amputation  is  by  adding  to  the  circular  cut 
a  vertical  incision  down  the  front  of  the  leg.  In  sawing  the 
bones  of  the  leg  the  surgeon,  who  stands  to  the  outer  side  of  the  right  leg  or 
to  the  inner  side  of  the  left  leg,  divides  the  fibula  first,  and  at  a  higher  level 
than  the  tibia,  and  bevels  the  anterior  surface  of  the  tibia.  In  sawing  the 
left  fibula  the  saw  points  to  the  floor;  in  sawing  the  right  fibula  it  points  to 
the  ceiling. 

Amputation  of  the  Leg  by  a  Long  Posterior  and  a  Short  Anterior 


Fig.  634.-S6- 
dillot's  amputa- 
tion of  the  leg 
(Wyeth). 


Disarticulation  at  the  Knee-joint 


1039 


Fig.  635. — Amputation  of  the  leg  by 
a  long  posterior  flap  (Gross). 


Flap.- — In  this  operation  a  posterior  U-shaped  iiap  is  made  equal  in  length 
and  breadth  to  the  diameter  of  the  limb.  The  skin-incision  is  begun  one  inch 
below  the  point  where  the  bone  is  to  be  sawn,  and  behind  the  inner  edge  of 
the  tibia,  and  is  carried  to  a  point  posterior  to  the  peronei  muscles.  The 
gastrocnemius  muscle  is  divided  transversely  at 
the  level  of  the  flap,  the  soft  parts  on  either 
side  in  the  line  of  the  flap  being  cut  to  the 
bone.  Through  these  vertical  cuts  the  muscles 
are  lifted  from  the  bones  and  are  divided 
through  their  lower  part  by  cutting  from  within 
outward.  The  anterior  flap  is  formed  by  mak- 
ing a  semilunar  skin-flap  and  by  cutting  the 
muscles  across  at  its  retracted  edge  (Fig.  635). 

Amputation  of  the  leg  by  lateral  flaps  is  not  a  popular  operation,  as  it 
offers  too  much  encouragement  to  subsequent  protrusion  of  the  bone. 

Amputation  just  below  the  Knee. — The  seat  of  election  is  one  inch  below 
the  tuberosities.  No  muscle  is  needed  in  the  flap.  Cut  two  flaps  of  skin, 
equal  in  size  and  semilunar  in  shape,  these  flaps  beginning  anteriorly  two 
inches  below  the  tuberosity  of  the  tibia.  One  flap  is  antero-extemal  and  the 
other  is  postero-internal.  The  flaps  are  pulled  up,  the  anterior  muscles 
are  cut  as  high  up  as  possible,  and  the  posterior  muscles  are  cut  through  the 
middle  of  the  portion  exposed  (Bell).  The  bone  is  sawn  one  inch  below  the 
tuberosity. 

Disarticulation  of  the  Knee. — In  disarticulation  by  the  long  anterior 
flap,  make  a  long  anterior  skin-flap,  incise  the  ligament  of  the  patella,  turn  up 
a  flap  containing  the  patella,  open  the  joint,  and  complete  the  disarticulation 
by  cutting  from  within  outward  and  downward.  The  knee  may  be  disarticu- 
lated by  means  of  a  long  anterior  and  a  short  posterior  flap.  Kocher  prefers 
the  obHque  incision  (Fig.  636).     This  secures  an  anterior  flap.     The  leg  is  so 


Fig.  636. —  Kocher's  obiique  incision  for  disarticulation  at  the  knee-joint  (Kocher). 


held  that  it  makes  an  angle  with  the  thigh  of  135  degrees  and  "the  inci- 
sion falls  in  the  continuation  of  the  long  axis  of  the  thigh"  (Kocher's  ''Text- 
book of  Operative  Surgery,"  translated  by  Harold  J.  Stiles).  The  poste- 
rior part  of  the  incision  is  opposite  the  line  of  the  joint  and  the  anterior 
part  of  the  incision  ends  four  finger-breadths  below  the  tibial  tubercle. 
Amputation  through  the  Femoral   Condyles, — Syme's  Method  by  a 


1 040 


Amputations 


Long  Posterior  Flap. — Carn-  a  skin-incision,  with  a  very  slight  downward 
curve  from  one  condyle  to  the  other,  across  the  middle  of  the  patella.  Cut 
down  to  the  bone,  retract  the  flap,  and  cut  the  quadriceps  above  the  patella. 
Insert  a  long  knife  at  one  angle  of  the  wound,  pass  it  back  of  the  femur,  and 
make  it  emerge  at  the  opposite  angle,  cutting  a  posterior  flap  eight  inches 
long.  Retract  the  posterior  flap,  clear  for  sawing,  and  section  the  condyles 
horizontally.  Garden  made  a  curved  section  of  the  condyles  at  their  widest 
part.     In  children  Buchanan  showed  that  we  can  easily  separate  the  lower 


Fig.  637. — Diagrammatic      representation 
Gritti's  operation. 


Fig.  638. — Diagrammatic  representation  of  Sa- 
banejeff's  operation. 


femoral  epiphysis.  In  GrittPs  supracondyloid  amputation  an  oblique  inci- 
sion is  made.  The  upper  end  of  the  incision  is  posterior  and  just  above  the 
condyles.  Its  lower  end  is  anterior  and  two  finger-breadths  below  the  patella 
(Kocher).  The  hgament  of  the  patella  is  cut,  the  flap  is  turned  up,  the  femur 
is  sawn  at  the  base  of  the  condyles,  the  articular  face  of  the  patella  is  sawn 
off,  and  the  sawn  patella  is  fastened  to  the  sawn  femur  and  the  flaps  are 
sutured  (Fig.  637).  Sabanejeff  makes  an  anterior  flap,  opens  the  knee- 
joint  from  behind,  saws  the  condyles  at  their  broadest  part,  takes  a  bone-flap 
from  the  anterior  portion  of  the  tibia  and  fastens  it  to  the  femur  (Fig.  638). 

Amputation  of  the  Thigh. — 
In  high  amputation  in  the  lower 
third  either  a  flap  or  a  circular 
operation  may  be  performed.  In 
a  double-flap  operation  a  semi- 
lunar skin-incision  should  be  made 
from  without  inward,  and  the 
muscles  should  be  cut  by  trans- 
fixion (Fig.  639).  In  the  lower 
third  Teale's  flap  or  the  long  an- 
terior flap  may  be  empk)yed.  The 
amputation  by  a  long  anterior  flap 
consists  in  making  a  lengthy  skin- 
flap,  reflecting  it,  cutting  the  ante- 
rior structures  to  the  bone,  again 
entering  the  long  knife  at  one  angle  of  the  incision,  pushing  it  back  of  the 
femur,  bringing  it  out  at  the  outer  angle,  and  cutting  the  structures  behind 
the  bone  directly  backward.     Bell  amputates  by  a  long  anterior  semilunar 


Fig.  639. — Amputation  of  tlie  thigh  (I'ryant). 


Disarticulation  at  the  Hip-joint 


1 04 1 


flap  and  a  short  posterior  flap.  In  amputations  in  the  upper  two-thirds  of 
the  thigh  the  best  phm  is  to  mark  out  equal  anterior  and  posterior  semilunar 
skin-flaps,  divide  the  skin  with  a  scalpel,  enter  the  long  knife  at  one  angle 
of  the  anterior  flap,  bring  it  out  at  the  other  angle,  and  cut  the  muscles  by 
transfixion.  Cut  the  posterior  flap  in  the  same  manner.  Some  surgeons 
prefer  a  long  anterior  semilunar  flap  and  a  short  posterior  semilunar  flap. 
The  pure  circular  amputation  is  not  adapted  to  the  thigh. 

Disarticulation  at  the  Hip-joint. — \arious  methods  have  been  employed 
to  prevent  or  limit  hemorrhage  during  this  formidable  operation.  Abernethy 
uses  digital  compression  of  the  external  ihac  artery  or  of  the  femoral  artery, 
to  prevent  hemorrhage  during  amputation  of  the  hip-joint.  This  is  an  ex- 
tremely tiresome  procedure;  the  finger  is  liable  to  slip;  and,  in  any  case, 
compression  so  situated  fails  to  intercept  the  blood-current  in  a  number  of 
large  vessels. 

Various  other  methods  ha\'e  been  emplo}'ed.  It  was  formerl}-  the  custom 
to  compress  the  aorta  by  means  of  an  abdominal  compressor  (Figs.  640,  641). 
A  tourniquet  is  very  likely  to  be  displaced  during  the  operation.  The  inten- 
tion is  to  compress  the  artery  against  the  spine,  but  in  eft'ecting  this  the  circu- 
lation in  a  portion  of  the  intestine  may  be  impaired.  In  any  case,  as  Senn 
says,  the  circulation  is  cut  off  from  half  the  body,  and  the  patient  is  exposed 
to  grave  danger  from  "  sudden  vascular  engorgement  of  important  internal 
organs"  (Senn).  Again,  an  abdominal  compressor  of  this  sort  does  not  arrest 
venous  bleeding.  A  number  of  years  ago  Davy  suggested  that  a  suitable 
cylindrical  piece  of  wood,  about  25  inches  long,  and  shaped  like  a  cone  at  the 
end,  might  be  introduced  into  the  rec- 
tum and  used  to  compress  the  common 
iliac  artery  upon  the  pelvic  brim.  This 
appliance  is  known  as  Davy's  lever. 
It  is  apt  to  slip,  and  may  do  serious 
damage  to  the  rectum. 

Some  surgeons  have  practised  pre- 
liminary ligation  of  the  common  femoral 
artery  or  of  the  external  iliac  artery, 
and  others  have  tied  the  vessels  while 
making  the  flaps.  If  any  form  of  com- 
pression is  used,  that  recommended  by 
Macewen,  of  Glasgow,  is  the  most  suc- 
cessful and  satisfactory  (Fig.  642).  The 
weight  of  the  assistant's  body  is  thrown 
upon  the  patient's  aorta  by  the  right 
fist,  placed  slightly  to  the  left  of  the 
umbilicus.  McBumey  has  suggested 
the  prevention  of  bleeding  by  making  a 
small  abdominal  incision  and  having  an  assistant  make  direct  digital  pres- 
sure upon  the  iliac  artery.  I  employed  McBurney's  method  in  a  recent  case 
and  found  it  most  satisfactory.  If  the  constricting  band  of  Esmarch  is  ap- 
plied by  the  ordinary  method,  it  is  certain  to  slip.  It  may  remain  in  place  if 
applied  as  a  figure  eight  of  the  thigh  and  the  pelvis,  but  even  then  it  is 
uncertain. 
66 


Fig.  640. — Paiicoast's  aorta  tourniquet. 


1042 


Amputations 


Fig.  641. — Von  Esmarch's  aorta  tourniquet. 


The  most  satisfactory  method  in  the  great  majority  of  cases  is  Wyeth's,in 
which  the  constrictor  is  held  in  place  by  the  preliminary  passage  of  two 
steel  pins.  Trendelenburg's  method  consisted  in  passing  one  pin  and 
winding  an  elastic  tube  about  it.  Wyeth  applied  the  principle  and  greatly 
improved  the  method.  The  outer  pin  is  inserted  an  inch  and  a  half 
below  and  a  little 
internal  to  the  ante- 
rior superior  spine  of 
the  ilium,  and  is 
brought  out  just 
back  of  the  great 
trochanter.  The  in- 
ner pin  is  entered 
one  inch  below  the 
level  of  the  crotch 
and  internal  to  the 
saphenous  opening, 
and    it    emerges    an 

inch  and  a  half  in  front  of  the  tuberosity  of  the  ischium.  A  sterile 
cork  is  pushed  on  the  end  of  each  pin,  to  save  the  surgeon  from  wounding 
himself  upon  the  sharp  points.  After  the  Hmb  has  been  emptied  of  blood 
by  holding  it  in  a  vertical  position  for  five  minutes  and  stroking  it 
from  the    periphery  toward  the   body,  the    constricting   band  is   fastened 

about  the  limb  above  the  pins. 
In  the  bloodless  method  of 
Wyeth  (Figs.  643,  644),  after 
the  passage  of  the  pins  and 
the  appHcation  of  the  band  of 
the  Esmarch  apparatus,  the 
amputation  is  proceeded  with. 
The  hip  is  brought  well  over 
the  edge  of  the  table,  a  circular 
incision  is  made  down  to  the 
deep  fascia  six  inches  below 
the  constricting  band,  and  is 
joined  by  a  longitudinal  skin- 
cut  reaching  from  the  band  to 
the  level  of  the  circular  incision, 
and  the  cuff  is  reflected  to  the 
level  of  the  lesser  trochanter. 
The  muscles  are  cut  by  a  cir- 
cular sweep  at  the  level  of  the 
retracted  cuff,  the  capsule  of  the 
hip-joint  is  opened  freely,  the 
cotyloid  ligament  is  cut  poste- 
riorly, the  thigh  is  bent  upward, 
forward,  and  inward  to  dislo- 
cate the  head  of  the  bone,  and,  using  the  thigh  as  a  handle,  the  round 
Hgament  is  incised  and  the  limb  removed.     After  ligating  the  vessels  and 


Fig.  642. — Macewen's  method  for  compression  of  the  ab- 
dominal aorta  ("American  Text-book  of  Surgery"). 


Wyeth's   Bloodless   ]\Icthod 


1043 


introducing  drainage-tubes  the  flaps  are  sewn  together  vertically.  The  old 
transfixion  operation  is  practically  extinct.  A  T-ampiitation  may  be  em- 
ployed.    It  consists  of  an  external  straight  incision  down  to  the  bone,  starting 


Fig  ^43  —Amputation  at  the  hip  joint — Wyeth's  bloodks's  method 

over  the  great  trochanter,  down  the  outer  side  of  the  limb,  and  a  circular  in- 
cision through  the  skin  five  inches  below  the  constricting  band,  the  muscles 
being  cut  by  a  circular  sweep  at  the  level  of  the  retracted  skin.    This  method 


Fig.  644.— Wyeth's  bloodless  amputation  at  the  hip-joint.  Cuff  of  skin  and  subcutaneous  fat 
turned  back,  muscles  divided  at  level  of  small  trochanter,  hone  partly  stripped,  and  large  vessels  ex- 
posed for  deligation. 

affords  easy  access  to  the  joint.  The  bloodless  method  of  Wyeth,  as  applied 
to  the  hip-joint  and  shoulder-joint,  is  one  of  the  notable  modern  advances 
in  the  art  of  surgery. 


I044 


Amputations 


Fig.  645.— Senn's  method  of  putifn miiii,'  bloodless  amputation  at  \.he  hip-joint.  Dislocation  of 
head  of  femur  and  upper  portion  of  sliaft  through  straight  external  incision.  Elastic  constrictors  in 
place,  the  anterior  one  tied  (Senn). 


Fig.  646.— Elastic  constriction  completed  by  constricting  the  posterior  segment  of  the  lliigh.     Flaps 
formed  including  all  the  tissues  down  to  the  muscles  (Senn). 


Senn's  Bloodless   Method  1045 

Senn's  Bloodless  Method. — The  elder  Senn  lias  devised  a  method  for  pre- 
venting hemorrhage  during  amputations  of  the  hii)-joint.  He  makes  a 
straight  incision,  about  eight  inches  in  length,  in  the  direction  of  the  long  axis 
of  the  femur  and  directly  over  the  center  of  the  great  trochanter.  This  inci- 
sion reaches  about  three  inches  above  the  upper  margin  of  the  great  trochan- 
ter. The  muscular  insertions  are  divided  close  to  the  bone,  and  the  thigh  is 
fle.xed,  strongly  adducted,  and  rotated  inward.  The  capsular  ligament  is 
divided  at  its  upper  and  posterior  aspect.  While  the  thigh  is  brought  into  a 
position  of  slight  flexion,  the  remaining  portion  oi  the  capsular  ligament  is 
cut.  Then  the  thigh  is  dislocated  outward,  and  the  ligamentum  teres  is  cut. 
If  this  cannot  be  accomplished,  the  head  of  the  bone  is  forcibly  dislocated 
upon  the  dorsum  of  the  ilium.  After  dislocating,  the  lesser  trochanter  and 
the  upper  part  of  the  femoral  shaft  are  cleared.  The  limb  is  now  brought 
down  in  a  straight  line  with  the  body,  the  thigh  is  slightly  flexed,  a  long  and 
stout  pair  of  forceps  is  inserted  into  the  wound  behind  the  femur  and  on  a 
level  with  the  normal  situation  of  the  lesser  trochanter,  and  the  instrument  is 
pushed  downward  and  inward,  two  inches  below  the  ramus  of  the  ischium 
and  just  behind  the  adductor  muscles.  As  soon  as  the  point  can  be  felt 
under  the  skin,  an  incision  two  inches  in  length  is  made  upon  it,  and  the 
instrument  is  forced  through  the  opening.  The  tunnel  in  the  tissues  is  en- 
larged by  opening  the  forceps.  A  piece  of  rubber  tubing  three-quarters  of 
an  inch  in  diameter  and  four  feet  in  length  is  caught  about  the  middle  with 
the  forceps  and  is  withdrawn.  The  rubber  tube  is  cut  in  two  at  about  the 
point  at  which  the  forceps  have  held  it,  and  half  of  the  tube  is  used  to  con- 
strict the  anterior  segment  of  the  thigh  (Fig.  645)  and  the  other  half  to 
constrict  the  remaining  portion  of  the  thigh  (Fig.  646).  Before  the  con- 
stricting bands  are  tied  the  limb  is  held  vertically  for  a  sufficient  length 
of  time  to  make  it  practically  bloodless;  the  amputation  is  then  completed 
(Senn's  "Practical  Surgery"). 

Other  Methods. — John  G.  Sheldon  ("Amer.  Med.,"  April  19,  1902)  has 
modified  Senn's  method  as  follows :  He  disarticulates  the  head  of  the  femur 
and  frees  the  upper  part  of  the  femur  from  its  attachments.  He  then  intro- 
duces a  pair  of  long,  stout  artery-forceps  behind  the  femur  and  clamps  the 
femoral  vessels.  He  forms  the  flap,  removes  the  limb,  and  Hgates  the  vessels. 
In  this  operation  the  surgeon  can  work  rapidly  and  can  make  a  flap  of  any 
size  or  shape,  and  is  not  hindered  by  a  constriction  apparatus;  but  this 
method  does  not  cut  off  the  bleeding  from  the  obturator  and  the  sciatic  artery. 

Larrey  amputated  by  lateral  flaps,  and  Liston  by  anteroposterior  flaps. 
Forneaux  Jordan's  method  consists  in  dividing  the  soft  parts  low  down., 
tying  the  blood-vessels  on  the  face  of  the  stump,  shelling  out  the  femur  from 
the  soft  parts,  and  disarticulating. 


1046  Diseases  of  the  Breast 


XXXVIII.   DISEASES  OF  THE  BREAST. 

Mammillitis  and  Fissure. — The  nipple  may  inflame  as  a  resuh  of 
injury,  but  the  condition  is  rarely  encountered  except  in  a  woman  who  is 
nursing  a  baby.  It  is  most  common  after  a  first  pregnancy,  when  the  nipple 
is  deformed  or  when  the  skin  is  delicate.  The  nipple  is  slightly  injured  during 
nursing,  and  the  epithelium  is  macerated  by  the  milk  and  saliva.  If  the  in- 
flammation is  not  arrested,  a  spot  excoriates  or  an  irritable  ulcer  forms  (a 
fissure).  A  fissure  is  often  surrounded  by  an  area  of  acute  inflammation, 
and  nursing  causes  intense  agony.  Because  of  the  pain  the  mother  is  apt 
to  extend  the  intervals  between  nursing,  and  as  a  consequence  the  breasts 
become  swollen  with  retained  milk.  The  ulcer  not  unusually  bleeds  when 
the  breast  is  taken  by  the  child.  Besides  the  fact  that  a  fissure  causes  pain 
to  the  mother,  it  often  leads  to  grave  trouble.  It  is  a  suppurating  area,  and  as 
such  may  lead  to  abscess  of  the  mother's  breast,  or  may  impair  the  health 
of  the  nursing  child. 

Prevention  of  Fissure. — During  pregnancy  the  nipples  should  be 
carefully  attended  to.  They  should  be  washed  often  in  sterile  water  and 
bathed  in  alcohol,  and  if  retracted  ought  to  be  drawn  out  repeatedly.  During 
lactation  the  nipples  are  washed  in  sterile  water,  dried,  and  dusted  with 
borated  talc  powder  as  soon  as  an  act  of  nursing  is  completed.  Washing  the 
nipples  regularly  with  the  following  solution  tends  to  prevent  the  formation 
of  a  fissure:  iodid  of  mercury,  gr.  ij;  alcohol,  5jss;  glycerin  and  distilled 
water,  da  a  pint  (Lepage).  If  a  small  abrasion  appears,  order  the  woman  to 
wear  a  nipple-shield  during  nursing,  and  after  each  act  of  nursing  to  wash 
the  part  with  hot  sterile  water,  dry,  and  dust  borated  talc  over  the  surface. 
If  a  fissure  forms,  wean  the  child  at  once,  and  dry  up  the  milk  in  both  breasts. 
It  is  useless  to  try  and  dry  it  up  in  one  breast.  Milk  may  be  dried  up  by 
applying  ointment  of  belladonna  locally,  and  administering  iodid  of  potassium 
internally,  by  strapping  the  breasts  with  adhesive  plaster  (Parker);  or  by 
applying  to  the  nipples  six  times  a  day  a  5  per  cent,  solution  of  cocain  in  equal 
parts  of  glycerin  and  water  (Joise).  The  fissure  is  not  treated  by  ointments. 
These  preparations  are  septic,  prevent  drainage,  and  aggravate  maceration. 
Wash  the  fissure  twice  a  day  with  peroxid  of  hydrogen,  dress  it  with  gauze 
wet  in  boric-acid  solution  (gr.  x  to  ,lj  of  water),  and  cover  the  dressing  with 
waxed  paper.     If  the  fissure  resists  treatment,  touch  it  with  lunar  caustic. 

Acute  Alastitis  and  Abscess. — Acute  inflammation  of  the  breast,  as 
a  result  of  injury  of  the  breast  or  nipple,  may  occur  in  either  sex  at  any  time 
of  life.  Very  commonly  in  both  sexes  a  few  days  after  birth  the  breast  be- 
comes distended  with  a  material  which  in  reality  is  milk.  The  fluid  is  usually 
small  in  quantity.  The  process  is  physiological,  and,  as  a  rule,  ceases  spon- 
taneously (Guelliot).  If  it  lingers,  the  application  of  belladonna  ointment 
will  stop  secretion.  If  the  nurse  meddles  with  and  tries  to  squeeze  out  the 
fluid,  acute  mastitis  is  apt  to  arise  in  one  gland,  or  occasionally  in  both.  The 
skin  of  the  breast  reddens,  the  gland  swells  and  becomes  tender  and  painful, 
the  child  loses  its  appetite  and  becomes  feverish,  restless,  and  sleepless.  Such 
a  condition  is  treated  by  the  local  use  of  lead-water  and  laudanum.  If  pus 
forms,  the  local  signs  and  constitutional  symptoms  are  aggravated.     Evacuate 


Acute  Abscess  of  the  Breast  1047 

the  pus,  dress  with  hot  antiseptic  fomentations,  and  be  sure  that  the  child 
is  well  nourished.     Tonics  and  stimulants  are  indicated. 

A  condition  identical  with  the  secretory  activity  of  the  glands  of  the  new- 
born may  occur  in  either  sex  at  puberty.  The  methods  of  treatment  are  the 
same  in  both  cases.  As  a  matter  of  fact,  rarely  more  than  one  lobule  at  this 
period  inflames,  and  suppuration  is  most  unusual. 

Mastitis  is  most  usually  met  with  in  a  woman  who  is  nursing  a  child,  and 
is  due  to  bacterial  infection.  Primipara  are  particularly  liable  to  develop 
mastitis.  So  are  women  with  deformed  nipples.  In  many  cases  an  abrasion 
of  the  nipple  exists,  and  through  this  breach  of  continuity  bacteria  gain 
entrance  to  the  breast-tissue.  The  abrasion  may  be  so  slight  that  it  can  only 
be  detected  when  the  nipple  is  examined  through  a  magnifying-glass  (Marma- 
duke  Sheild).  Streptococcic  infections  are  very  generally  due  to  inoculation 
of  a  fissure  of  the  nipple.  Bacteria  may  pass  up  the  milk-ducts,  coagu- 
lating the  milk  and  penetrating  through  the  walls  of  the  acini.  Staphylococci 
not  unusually  pursue  this  route  in  reaching  the  breast-tissue.  Occasionally 
causative  bacteria  reach  the  breast  through  the  arteries  (in  septicemia  and 
in  septic  wounds  of  the  genital  organs). 

Symptoms. — There  are  pain,  swelling,  and  tenderness  in  the  breast,  and 
in  most  cases  a  fissure  or  abrasion  exists.  There  is  a  febrile  condition.  Occa- 
sionally a  chill  ushers  in  the  attack. 

Treatirient. — Order  the  patient  to  suspend  nursing.  The  physician  en- 
deavors to  arrest  the  secretion  of  milk.  Treat  the  nipple  as  advised  on 
page  1046.  Support  the  breast  and  apply  ichthyol  ointment  or  lead-water 
and  laudanum. 

Mastitis  may  undergo  resolution;  it  may  terminate  in  organization  and 
induration;  it  may  eventuate  in  suppuration. 

Acute  abscess  of  the  breast  follows  acute  mastitis.  There  may  be 
but  one  area  of  suppuration,  or  multiple  foci  may  exist,  which  eventually 
fuse.  The  symptoms  of  mastitis,  local  and  constitutional,  are  greatly  aggra- 
vated. After  a  time  the  skin  becomes  dusky  and  edematous.  The  axillary 
and  superficial  cervical  glands  enlarge.  The  abscess  will  eventually  open 
spontaneously  at  one  or  more  points,  leaving  branching  fistulEe.  A  super- 
ficial abscess  is  situated  just  beneath  the  nipple,  and  pus  may  flow  from  the 
nipple. 

An  intramammary  abscess  is  in  the  depths  of  the  gland.  There  are  often 
multiple  foci  of  suppuration.  Nodules  are  felt  in  the  gland,  ])us  may  run  from 
the  nipple,  but  cutaneous  redness  is  late  in  appearing. 

Retromammary  abscess  is  a  rather  rare  condition.  It  may  occur  alone 
or  be  associated  and  connected  with  an  area  of  intramammary  suppuration. 
It  may  result  from  metastasis  or  from  caries  of  a  rib.  The  breast  is  lifted  up 
by  the  fluid  l^eneath  it. 

Treatment. — Open  a  superficial  abscess  by  an  incision  radiating  from 
the  nipple.  Treat  as  any  other  acute  abscess.  An  intramammary  abscess 
should  be  opened  by  a  radiating  incision,  and  pockets  of  pus  should  be  broken 
into  with  the  finger.  An  examination  is  made  to  determine  if  a  retromammary 
abscess  also  exists.  If  this  is  found  to  be  the  case,  an  incision  is  made  at  the 
point  of  junction  of  the  thorax  and  mammary  gland,  and  at  the  lower  border 
of  the  gland.     The  gland  is  raised  from  the  chest-wall,  the  pus  evacuated. 


1048  Diseases  of  the  Breast 

a  drainage-tube  is  inserted,  and  a  few  sutures  are  introduced.  If  retromam- 
mary abscess  exists  alone,  make  the  last-named  incision  in  the  first  place. 

Chronic  Mastitis. — This  condition  may  be  present  in  only  a  portion 
of  the  breast,  or  may  attack  many  lobules  (lobular  mastitis).  The  ordinary 
form  may  arise  after  weaning  a  child,  or  may  be  due  to  a  blow,  to  the  pressure 
of  corsets,  or  to  numerous  slight  traumatisms.  It  may  occur  in  the  young, 
the  middle  aged,  or  the  old.  The  patient  has  slight  pain  at  times  in  the 
gland.  Examination  detects  a  firm,  elastic  area,  which  is  somewhat  tender 
and  does  not  possess  distinct  margins.  The  skin  is  not  adherent  to  the 
mass  unless  suppuration  occurs.  If  the  mass  is  pressed  against  the  chest 
by  the  surgeon's  fingers,  it  becomes  evident  that  no  real  tumor  exists. 

Treatment. — Remove  any  cause  of  irritation.  Support  the  breast  in  a 
sling.  Apply  ichthyol  ointment.  During  the  night  employ  a  hot-water  bag. 
If  pus  forms,  treat  as  before  directed. 

Chronic  lobular  mastitis  is  a  condition  in  which  numerous  lobules 
become  indurated.  The  real  cause  of  this  condition  is  unknown.  It  may 
occur  at  any  age  after  puberty,  and  often  attacks  both  breasts.  Such  a 
breast  is  apt  to  be  painful,  especially  at  the  menstrual  periods;  it  feels  un- 
natural, solid,  and  careful  examination  detects  numerous  indurated  areas, 
each  of  which  is  of  small  size.  At  the  menstrual  period  the  breast  enlarges 
and  new  nodules  may  be  detected.  In  some  of  these  cases  violent  neuralgic 
pains  are  present  in  the  gland  (mastodynia).  Chronic  lobular  mastitis  is  apt 
to  lead  to  cyst-formation.  When  cysts  form  fluid  may  occasionally  discharge 
from  the  nipple. 

Treatment. — Support  the  breast  and  apply  ichthyol  ointment  or  bella- 
donna ointment.  Examine  the  generative  organs  and  correct  any  existing 
abnormality.  Improve  the  general  health  by  good  food,  tonics,  and  open-air 
life.  In  cases  where  multiple  cysts  are  known  to  exist  the  question  of  treat- 
ment is  uncertain.  There  seems  to  be  little  doubt  that  such  cases  tend 
in  some  instances  to  eventuate  in  cancer.  I  believe  that  the  proper  treat- 
ment when  multiple  cysts  exist  is  extirpation  of  the  breast. 

Tuberculosis  of  the  Mammary  Qland.^(See  page  125.) 

Cysts  and  Tumors  of  the  Nipple.— Tumors  are  rare  in  the  nipple, 
but  do  sometimes  occur.  The  following  growths  are  occasionally  seen: 
fibroma,  angeioma,  papilloma,  myxoma,  myoma,  and  epithehoma.  Seba- 
ceous cysts  of  the  nipple  and  areola  are  not  very  unusual.  A  cancer  of  the 
nipple  may  be  a  primary  growth,  or  may  be  secondary  to  gland  cancer. 
Primary  epithelioma  of  the  nipple  presents  the  same  general  characters  as 
epithelioma  in  any  other  region.  It  begins  as  an  indurated  area  in  the  areola, 
or  an  excoriation  of  the  nipple.  Ulceration  soon  occurs.  The  ulcer  is  irregu- 
lar in  outline,  has  hard  edges,  and  furnishes  a  foul,  red,  sanious,  and  fetid 
discharge.  The  mammary  gland  becomes  infiltrated  at  an  early  period. 
The  subclavian  glands  enlarge,  and  later  the  axillary  glands.  Such  a 
growth  must  not  be  confounded  with  a  chancre  of  the  nipple. 

Treatment  of  Tumors  of  the  Nipple. — Innocent  tumors  are  to  be  excised 
and  the  breast  need  not  be  removed. 

Epithelioma  of  the  nipple  requires  the  complete  extirpation  of  the  breast, 
and  also  the  clearing  out  of  the  lymphatic  contents  of  the  axilla,  and  possibly 
of  the  subclavian  triangle. 


Tumors  and  Cysts  of  the  ^lammary  Gland  1049 

Paget's  Disease  of  the  Nipple  (Malignant  Dermatitis). — This  con- 
dition is  a  chronic  inllammaticMi  of  the  epithehal  layer  of  the  nipple  and 
areola  occurring  in  women  beyond  middle  life,  and  is  a  not  unusual  precursor 
of  epithelioma  of  the  nipple  and  of  duct  cancer.  Paget's  disease  is  not  a  simple 
eczema,  it  is  not  associated  with  the  usual  causes  and  attendants  of  eczema, 
either  local  or  constitutional,  and  is  not  cured  by  remedies  which  control 
the  ordinary  disease. 

The  diseased  area  is  raw  and  red,  and  from  it  exudes  copiously  a  thick, 
yellow  discharge.  In  some  cases  Paget's  disease  is  secondary  to  duct  cancer, 
auto-infection  of  the  nipple  having  been  effected  by  the  fluid  flowing  from 
the  ducts.  Investigations  have  shown  the  presence  of  psorosperms  in  areas 
of  Paget's  disease. 

Treatment  consists  in  removal  of  the  entire  Ijreast  and  clearing  out  (jf 
the  axilla  and  subcla\-ian  triangle. 

Tumors  and  Cysts  of  the  Wammary  Gland. — These  tumors  may 
be  innocent  or  malignant. 

Innocent  Tumors  of  the  Mammary  Gland. — The  innocent  tumors 
are:  Fibro-adowmala  or  cystic  adenomata,  myxomata,  villous  papillomata, 
and  angiomata.  It  is  maintained  by  most  authorities  that  any  innocent 
tumor  of  the  gland  may  and  often  does  become  malignant. 

Fibro-adenoma. — The  nomenclature  of  fibro-adenomata  is  in  a  state 
of  great  confusion.  The  name  fibro-adenoma  was  given  by  Cornil  and 
Ranvier  to  the  same  sort  of  growth  which  the  younger  Gross  called  a  fibroma, 
Billroth  an  adeno-fibroma,  and  Sir  Astley  Cooper  a  chronic  mammary  tumor. 
It  is  doubtful  if  a  pure  fibroma  ever  occurs  in  the  mammary  gland. 
A  fibro-adenoma  consists  of  acini  surrounded  by  fibrous  tissue.  Each  of 
these  structures  proliferates,  but  the  fibrous  tissue  does  so  much  more  rapidly 
than'  the  glandular.  A  growth  of  this  character  is  surrounded  by  a  capsule, 
and  is  movable.  It  is  firm,  elastic,  lobulated,  superficially  situated,  and  of 
slow  growth.  It  is  unassociated  with  retracted  nipple,  glandular  enlargement, 
adhesion  to  the  skin,  or  cachexia,  and  may  occur  at  any  age  up  to  fifty,  but 
is  most  common  between  twenty  and  thirty  (J.  Bland  Sutton).  Such  a 
tumor  is  rarely  very  painful,  but  it  may  be  tender  on  rough  handling  and 
may  be  painful  at  the  menstrual  period.  As  a  rule,  there  is  but  one  of  these 
tumors  in  a  mammary  gland,  but  one  may  exist  in  each  gland. 

Treatment. — Extirpation  of  the  tumor. 

Cystic  adenoma  (adenocele)  is  a  rare  form  of  slowly  growing  tumor, 
wliich  is  apt  to  attain  a  large  size,  which  is  nodular  in  outline,  hard  to 
the  touch,  and  firmly  attached  to  the  mammary  gland,  but  mobile  upon 
the  chest.  A  cystic  adenoma  has  a  distinct  capsule.  This  form  of  tumor  is 
painless,  and  is  most  apt  to  occur  in  women  between  thirty  and  forty  who 
have  borne  children.  The  growth  is  adherent  to  the  skin,  but  the  cuta- 
neous surface  is  not  discolored,  the  cutaneous  veins  are  not  distended,  the 
axillary  glands  are  not  enlarged,  and  the  nipple  is  not  retracted.  From 
the  walls  of  the  dilated  acini  papillomatous  growths  are  apt  to  arise  (in- 
tracystic  vegetations). 

Trcaimcut. — Removal  of  the  breast. 

Myxoma  is  a  rare  tumor,  and  only  occurs  in  a  person  of  middle  age. 
The  growth  is  solitarv,  is  soft,  mav  be  round  or  lobulated,  and  occasionally 


1050  Diseases  of  the  Breast 

f ungates.  The  nipple  is  not  retracted,  the  superficial  veins  are  not  distended, 
and  the  axillary  glands  are  not  enlarged. 

Treatment. — Removal  of  the  mammary  gland. 

Angioma. — This  form  of  tumor  is  very  rare.  It  may  arise  secondarily 
to  a  nevus  of  the  skin  (Sutton).  The  diagnosis  of  angioma  of  the  skin  is 
readily  made.  In  a  cavernous  angioma  of  the  breast  it  will  be  found  that 
the  tumor  can  be  lessened  in  size  by  pressure,  and  will  be  increased  in  size 
by  coughing,  laughing,  and  holding  the  breath.  Pulsation  may  be  detected 
and  a  bruit  may  be  audible. 

Treatment. — For  treatment  of  nevus  see  page  258.  If  a  cavernous  angioma 
exists  in  the  mammary  gland,  it  will  be  necessary  to  extirpate  the  gland. 

Cysts  of  the  Mammary  Gland. — Involution  cysts  (cystic  degenera- 
tion of  the  mamma)  occur  in  women  who  are  approaching  the  menopause. 
They  occur  earlier  in  those  who  are  sterile  than  in  those  who  have  borne 
children,  and  may  arise  after  chronic  mastitis.  The  parenchyma  of  the  gland 
undergoes  atrophic  change,  but  the  ducts  remain,  become  blocked  and  dilated. 
Numerous  small  cysts  form,  and  both  glands,  as  a  rule,  suffer.  Villous 
growths  may  arise  in  the  walls  of  the  ducts.  In  some  cases  there  is  much 
white  fibrous  tissue  between  the  cysts  (cystic  fibroma). 

The  subjects  of  this  disease  are  often  nervous,  hysterical,  and  despondent. 
One  or  more  ill-defined  indurations  are  detected.  Frequently  there  is  a  history 
of  discharge  from  the  nipple  and  of  attacks  of  lancinating  pain  in  the  breast. 
Cystic  breasts  are  dangerous,  because  the  intracystic  vegetations  are  liable  to 
eventuate  in  duct  cancer. 

Treatment. — In  such  cases,  after  confirming  the  diagnosis  by  an  exploratory 
incision,  remove  the  entire  breast  (Snow). 

Lacteal  cyst  (galactocele)  is  an  accumulation  of  milk  brought  about  by 
blocking  of  some  of  the  milk-ducts.  It  arises  soon  after  the  delivery  of  the 
child,  and  grows  rapidly.  A  large  quantity  of  milk  may  collect,  and  rupture 
of  the  cyst-walls  can  occur,  the  fluid  passing  into  the  glandular  connective 
tissue. 

A  galactocele  is  rounded,  fluctuates  distinctly,  and  increases  in  size  during 
nursing.  There  is  httle  or  no  pain.  In  some  cases  the  contents  of  the  cyst 
coagulate  and  a  solid  mass  is  formed. 

Treatment. — Incision  and  drainage. 

Hydatid  cysts  are  rare,  but  do  occasionally  occur.  There  are  2,3  positive 
cases  on  record  (Le  Conte,  in  "Amer.  Jour.  Med.  Sciences,"  Sept.,  1901). 
A  small,  hard,  movable,  and  painless  mass  appears  in  the  mammary  gland. 
Usually  it  gradually  increases  in  size,  but  it  may  grow  rapidly  for  a  time 
and  then  remain  apparently  almost  stationary  for  a  period.  If  rapid  growth 
takes  place  there  is  always  pain,  and  pain  is  usual  in  any  case  when  the  cyst 
attains  considerable  size.  Fluctuation  is  often  absent  and  crepitation  is  never 
obtained  (Le  Conte).     Suppuration  is  apt  to  occur  and  sinuses  may  form. 

Treatment. — A  small  and  recent  cyst  may  be  extirpated.  If  the  cyst  is 
not  recent,  but  is  fairly  large  and  adherent,  incise,  evacuate,  and  pack  with 
gauze.  If  the  c}%t  is  large  and  adherent,  but  is  surrounded  by  considera- 
ble breast-tissue,  partially  amputate  the  breast  (Le  Conte).  If  the  cyst  is 
large  and  the  breast  practically  destroyed,  or  if  the  nipple  adheres  to  the 
cyst,  remove  the  mammary  gland  (Le  Conte). 


Malignant  Tumors  of  the  Mammar>'  Gland  105  i 

Malignant  tumors  of  the  mammary  gland  are  ten  times  more 

common  than  innocent  tumors. 

Sarcoma. — Sarcoma  of  the  mammary  gland  is  a  ver_\-  rare  growth  (less 
than  10  per  cent,  of  breast  tumors).  It  may  occur  at  any  age  from  puberty 
to  old  age,  but  is  most  common  from  twenty  to  thirty-five.  The  growth 
may  be  composed  of  round  cells  or  spindle  cells;  both  varieties  may  be 
present,  and  myeloid  cells  may  be  found.  Circumscribed  sarcoma  arises 
usually  between  the  ages  of  twenty  and  thirty;  it  is  firm  to  the  touch,  as 
it  contains  much  fibrous  tissue,  is  painless,  does  not  grow  very  rapidly,  glands 
are  not  involved,  and  there  is  no  cachexia.  The  nipple  is  not  retracted. 
The  growth  may  adhere  to  the  skin.  It  is  composed  of  giant  cells  or  spindle 
cells,  and  rarely  returns  after  e.xtirpation  of  the  breast. 

Diffused  sarcoma  is  composed  of  small  round  cells,  arises  in  the  center 
of  the  breast,  and  grows  with  great  rapidity.  It  is  most  commonly  met 
with  about  the  age  of  thirty-five,  and  a  history  of  injury  can  often  be  ehcited. 
The  tumor  is  soft,  some  parts  being  softer  than  others  because  of  cyst-forma- 
tion. It  is  usually  mobile  upon  the  thorax,  though  it  soon  becomes  adherent 
to  the  skin.  The  tumor  reaches  a  very  great  size,  and  soon  fungates  through 
the  skin.  There  is  little  or  no  pain.  The  cutaneous  veins  over  the  tumor 
are  distended,  the  nipple  is  not  retracted,  and  the  axillary  glands  are  not 
often  enlarged.     Diffuse  sarcoma  is  apt  to  recur  after  removal. 

Treatment. — Remove  the  breast,  and  if  the  muscles  of  the  chest-wall  are 
infiltrated,  remove  them.  The  axillary  glands  are  removed  if  they  are  en- 
larged, but  not  otherwise.  Operation  will  not  cure  when  metastases  exist. 
If  the  case  is  inoperable,  we  can  try  the  use  of  Coley's  fluid.  If  the  toxins 
of  erysipelas  fail  to  arrest  the  progress  of  the  disease,  keep  the  patient  as 
comfortable  as  possible  by  the  administration  of  cocain  and  morphin. 

Carcinoma  or  Cancer  of  the  Mammary  Gland. — The  great  majority 
of  mammary  tumors  belong  to  the  genus  carcinoma.  Cancer  is  due  to  pro- 
liferation of  the  epithelium  of  the  acini  (acinous  cancer)  or  of  the  ducts  (duct 
cancer). 

Acinous  cancer  is  vastly  more  common  than  duct  cancer.  Usually  there 
is  much  connective  tissue  and  but  httle  parenchyma  in  the  growth  (scirrhus 
cancer).  In  some  cases  there  is  little  connective  tissue  and  much  paren- 
chyma (encephaloid  or  medullary  cancer).  If  colloid  degeneration  of  the 
parenchyma  or  stroma  occurs,  the  growth  is  spoken  of  as  colloid  cancer. 

Scirrhus,  the  common  form  of  acinous  cancer,  is  almost  as  hard  as  stone. 
On  section  it  is  concave,  and  Sutton  says  '"resembles  an  unripe  pear.''  The 
tumor  is  w-ithout  a  capsule,  and  the  epithelial  cells  are  surrounded  by  masses 
of  fibrous  tissue.  Portions  of  tissue,  even  some  distance  away  from  the 
tumor,  contain  foci  of  proliferating  embryonic  epithelial  cells.  In  atrophic 
or  withering  scirrhus  the  fibrous  stroma  contracts  and  epithelial  cells  undergo 
fatty  degeneration  (Senn). 

Causes  a7id  Symptoms. — Scirrhus  is  more  common  among  women  who 
have  borne  children  than  among  those  who  have  not.  Heredity  is  manifest 
in  only  about  10  per  cent,  of  cases  (Bryant).  The  young-er  Gross  found  it 
in  I  case  out  of  g.  Trauma  has  no  apparent  influence  in  producing  cancer. 
The  disease  is  rare  before  the  age  of  thirty-five,  and  is  most  common  between 
forty-five  and  fifty.     The  author  operated  for  scirrhus  of  the  breast  on   a 


1052  Diseases  of  the  Breast 

woman  only  twenty-seven  years  of  age.  Henry  saw  a  woman  of  twenty-one 
with  cancer.  It  is  frequently  met  with  in  the  aged.  These  tumors  are 
rare  in  the  negro  race.  A  hard  nodule  is  found  in  the  breast,  usually  under 
the  nipple,  but  possibly  far  away  from  it.  The  growth  is  nodular,  and  is 
immobile  from  the  beginning.  In  a  large,  fat  breast  there  is  often  a  deceptive 
sense  of  mobihty,  because  some  of  the  breast-tissue  moves  with  the  tumor. 
The  cancer  may  have  been  present  for  a  considerable  time  before  being 
discovered.  In  obscure  lesions  of  bones  and  viscera  examine  the  mammary 
glands,  because  the  trouble  might  be  due  to  metastasis  from  an  undiscovered 
carcinoma  of  the  breast.  Retraction  of  the  nipple  is  present  in  over  one- 
half  of  the  cases  (S.  W.  Gross).  It  occurs  when  the  growth  is  near  the  nipple, 
and  is  due  to  the  contracting  fibrous  tissues  of  the  tumor  pulhng  on  the  milk- 
ducts.  If  the  growth  is  far  away  from  the  nipple,  a  dimple  is  apt  to  form 
on  the  skin  of  the  breast  because  of  the  puUing  upon  the  suspensory  fibers. 

Glandular  enlargement  in  the  axilla  soon  follows  the  appearance  of  a 
scirrhus;  the  glands  become  very  hard  and  adherent.  In  over  60  per  cent, 
of  persons  the  glands  of  the  axilla  are  felt  to  be  enlarged  when  the  patient 
first  comes  for  treatment.  Because  the  surgeon  cannot  feel  enlarged  glands 
is  no. proof  that  there  are  none.  As  a  matter  of  fact,  the  glands  are  usually 
involved  within  two  months  of  the  beginning  of  the  disease,  but  the  involve- 
ment can  rarely  be  detected  externally  until  months  later.  Enlargement  of 
the  axillary  glands  is  followed  by  enlargement  of  the  glands  in  the  posterior 
cervical  triangle  and  in  the  mediastinum.  Herbert  Snow  has  shown  that 
the  blocking  of  the  axillary  glands  often  leads  to  regurgitation  of  lymph 
containing  cancer-cells,  the  cells  being  thus  deposited  in  the  head  of  the 
humerus  and  the  thymus  gland.  Cells  in  the  thymus,  after  a  time,  cause 
a  projection  of  the  sternum  (the  sternal  symptom).  When  the  axillary 
lymphatics  are  extensively  involved  the  arm  swells  from  obstruction  to  the 
lymph-flow  (lymphedema)  or  pressure  upon  the  vein.  The  tumor  usually 
grows  rather  slowly  unless  lactation  is  established,  then  it  grows  rapidly. 
As  it  grows  it  infiltrates  adjacent  structures  (the  pectoral  fascia,  pectoral 
muscles,  subcutaneous  cellular  tissue,  and  skin).  When  the  skin  is  destroyed 
an  ulcer  forms,  and  around  this  ulcer  the  skin  becomes  red  and  filled  with 
cancerous  nodules,  which  feel  like  shot  in  the  skin.  Metastases  are  apt  to 
occur  into  the  bones,  liver,  brain,  pleura,  spine,  thymus  gland,  and  rarely 
the  eye. 

Pain  is  usually  present  in  scirrhus  carcinoma.  It  is  lancinating  and 
neuralgic  in  character,  and  not  brought  on  or  increased  by  handhng.  It 
ceases  if  colloid  degeneration  begins.  The  general  heaUh  is  usually  unim- 
paired until  ulceration  takes  place,  when  cachexia  arises.  The  cancer  en 
cuirasse  of  Velpeau  is  a  condition  in  which  the  lymphatic  vessels  of  the  skin 
are  extensively  invaded,  the  growth  itself  being  adherent  to  the  wall  of  the 
thorax.  In  this  condition  the  chest-wall  is  fixed,  respiration  is  difficult,  and 
the  temperature  is  commonly  somewhat  elevated. 

In  atrophic  or  withering  scirrhus  the  contraction  is  so  great  that  it  seems 
as  though  the  mammary  gland  had  been  removed.  The  duration  of  scirrhus, 
when  left  to  run  its  course,  varies,  but  the  disease  generally  produces  death 
within  two  and  a  half  years.  Occasionally  it  causes  death  within  a  year. 
In  atrophic  scirrhus  the  patient  may  live  for  many  years. 


Halsted's  Operation  1053 

Duct  cancer  is  not  a  common  growth.  It  arises  from  the  duct-walls  in 
conditions  of  cystic  degeneration  of  the  mammary  gland.  The  tumor  is 
softer  than  the  acinous  growth,  and  is  not  nodular.  There  is  no  pain,  no 
retraction  of  the  nipple,  no  skin  dimple.  Serous  or  bloody  fluid  may  often 
be  squeezed  from  the  nipple.  A  duct  cancer  grows,  infiltrates  slowly,  and 
involves  adjacent  glands  later  than  does  scirrhus. 

Cancer  of  the  Male  Breast. — This  condition  is  seldom  met  with,  though 
I  believe  it  to  be  more  common  than  is  generally  supposed.  I  have  seen  2 
cases  within  the  last  ten  years.  Each  patient  was  in  the  early  forties;  neither 
complained  of  pain.  I11  one,  the  breast  had  been  extremel}'  large  from  early 
years.  In  each  case  the  growth  was  indurated,  but  in  neither  was  there  any 
retraction  of  the  nipple.  The  condition  in  each  patient  was  scirrhus  carci- 
noma. Warfield  has  collected  32  cases  from  literature  and  has  added  5 
others  ("Bull,  of  Johns  Hopkins  Hosp.,"  Oct.,  1901).  The  patients  v.ere 
between  forty  and  seventy  years  of  age.  Eight  gave  a  history  of  injury;  in  9 
cases  there  was  pain,  and  in  12  the  nipple  was  retracted. 

Treatment  of  Carcinoma  of  the  Mammary  Gland. — The  treatment  is 
earl}-  and  thorough  operation;  the  earlier  and  the  more  thorough,  the  better. 
The  older  surgeons  operated  simply  to  prolong  life  a  few  months;  the  modem 
surgeon  operates  with  the  hope  of  curing  the  patient.  In  1878  Billroth's 
statistics  showed  only  S  cures  in  143  cases.  In  1896  ^^'.  Watson  Cheyne  re- 
ported 12  cures  out  of  21  cases  (57  per  cent.).  The  operation  should  remove 
the  breast  and  much  of  the  skin  above  it,  the  pectoral  fascia,  and  often  the 
pectoral  muscles;  the  fat  and  glands  of  the  axilla,  and  sometimes  the  fat  and 
glands  of  the  subclavian  triangle.  If  three  years  after  an  operation  there  has 
been  no  return,  we  regard  the  case  as  cured  (\'olkmann's  hmit).  As  a  matter 
of  fact,  recurrences  are  noted  after  five  years,  and  this  limit  should  be  used 
instead  of  three  years.  Certain  cases  are  unsuited  for  a  radical  operation : 
cases  in  which  metastases  exist;  cases  of  cancer  en  cuirasse;  cases  where 
axillary  involvement  is  very  great.  Cheyne  would  also  rule  out  cases  where 
large  glands  may  be  felt  above  the  clavicle,  believing  that  in  such  cases  the 
mediastinal  glands  must  be  cancerous.* 

HalstecVs  Operation. — Halsted  performs  a  very  radical  operation.  He 
removes  suspected  tissue  in  one  piece,  and  thus  prevents  carcinoma  cells 
falling  in  the  wound,  for  it  is  well  known  that  if  such  cells  should  fall  into  the 
wound  they  may  grow  just  as  may  a  graft  of  healthy  epithelium.  The  neck, 
slioulder,  the  arm  to  the  elbow,  the  entire  surface  of  the  chest  down  to  the 
waist,  both  breasts,  the  axilla,  the  side  and  the  back  of  the  diseased  side  must 
be  sterilized.  It  is  necessary  to  have,  besides  scali^els  and  the  ordinary  instru- 
ments for  an  operation,  a  great  number  of  hemostatic  forceps  (80  tc  loc). 
Place  the  patient  recumbent,  with  a  sand-pillow  under  the  shoulder  of  the  af- 
fected side.  The  shoulder  is  right  at  the  edge  of  the  bed.  and  a  nurse  holds  the 
arm  from  the  side.  Halsted  describes  his  operation  as  follows:!  The  skin-in- 
cision is  made  as  shcnvn  in  Fig.  647,  and  is  carried  at  once  through  the  fat. 
The  triangular  skin-fiap  {a,  b,  c,)  is  turned  down.  The  costal  insertions  of 
the  great  pectoral  muscle  and  the  muscle  are  split  between  the  clavicle  and 
costal  ])ortions  and  up  to  a  point  opposite  to  the  scalene  tubercle,  and  at  this 

*See  "Objects  and  Limits  of  Operation  for  Cancer,''  by  ^V.  Watson  Cheyne. 
f  Johns  Hopkins  Hosp.  Reports,  vol.  iv  ;  Annals  of  Surgery,  Nov.,  1S94. 


1054 


Diseases  of  the  Breast 


point  the  clavicular  portion  of  the  muscle  and  the  tissue  overlying  it  are 
cut  through  close  to  the  clavicle,  and  the  apex  of  the  axilla  is  at  once  ex- 
posed. The  cellular  tissue  under  the  clavicular  portion  of  the  muscle  is  dis- 
sected from  the  muscle,  and  the  sphtting  of  the  muscle  is  continued  on  to 
the  humerus.     The  part  of  the  muscle  to  be  removed  is  cut  through  close 


Fig.  647. — Halsted's  operation  for  carcinoma  of  the  breast ;  the  first  incision. 

to  its  humeral  insertion.  The  whole  mass  circumscribed  by  the  first  in- 
cision (skin,  breast,  areolar  tissue,  and  fat)  is  raised  with  considerable  force 
in  order  to  put  the  submuscular  fascia  on  the  stretch  as  it  is  stripped  from  the 
thorax  close  to  the  ribs.     It  is  well  to  include  the  dehcate  sheath  of  the  pector- 


[ 

■    op 

j" 

:.   ^<;' 

^,..  .._. 

Fig.  648.— Halsted's  operation  for  carcinoma  of  the  breast ;  the  mass  turned  down. 

alis  minor  muscle.  The  lower  and  outer  boundary  of  the  lesser  pectoral  having 
b^en  passed  and  exposed,  the  muscle  is  cut  at  a  right,  angle  to  its  fibers  and 
a  little  below  the  middle.  The  tissue  over  the  pectoralis  minor  muscle  near 
its  coracoid  insertion  is  divided  as  far  out  as  possible,  and  is  then  reflected 
inward  to  prepare  for  the  reflection  upward  of  this  part  (jf  the  minor  muscle. 


Operation   for  Mammary  Carcinoma 


1055 


The  upper  portion  of  the  minor  muscle  is  retracted  upward  (Fig.  648).     Some 

surgeons  do  not  remove  the  lesser  pectoral  muscle.     I  believe  it  should  be 

removed,  because  the  axilla  can  then  be  more  easily  and  rapidly  cleared. 

The  removal  of  the  muscle  does  not  impair  arm  movements,  and  its  retention 

leads  to  the  formation,  when  healing  is  complete,  of  a  cord-like  band  in  front 

of  the  axilla.     (See  Douglas  Drew,  in  "Brit.  Med.  Jour.,"  May  17,  1902.) 

The  small  blood-vessels  under  the  minor  muscle  are  carefully  separated  from 

it,  are  dissected  out  very  clear,  and  are  ligated  close  to  the  axillar}'  vessels. 

Having  exposed  the  subclavian  vein  at  the  highest  possible  point  below  the 

clavicle,  the  contents  of  the  axilla  are  dissected  away  with  a  sharp  knife  and 

the  vein  and  its  branches  are  stripped  absolutely  clean.     The  loose  tissue  about 

the  artery  and  the  nerves  should  also  be  removed.     When  the  vessels  are 

cleared  the  axillary  contents  are  rapidly  stripped 

from  the  inner  walls  of  the  axilla  and  the  lateral 

wall  of  the  thorax.     The  fascia  which  binds  the 

mass  to  the  chest  is  cut  close  to  the  ribs  and  the 

serratus  magnus  muscle.     Just  before  reaching 

the  junction  of  the  posterior  and  lateral  walls  of 

the  axilla,  an  assistant  draws  the  triangular  flap 

of  skin  outward  in  order  to  spread  out  the  tissue 

which  hes  upon  the  subscapularis,  teres  major, 

and   latissimus  dorsi   muscles.      The  operator 

cleans  the    posterior  wall   of   the    axilla   from 

within   outward.     The  subscapular  vessels  are 

clearly  exposed,  and  are  caught  before  they  are 

cut.     In  some  cases  the  subscapular  nerves  are 

removed,  in  others  they  are  permitted  to  remain. 

Having  passed  these  nerves  the  mass  is  turned 

back  into  its  normal  position  and  severed  from 

the  body  of  the  patient  by  a  stroke  of  the  knife 

from  b  to  c,  repeating  the  first  cut  through  the 

skin.     Every  bleeding  point,  however  small,  is 

tied  with  fine  silk.     From  60  to  100  ligatures,  or  even  more,  may  l:)e  required. 

After  the  completion  of  the  operation  the  wound  into  the  axilla  is  closed 
with  a  subcuticular  stitch  of  silver  wire;  if  a  cut  has  been  carried  above  the 
clavicle,  it  is  closed  in  the  same  manner,  and  the  edges  of  the  elliptical  opening 
are  brought  nearer  together  by  a  purse-string  subcuticular  stitch.  Thiersch 
grafts  cut  from  the  patient's  thigh  are  used  to  cover  the  gap.  Silver  foil  is 
placed  over  the  wound,  this  is  covered  with  gauze,  bandages  are  appHed,  and 
the  dressing  is  overlaid  by  a  plaster-of-Paris  bandage,  which  includes  the 
head,  neck,  chest,  and  arm.  The  area  from  which  grafts  were  taken  is 
dressed  with  sterile  gauze  or  an  ointment  containing  boric  acid. 

The  Younger  Sennas  Incision. — A  very  useful  incision  is  that  described 
bv  the  younger  Senn,  and  shown  in  Fig.  649.  The  l^reast  is  circum- 
scribed by  two  curvilinear  incisions  whicli  meet  above,  at  tlie  border  of 
the  great  pectoral  muscle.  The  incision  is  continued  a  little  internal 
to  the  outer  border  of  the  muscle  to  about  one  inch  above  the  apex 
of  the  axilla,  when  it  is  curved  outward  in  the  deltoid  region,  and  termi- 
nates at  the  level  of  the  apex  of  the  axilla.      The  breast  is  removed   fmm 


Fig.  649. — The  younger  Semi's 
incision  for  ampulation  of  the 
breast. 


1056  Diseases  of  the  Breast 

the  waU  of  the  chest,  and  is  then  suspended  by  axihary  glands  and  fat, 
which  are  removed  en  masse.*^  This  incision  gives  a  free  exposure,  opens 
the  axilla  from  in  front,  enables  the  surgeon  to  quickly  locate  and  freely  ex- 
pose the  axillary  vein,  and  the  resulting  scar  does  not  limit  materially  the 
motions  of  the  arm. 

Inoperable  Malignant  Diseases  of  the  Breast.— This  term  implies 
that  a  radical  operation  looking  to  cure  is  impossible.  The  conditions  in 
which  it  is  impossible  have  already  been  specified  (page  1053).  Even  if  the 
case  is  judged  inoperable  from  the  radical  standpoint,  it  may  be  wise  to  re- 
move the  mammary  gland,  in  order  to  free  the  patient  from  a  hideous,  ulcer- 
ating area,  violent  pain,  and  harassing  hemorrhage. 

It  has  been  suggested  that  some  cases  inoperable  by  ordinary  methods  may 
be  subjected  to  removal  of  the  entire  upper  extremity  or  to  disarticulation  at 
the  shoulder-joint  with  some  prospect  of  cure.  My  own  view,  however,  is  that 
when  a  case  has  advanced  so  far  that  it  is  not  amenable  to  ordinary  operative 
treatment,  neither  of  the  above-mentioned  procedures  offers  any  reasonable 
chance  of  success.  If  the  pain  is  excessively  violent  in  an  inoperable  case, 
the  surgeon  may  relieve  it  by  dividing  the  brachial  plexus,  or  perhaps  by 
disarticulating  at  the  shoulder-joint. 

An  inoperable  case  may  be  greatly  improved — for  a  time,  at  least — by 
the  use  of  the  ,x-rays;  and  even  when  the  condition  is  not  benefited  in  other 
wavs,  this  new  force  usually  mitigates  or  greatly  relieves  the  pain. 

Beatson's  Operation,  or  Double  Oophorectomy. — It  has  been  pointed 
out  by  this  surgeon  that  there  is  a  certain  similarity  between  the  formation  of 
cancer  in  the  mammary  gland  and  the  process  of  lactation.  In  each  there  is 
an  enormous  production  of  embryonal  epithelial  cells;  but  in  lactation  the 
epithelial  cells  undergo  fatty  degeneration,  and  in  cancer-formation  they  do 
not  do  so,  but  penetrate  into  the  tubules  and  the  acini  and  infiltrate  the 
gland-structure.  Beatson  further  points  out  that  when  a  lactating  cow  is 
spaved,  it  continues  to  give  milk  indefinitely.  This  seems  to  indicate  that 
removing  the  ovaries  favors  the  fatty  degeneration  of  the  epithelial  cells. 
This  operation  has  been  performed  in  cases  of  inoperable  carcinoma  of  the 
breast,  in  the  hope  of  bringing  about  degeneration  in  the  tumor-mass.  In 
the  great  majority  of  cases  it  fails  utterly;  but  now  and  then  it  secures  a 
notable  improvement,  and  in  a  very  few  cases  cure  seems  to  have  been  obtained. 
Abbe  obtained  an  apparent  cure  in  two  patients.  It  was  at  first  thought 
that  the  operation  would  be  appHcable  only  to  persons  that  have  not  passed 
the  menopause,  but  one  of  Abbe's  patients  was  over  seventy  years  of  age. 
Butlin,  however,  says  that  there  is  no  genuine  cure  secured  by  this  operation 
on  record.  My  own  view  is  that  the  procedure  offers  but  little  prospect  of 
success,  but  that,  as  it  does  offer  some,  the  exact  facts  should  be  placed  before 
the  patient,  and  she  should  be  permitted  to  choose  whether  or  not  she  wishes 
the  operation  performed.  The  operation  is  not  to  be  considered,  however, 
if  visceral  deposits  exist. 

*  See  the  younger  Serin  in  Jour.  Amer.  Med.  Assoc,  May  27,  1899. 


Skiagraphy  1057 


XXXIX.  SKIAGRAPHY,  OR  THE  EMPLOYMENT  OF  THE 
RONTQEN   RAYS. 

The  cathode  rays  were  discovered  by  Hittorf,  in  1869,  while  passing  an 
induction  current  through  a  vacuum  tube.  Crookes,  of  London,  greatly 
improved  the  vacuum  tube,  and  obtained  a  rarefaction  which  left  in 
the  tube  but  the  one-millionth  of  an  atmosphere.  This  last-named  ob- 
server found  that  when  an  interrupted  current  of  high  potential  is  passed 
through  a  vacuum  which  is  nearly  perfect,  fluorescence  takes  place.  Li  a 
Crookes  tube  the  positive  electrode  is  placed  at  some  inditterent  point,  and  the 
current  from  the  negative  electrode  flows  not  to  the  positive,  but  directly  to 
the  wall  of  the  tube  opposite  the  cathode,  and  at  this  point  the  phosphorescent 
glow  is  detected. 

In  1895,  Rontgen,  of  ^^'urzburg,  while  making  a  study  of  cathode  rays 
as  de\eloped  in  Crookes's  tubes,  discovered  the  energy  which  he  named  the 
.v-rays.  Rontgen  showed  that  at  the  wall  of  the  Crookes  tube  opposite  the 
negative  electrode  a  new  and  hitherto  unknown  energy  is  generated.  Be- 
cause of  the  uncertain  character  of  this  energy  he  gave  to  its  manifestation  the 
name  of  the  x  or  unknown  rays. 

The  -T-rays  are  invisible;  cannot  be  deflected,  reflected,  refracted,  or 
concentrated;  are  not  influenced  by  the  magnet;  and  produce  none  of  the 
ordinarily  recognized  efi'ects  of  heat.  They  cause  fluorescence  in  certain 
substances,  notably  in  tungstate  of  calcium  (Edison),  platinocyanid  of  barium 
(Rontgen),  and  platinocyanid  of  potassium.  They  have  a  marvellous  power 
of  penetration,  and  pass  through  many  substances  which  are  opacjue  to  sun- 
light, ultraviolet  light,  and  ordinary  electric  light.  They  are  readily  trans- 
mitted by  water,  organic  substances,  leather,  cloth,  paper,  and  flesh.  Bone 
transmits  them  less  easily,  and  metal  still  less  easily,  but  no  substance 
absolutely  prevents  their  transmission.  An  ordinary  dry  photographic  plate 
is  sensitive  to  the  rays.  If  the  rays  are  intercepted  by  a  body  not  readily 
permeable  which  is  placed  between  the  Crookes  tube  and  the  photographic 
plate,  a  shadow  will  be  cast,  and  a  picture  of  this  shadow  will  be  formed 
upon  the  plate.  Such  a  picture  is  known  as  a  skiagraph  or  radiograph.  If 
a  body  more  or  less  resistant  to  the  rays  is  placed  between  the  tube  and  a 
fluorescent  screen,  the  body  casts  a  shadow  on  the  screen,  and  the  portion 
of  the  screen  free  from  shadow  glows  with  fluorescence.  Such  a  screen  is 
known  as  a  fluoroscope.  It  will  thus  be  seen  that  the  .v-rays  enable  the  sur- 
geon to  look  beneath  the  skin  and  to  see  those  things  which  before  the  dis- 
covery of  Rontgen  were  unseeable  during  life.* 

The  real  nature  of  the  .Y-rays  is  unknown.  They  are  not  heat-rays;  they 
are  not  ultraviolet  rays.     Rontgen  thinks  they  are  longitudinal  ether-waves. 

*  See  particularly  Rontgen's  report  to  the  Physico-Medical  Society  of  Wiirzburg,  Dec, 
1S95  ;  also  the  article  upon  the  .»-rays  by  S.  H.  Monell,  in  the  Brooklyn  Med.  Jour.,  May, 
1896.  "The  Rontgen  Rays  in  Therapeutics  and  Diagnosis,"  by  \V.  A.  Pusey  and  E.  W. 
Caldwell;  "Fractures,"  by  Carl  Beck  ;  "The  Rontgen  Rays  in  Medicine  and  Surgery," 
by  F.  H.  Williams.  I-.  Herschel  Harris,  in  Australasian  Med.  Gaz.,  Jan.  25  and  Feb.  20, 
1902.  J.  Rudis-Jicinsky,  in  N.  V.  Med.  Jour.,  March  23,  1902.  Carl  Beck,  in  Jour.  Am. 
Med.  Assoc,  Jan.  5,  1901.  C.  L.  Leonard,  in  Annals  of  Surgery,  April.  1901,  and  in 
Jour.  Am.  Med.  Assoc,  Julv  21,  1901. 
67 


1058  Skiagraphy 

L.  Herschel  Harris  (''Australasian  Med.  Gaz.,"  Jan.  25  and  Feb.  20, 
1902)  says  it  is  generally  believed  that  they  are  transverse  ether  vibrations 
of  short  period,  wave-like  in  character  and  produced  by  a  bombardment 
of  the  anti-cathode  with  highly  charged  molecules  from  the  cathode. 
Monell  says:  "They  appear  to  be  originated  at  the  site  of  the  greatest  elec- 
trical activity  within  the  tube,  and  their  real  nature  is  as  unknown  as  the 
nature  of  heat,  gravity,  electricity,  mind,  and  of  hfe  itself." 

To  obtain  .the  rays  a  good  apparatus  is  essential.  i\n  ordinary  medical 
batterv  is  incapable  of  producing  them,  as  it  is  absolutely  necessary  to  have 
a  current  of  high  tension.  The  discoverer  used  a  Ruhmkorff  coil,  but  this  is 
by  no  means  the  most  satisfactory  apparatus  to  employ.  Some  experimenters 
have  made  use  of  a  "powerful  static  machine  and  transformer  coils"  (Monell). 
Swinton  uses  twelve  half-gallon  Leyden  jars  and  discharges  them  through  the 
primary  coil,  the  secondary  circuit  being  a  Tesla  oil  coil. 

The  current  is  best  taken  from  the  street-light  circuit.  Monell  says  that 
this  current  should  be  controlled  by  an  interrupter,  the  interruptions  of  which 
are  100  per  second.  The  interrupted  current  is  to  be  passed  into  an  induction 
coil,  and  the  secondary  current  is  to  be  conveyed  into  the  Crookes  tube  by  two 
wires.  The  secondary  current  thus  produced  will  furnish  a  spark  five  or 
six  inches  long.  In  order  to  take  a  skiagraph  of  deep  structures  a  high 
vacuum  should  be  used.  For  x-ray  therapy  the  ordinary  tube  should  not  be 
used  because  the  intensity  of  the  vacuum  is  too  changeable.  A  tube  with  a 
definite  or  controllable  vacuum  is  required  for  such  work. 

When  the  surgeon  is  about  to  use  the  a--rays,  he  must  remove  from  the 
person  of  the  individual  anything  that  might  cause  confusion  or  lead  to  error. 
If  the  foot  is  to  be  examined,  remove  the  shoes,  because  shoes  contain  nails; 
if  the  hand  is  to  be  examined,  remove  the  gloves  if  they  are  fastened  with 
buttons  of  bone  or  metal;  if  the  thigh  is  to  be  examined,  remove  coins,  keys, 
knives,  etc.,  from  the  pocket;  a  garter,  if  it  has  a  metal  clasp,  should  be 
taken  off. 

In  order  to  get  the  best  results  from  the  Rontgen  rays,  not  only  must  the 
apparatus  be  good,  but  the  man  who  uses  it  must  be  expert.  Pictures  taken 
by  an  unskilled  man  lack  clearness  of  outline,  and  may  even  lead  to  posi- 
tively erroneous  conclusions.  Nevertheless,  a  person  used  to  the  employ- 
ment of  scientific  apparatus  can  very  soon  become  sufliciently  expert  to 
take  fairly  clear  pictures  which  should  not  lead  to  error.  Maurice  H.  Rich- 
ardson *  maintains  that  the  Rontgen  rays  can  be  employed  successfully  in 
the  routine  office  practice  of  a  general  practitioner. 

The  surgeon  may  utilize  the  x-rays  by  means  of  a  fluoroscope.  Edison's 
fluoroscope  consists  of  four  sides  of  a  box,  one  end  being  open  and  made  to 
fit  tightly  over  the  observer's  eyes,  the  other  end  being  closed  with  cardboard 
made  fluorescent  by  smearing  it  with  mucilage,  and,  before  the  mucilage  is 
quite  dry,  sprinkling  it  with  crystals  of  tungstate  of  calcium.  If  it  is  desired 
to  examine  the  hand  with  a  fluoroscope,  the  extremity  is  held  opposite  an 
excited  Crookes  tube  and  from  six  to  ten  inches  away  from  it,  the  end  of  the 
fluoroscope  which  is  covered  with  fluorescent  paper  is  placed  near  the  surface 
of  the  hand  which  is  away  from  the  tube,  and  the  observer  looks  through  the 
other  end  of  the  instrument.     The  flesh  seems  but  a  dim  haze  and  the  shadows 

*Mec].  News,  Dec,  1896. 


X-ray  Burns  I059 

of  the  bones  are  distinctly  t)utline(l.  The  tluoroscope  can  be  easily  used,  and 
gives  reliable  results  in  studies  upon  the  hands  and  feet,  but  when  deeper 
structures  are  to  be  investigated,  or  when  absolute  accuracy  is  essential,  it  is 
better  to  take  a  skiagraph.  The  value  of  flouroscopy  is  constantly  increasing 
as  better  electrical  appliances  and  Crookes's  tubes  are  being  made. 

If  thick  tissues  require  to  be  penetrated  by  the  rays,  if  great  accuracy  is 
necessary,  or  if  a  permanent  record  is  to  be  retained,  a  skiagraph  must  be 
taken.  In  taking  these  pictures  dry  plates  can  be  used;  the-  plate  need  not 
be  removed  from  its  wooden  case  during  the  process,  and  it  is  not  necessary 
to  conduct  the  proceeding  in  a  dark  room.  The  tube  should  be  from  twelve 
to  fifteen  inches  away  from  the  surface  of  the  body.  The  plate  must  be  fas- 
tened to  the  surface  exactly  opposite  the  tube.  It  is  necessar}'  to  obser\e  care 
in  the  adjustment  of  the  plate,  because  the  .v-rays  travel  only  in  straight  hnes, 
and  any  carelessness  of  adjustment  will  lead  to  curious  and  misleading  aber- 
ration in  the  picture.  The  length  of  exposure  necessary  varies  with  the  thick- 
ness of  the  tissues,  the  structure  of  the  part,  the  nature  of  the  body  we  wish  a 
picture  of,  and  the  perfection  of  the  apparatus.  The  time  may  be  from  three 
minutes  to  thirty  minutes  or  more.  Prolonged  exposure  is  undesirable  if  it 
can  be  avoided,  as  it  may  produce  an  .v-ray  "burn."  The  use  of  an  im- 
proper apparatus  or  placing  the  tube  too  close  to  the  body  may  be  followed 
by  a  bum.  Occasionally,  in  spite  of  the  utmost  care,  injury  will  be  done  by 
the  .v-rays.  In  treating  a  malignant  growth  by  the  .r-rays  the  adjacent 
healthy  tissue  is  protected  from  burning  by  a  covering  of  lead  foil. 

The  so-called  :x:-ray  "bum"  is  not  a  burn  at  all.  A  burn  is  due  to  the 
contact  of  heat,  begins  upon  the  surface,  is  accompanied  with  pain  from  the 
moment  of  application,  and  is  followed  by  inflammatory  changes,  beginning 
on  the  surface.  An  .r-ray  "  burn  "  is  not  manifest  for  several  days  or  even  sev- 
eral weeks  after  the  application  of  the  rays,  at  which  period  an  intiammatory 
or  a  gangrenous  process  arises,  which  begins  within  the  tissues  and  subse- 
quently involves  the  surface.*  Inflammation  may  pass  away  or  ma}'  even- 
tuate in  gangrene,  and  a  gangrenous  area  is  w^hite  in  color,  "  leathery,  stringy, 
tough"  (Hopkins).  Hopkins  calls  the  process  "white  gangrene."!  These 
burns  are  often  accompanied  by  loss  of  hair  or  nails  in  the  damaged  area, 
.they  require  months  to  heal,  if  they  heal  at  all,  are  very  painful,  and  are  not 
improved  by  the  treatment  which  relieves  ordinary  bums.  In  some  cases 
the  consequences  are  very  serious.  In  a  case  reported  b\-  J.  P.  Tuttlc.  it 
became  necessary  to  amputate  the  thigh.  J  The  lesions  occasionally  produced 
b}-  the  .v-rays  are  probably  trophic  changes.  Sections  made  bv  \'issman  from 
Tuttle's  case  indicated  that  the  lesion  was  a  gangrenous  process  due  to  arter- 
itis of  the  smaller  vessels.  Various  theories  have  been  advanced  to  account 
for  the  occurrence  of  .r-ray  gangrene,  viz.:  liberation  of  ozone  in  the  tissues 
(Tcsla)»:  interference  with  cellular  nutrition  caused  by  static  electric  currents 
"induced  by  the  introduction  of  the  patient's  tissues  into  the  high  potential 
induction-field  surrounding  the  tube"  (Leonard);  the  destruction  of  the 
nerve-supply  of  the  tissue  (Hopkins) ;  irritation  of  the  peripheral  extremities 
of  the  sensory  nerves,  causing  paralysis  of  the  vaso-motors  (Rudis-Jicinsky); 

*  E.  B.  Bronson,  in  tlie  debate  on  J-  B.  Tuttle's  case,  Med.  Record,  March  5,  1898. 
f  G.  G.  Hopkins,  Phila.  Med.  ^om.,  Jan.  6,  1900. 
JMed.  Record,  May  5,  1898. 


lo6o  Skiagraphy 

an  electrolytic  action  of  a  current  generated  in  the  tissues  by  induction  from 
the  tube  (Judd).  These  .r-ray  injuries  are  most  liable  to  occur  when  a  Ruhm- 
korff  coil  is  used,  and  such  a  condition  is  very  rarely  caused  by  a  static 
machine.  Hopkins  says  the  lesions  "  are  produced  more  frequently  by  tubes 
that  are  energized  by  alternating  currents  than  by  those  energized  in  any 
other  way."  He  has  only  found  record  of  four  cases  produced  when  a  static 
machine  was  used.  It  has  been  suggested  that  a  thin  piece  of  aluminum,  a 
plate  of  platinum,  or  a  sheet  of  gold-leaf,  placed  upon  the  part  while  it  is 
exposed  to  the  .T-rays,  will  prevent  the  occurrence  of  these  injuries. 

A  recent  a-ray  burn  may  be  treated  for  a  time  with  vaselin.  No  irritant 
appHcation  should  be  employed.  In  a  non-ulcerated  area  the  itching  will  be 
allayed  and  repair  favored  by  a  preparation  used  by  Dr.  Martin  F.  Engman 
(''Interstate  Med.  Jour.,"  July,  1903).  It  consists  of  12  drams  of  boric 
acid,  I  ounce  of  zinc  oxid,  i  ounce  of  starch,  i  ounce  of  subnitrate  of  bismuth, 
I  ounce  of  olive  oil,  3  ounces  of  lime-water,  3  ounces  of  lanohn,  and  12  drams 
of  rose-water.  The  powder  is  rubbed  in  a  mortar,  the  lanolin  is"  added. 
The  olive  oil  and  lime-water  mixed  are  slowly  added  to  the  powder  and  lano- 
lin. The  mixture  is  stirred,  the  rose-water  is  added,  and  the  preparation  is 
beaten  into  a  creamy  paste.  If  itching  is  severe,  i  to  2  per  cent,  of  carbolic 
acid  is  added.  The  paste  is  spread  on  several  thicknesses  of  gauze  and  the 
gauze  is  covered  with  a  rubber  dam.  When  ulceration  occurs,  dressings  of 
normal  salt  solution  may  prove  of  benefit.  Skin-grafting  may  succeed  in 
remedying  an  ulceration  following  an  x-ray  injury;  but,  as  a  rule,  the  grafts 
do  not  grow,  or  if  they  adhere  are- very  apt  to  break  down  after  a  time.  In 
many  cases  the  best  treatment  is  excision  (Powell).  Can  the  .T-rays  cause 
death?  Death  may  follow  a  burn  without  being  directly  due  to  it.  There 
are  4  reported  cases  in  which  death  followed  .-r-ray  burns,  but  in  not  one  case 
is  it  certain  that  the  burn  was  directly  responsible  (Rubel,  in  "Jour.  Amer. 
Med.  Assoc,"  Nov.  22,  1902). 

The  uses  of  the  x-rays  are  legion.  They  are  of  the  greatest  possible  value 
in  the  location  of  foreign  bodies,  especially  bodies  of  metal,  glass,  or  bone, 
such  as  bullets,  and  needles,  glass,  splinters,  etc.  Bullets  are  readily  detected 
in  the  extremities;  have  been  found  in  the  lung-substance  and  bronchi  (Row- 
land), in  the  brain  (Schier,  Brissaud  and  Londe,  Keen  and  Sweet,  Henchen 
and  Sennauer,  Bruce,  Willy  Meyer),  in  the  abdomen,  the  pelvis,  a  joint,  the 
spine,  and  the  eye.  The  x-rays  will  enable  us  after  an  abdominal  operation 
to  locate  a  Murphy  button  and  tell  when  it  has  loosened  and  descended.  For- 
eign bodies,  especially  if  metallic,  in  the  esophagus,  stomach,  intestine,  and 
air-[)assages;  enteroliths  and  mineral  calculi  in  the  salivary  ducts,  bladder, 
ureter,  and  kidney  can  be  detected.  Henry  Morris  tells  us  that  a  calculus  in 
the  kidney  may  exist  and  yet  escape  detection  with  the  rays,  because  the 
kidney  is  very  deeply  placed,  is  under  the  ribs  and  close  to  the  vertebral 
column.  Occasionally  a  drainage-tube  lost  in  the  pleural  sac  may  be  discov- 
ered. Most  observers  state  that  gall-stones  cannot  be  skiagraphed  in  the  liv- 
ing body.  Cattell  has  succeeded  in  one  case  and  Carl  Beck  has  succeeded.* 
The  rays  may  fail  to  disclose  a  foreign  body  because  of  its  l)eing  overshadowed 
by  a  bone  (Carless),  but  prolonged  exposure  or  the  taking  of  another  picture 
with  the  |)art  in  another  position  will  bring  it  into  view.  In  many  cases  a 
*N.  Y.  Med.  Jour.,  Jan.  20,  1900. 


RUNTGEN   RAYS. 


Plate  io. 


2  :^ 

1.  Gunshot-wound  of  the  Lung.  kih-rcscction  for  secondary  licmorrliage  inlo  the 
pleural  sac  ten  days  after  the  injury;  bullet  not  removed.  Hemorrhage  arrested  by  pack- 
ing with  gauze.    Skiagraph  taken  three  months  afterward  shows  the  bullet.     (Author's  case.) 

2.  Fracture  of  Lower  End  of  the  Femur.  Reduction  of  fragments  impossible  because 
of  the  interposition  of  a  loose  piece  of  bone  and  much  muscle  between  fragments.  (Author's 
case.) 

3.  Case  shown  in  Figure  2,  Three  Months  after  the  Operation  of  Wiring.  Nine  months 
after  operation,  the  man  is  walking  al">ut  with  case,  and  the  wire  is  still  in  place. 

('rhe  above  skiagraphs  are  from  the  A'-Kay  Laboratory  of  the  Jefferson  Medical  College 
Hospital.) 


Method   of  Locating  Foreien   Bodies 


1 06 1 


skiagraph  does  nut  indicate  how  deepl\-  in  the  tissues  a  foreign  Ijody  hes,  or 
upon  which  side  of  a  bone  it  is  lodged.*  If  there  is  doubt,  take  several  pic- 
tures from  ditTerent  positions  (triangulation),  skiagraph  over  a  surface  marked 
in  squares,  insert  guide-needles  into  the  tissues  before  taking  the  final  picture, 
or  employ  Sweet's  apparatus.  Sweet's  apparatus  has  been  used  successfully 
for  the  location  of  foreign  bodies  in  the  eye,  but  a  modification  of  the  original 
apparatus  has  recently  been  used  to  skiagraph  other  regions  of  the  body. 
Sweet's  apparatus  is  used  as  follows :f  "The  essential  features  of  this  appa- 
ratus and  the  method  of  employing  it  are  shown  in  the  illustration  (Fig.  650). 
An  adjustable  arm  carries  two  ball-pointed  rods  which  are  at  a  known  dis- 


Fig.  650. — W.  M.  Sweet's  x-vny  apparatus  for  locating  foreign  bodies. 

tance  apart,  and  are  parallel  with  each  other  and  with  the  photograjPiic  plate, 
while  the  balls  are  perpendicular  to  each  other  and  the  plate. 

"When  the  skiagraphs  are  made,  one  of  the  indicator-balls  rests  against 
the  skin  at  any  point  in  the  neighborhood  of  the  foreign  body,  while  the 
second  indicator  is  toward  the  plate.  The  spot  on  the  skin  at  which  one  of 
the  indicator-balls  rests  is  marked  with  silver  nitrate,  as  the  j^osition  of  the 
foreign  body  is  measured  from  this  point. 

"Two  skiagraphs  are  made  to  give  different  relations  of  the  shadows  of 
the  two  indicators  and  the  bullet,  one  exposure  with  the  tube  horizontal,  or 
nearly  so,  with  the  plane  of  the  indicators,  and  a  second  exposure  with  the 
tube  at  any  distance  above  or  below  lliis  ])lane.     Since  the  sliadow  of  the 

*  Battle's  case  in  Lancet,  Feb.  29,  1896. 

f  W.  W.  Keen,  in  Phila.  Med.  jour.,  Jan.  6,  1900. 


I062 


Skiagraphy 


■ig.  651.— Skiagr:ii>h  in.idr  with  tube  huri/.uiital  to  plane  of  indicators.     The  bullet  is  well  seen. 
Opposite  A  are  seen  the  two  balls  at  the  ends  of  the  rods. 


Fij(.  652. 


-Skiagraph  ri 

0))posit 


\  illi  lube  above  horizontal  plane  of  indicators.      I  In-  build  i;- 
A  and  />'  arc  seen  the  two  balls  at  the  ends  of  the  rods. 


Method  of  Locatinfr  Foreie^n   Bodies 


1063 


foreign  body  preserves  at  all  times  a  fixed  relation  with  respect  to  the  shadows 
of  the  two  indicator-balls  in  whatever  position  the  tube  is  placed,  and  since 
the  situation  of  the  two  balls  is  known,  the  location  of  the  foreign  body  in  the 
tissues  is  readily  determined  from  a  study  of  the  planes  of  shadow  at  the  two 
exposures. 

"  When  the  skiagraphs  of  the  case  here  reported  were  made,  the  anterior 
surface  of  the  leg  was  placed  upon  the  bottom  of  the  right-angle  sup- 
port of  the  apparatus,  the  plate  to  the  inner  side  of  the  knee,  one  indicator- 
ball  resting  on  the  skin  nearly  in  the  center  of  the  popliteal  space.  The 
skiagraph  made  with  the  tube  horizontal  with  the  plane  of  the  indicators  is 
shown  in  Fig.  651,  and  the  second  skia- 
graph with  the  tube  a  short  distance 
above  the  first  position  is  seen  in  Fig. 
652.  Both  negatives  show  the  leg  as 
viewed  from  the  outer  side,  with  the 
posterior  surface  of  the  leg  uppermost. 

"In  determining  the  position  of  the 
bullet  a  spot  is  made  upon  paper  to 
indicate  the  point  on  the  skin  at  which 
one  of  the  indicator-balls  rested  at  the 
time  of  the  exposure,  a  second  spot 
being  made  two  inches  from  the  first, 
to  represent  the  fixed  distance  between 
the  two  balls.  These  are  shown  at 
A  and  B,  upper  diagram,  Fig.  653. 
The  first  negative  is  now  taken.  The 
distance  the  shadow  of  the  bullet  is 
below  the  shadow  of  each  of  the  two  in- 
dicators is  measured,  and  this  distance 
entered  below  the  spots  representing 
the  two  balls  when  the  exposure  was 
made  (C  and  D).  A  fine  drawn  through 
these  points  indicates  the  plane  of 
shadow  of  the  bullet  when  the  first  skia- 
graph was  made.  Similar  measure- 
ments are  made  from  the  second  nega- 
tive and  marked  below  the  spots  .1 
and  B,  the  fine  through  the  spots  (F 
wheii  the  second  negative  was  made, 
cross  (A")  is  the  position  of  tlie  bullet 
side  of  the  nitrate  of  silver  spot  on  the  skin. 

"  In  determining  the  depth  of  the  bullet  in  the  tissues,  a  second  diagram 
is  made  to  indicate  the  position  of  the  two  balls,  as  viewed  from  a  cross-section 
of  the  leg.  Since  the  tube  was  only  twenty-four  inches  away  at  the  time  of 
the  exposure,  the  convergence  of  the  rays  in  an  object  as  large  as  the  leg  must 
be  allowed  for.  This  is  done  by  measuring  the  distance  the  shadow  of  one 
ball  is  behind  that  of  the  other,  entering  this  distance  (.1  K)  on  the  diagram, 
and  marking  on  a  line  through  this  jioint,  twenty-four  inches  from  the  ball 
restins;  on  the  skin,  the  situation  of  the  tube.     If  we  now  measure  the  distance 


Fig.  653. — Method  of  indicating  location  of 
bullet.  Upper  diagram,  posterior  view  of  leg 
from  above.  Lower  diagram,  cross-section  of 
leg,  near  knee-joint. 

and  H)  giving  the  plane  of  shadow 
Where  these  two  planes  of  shadow 
as  measured  below,  and  to  the  inner 


1064  Skiagraphy 

the  shadow  of  the  bullet  on  the  first  negative  is  back  of  that  of  the  shadow  of 
the  ball  on  the  skin,  enter  this  distance  in  the  plane  of  this  indicator  {B  M), 
and  draw  a  line  from  the  situation  of  the  tube  through  this  point,  we  obtain 
the  plane  of  the  shadow  of  the  bullet  when  the  exposure  was  made.  Drawing 
a  line  from  the  position  of  the  bullet  as  previously  found  on  the  first  diagram, 
the  intersection  of  this  line  with  the  plane  of  shadow  upon  the  second  diagram 
gives  the  situation  of  the  bullet  from  a  cross-section  view  of  the  leg.  For 
purposes  of  greater  clearness,  outlines  of  the  leg  have  been  shown  in  the  two 
diagrams,  although  this  is  unnecessary  in  practice,  since  the  position  of  the 
foreign  body  in  respect  to  a  known  point  upon  the  integument  is  all  that  is 
required.  The  position  of  the  bullet  was  shown  to  be  one  inch  toward  the 
inner  side  of  the  spot  on  the  skin  at  which  one  of  the  indicator-balls  rested, 
one  and  a  quarter  inches  below  this  spot,  toward  the  ankle,  and  embedded  in 
the  tissues  to  the  depth  of  one  and  a  half  inches.  Both  skiagraphs  show  the 
bullet  close  to  the  bone,  but,  owing  to  the  false  projection,  so  common  in  all  x- 
ray  pictures,  it  is  impossible  to  say  whether  the  bullet  was  embedded  in  the 
bone  or  not."  Morris  tells  us  to  be  somewhat  skeptical  in  accepting  unre- 
servedly the  evidence  offered  by  a  skiagraph,  as  slight  carelessness  in  taking 
the  picture  may  mean  great  distortion  and  consequent  error. 

In  detecting  fractures  and  dislocations  the  Rontgen  rays  are  of  great  value, 
especially  when  there  is  much  swelling,  when  there  is  httle  displacement,  and 
when  the  fracture  is  in  or  about  a  joint.  The  rays  enable  us  to  determine  the 
nature  of  the  injury,  the  amount  of  splintering,  the  existence  of  impaction,  the 
question  whether  or  not  the  fragments  are  in  contact  and  can  be  brought  into 
contact;  the  direction  of  the  line  of  fracture,  the  variety  of  deformity,  the 
existence  of  more  than  one  fracture,  the  presence  of  epiphyseal  separation  or 
dislocation  alone  or  with  a  fracture,  the  existence  of  an  ununited  fracture, 
and  the  question  if  the  splints  are  holding  the  fragments  in  accurate  apposi- 
tion. Fractures  of  the  skull,  if  involving  both  tables  of  the  vault,  may  be 
recognized;  it  is  possible  that  fractures  of  the  inner  table  may  be  found;  frac- 
tures of  the  base  can  be  seen,  but  with  difficulty.  Fractures  of  the  spine  can 
be  skiagraphed,  but  never  show  very  clearly.  To  take  a  picture  of  a  fractured 
rib,  first  limit  chest-motion  by  bandaging  (White).  The  .v-rays  may  be  of  value 
in  enabling  the  surgeon  to  recognize  rheumatoid  arthritis;  bone-  and  joint-tu- 
berculosis (the  tuberculous  area  being  lighter  than  the  sound  bone) ;  the  amount 
of  acetabular  rim  present  in  congenital  dislocation  of  the  hip-joint  (Rowland) ; 
the  state  of  the.l^ones  in  a  crushed  limb  (J.  Hall  Edwards);  bone  deformity; 
osseous  tumors;  bone  displacement  (as  in  Morton's  foot) ;  osteomyelitis;  caries; 
necrosis;  and  osteosarcoma.  By  skiagraphy  we  are  enabled  to  decide  on  the 
proper  situation  to  perform  osteotomy,  and  if  a  deformity  of  the  foot  can  be 
amended  without  operation  (Willard).  The  position  of  the  fetus  in  utero 
can  be  definitely  made  out. 

Applied  to  the  soft  parts,  the  new  ])rocess  has  ol)tained  interesting  but  n<A 
as  yet  many  practically  useful  results.  Fibrous  tumors  can  be  seen,  but  ma- 
lignant tumors,  unless  they  contain  calcareous  or  fibrous  elements,  cannot 
be  definitely  made  out;  loose  bodies  in  a  joint  can  often  be  detected.  The 
.shadow  of  the  heart  can  be  made  out,  and  the  outlines  of  the  diaphragm,  kidney, 
and  liver  can  be  thrown  upon  the  screen.  If  the  stomach  is  distended  with 
gas,  it  shows  as  a  light  area  upon  a  dark  background  (Hedley).     If  food   is 


The   X-ra}'s   in   Malignant  Disease  1065 

eaten  after  being  mixed  wilii  subnitrate  of  bismuth,  the  outline  of  the  viscus 
becomes  fairly  distinct.  Thickened  pleura,  pleural  effusion,  pulmonary  con- 
solidation, abscess  of  the  lung,  pericardial  effusion,  aortic  aneurysm;  cavities 
in  the  lungs,  and  atheromatous  blood-vessels  may  be  made  out  with  more  or 
less  distinctness.  If  a  sinus  is  injected  with  iodoform  emulsion,  a  picture  of  it 
can  be  taken,  because  the  emulsion  casts  a  shadow  when  placed  in  the  path  of 
the  .v-rays  (J.  Hall  Edwards). 

The  X=ravs  in  Malignant  Disease.  — of  late  the  surprising  fact 

has  been  demonstrated  that  .v-rays  may  alleviate,  or  even,  it  may  be, 
cure,  malignant  disease.  So  far  it  does  not  seem  likely  that  internal 
cancer  can  be  notably  affected,  although  even  in  these  cases  the  rays  seem 
to  lessen  pain.  Surface  epitheliomata  may  entirely  disappear  and  enlarged 
lymphatic  glands  associated  with  epitheliomata  sometimes  shrink  up  and 
pass  away.  In  two  dreadful  cases  of  inoperable  and  recurrent  cancer 
of  the  face  with  extensive  lymphatic  involvement  in  which  the  ra\s  were 
used  I  have  seen  apparent  cure  result.  Unfortunately,  the  cure  is  more 
apparent  than  real,  and  in  every  case  which  I  have  watched  the  growth 
has  begun  again  after  weeks  of  apparent  immunity  and  has  progressed  with 
fearful  speed.  Nevertheless,  it  is  most  important  to  know  that  we  have  a 
remedy  which  relieves  pain  even  in  advanced  cases,  lessens  bleeding  and  dis- 
charge, and  which  will  often  for  a  time  arrest  the  ravages  of  this  fearful 
malady,  prolong  life,  and  add  to  comfort  when  nothing  else  is  of  avail.  It 
may  be  that  with  increase  of  knowledge  we  may  learn  that  an  apparently 
cured  case  can  be  kept  well  by  the  continued  use  of  the  rays  from  time  to  time. 
Francis  H.  Williams  says  that  for  this  work  a  good-sized  static  machine  or  coil 
is  needed  and  the  spark-gap  should  be  adjustable.  If  the  growth  is  superficial, 
a  tube  of  low  resistance  is  used;  if  it  is  deeper,  one  of  high  resistance  is  em- 
ployed. The  tube  is  placed  in  a  holder,  the  interior  of  which  is  painted  with 
white  lead.  A  screen  of  lead  is  used  to  reduce  the  cone  of  the  rays  to  a  size 
but  little  larger  than  that  of  the  area  to  be  treated.  If  cavities  are  to  be 
treated,  the  rays  are  passed  through  a  cylindrical  speculum  of  glass,  ^\■hich 
is  surrounded  by  a  sheet-tin  shield.  , 

At  each  sitting  the  exposure  is  from  live  to  ten  minutes  in  the  beginning, 
but  later  it  may  be  increased  to  twenty  minutes  or  more.  Three  or  four 
exposures  a  week  are  given.  Williams  points  out  that  a  rapidly  growing 
tumor  should  receive  an  exposure  of  not  more  than  five  minutes ;  and 
that  if,  a  day  or  two  later,  there  is  pricking  and  slight  irritation,  these 
signs  should  be  regarded  as  distinctlv  favorable  (Dr.  Francis  H.  Williams, 
before  the  New  York  Academy  of  Medicine,  March  6,  1902;  reported  in 
the  "Med.  Record,"  March  15,  iqo2). 

It  may  be  very  quickly  determined  whether  the  .v-ra\s  will  help  the  patient 
or  not.  For  instance,  if  an  epithelioma  is  going  to  be  benefited,  it  will  begin 
to  show  improvement  within  two  weeks. 

Some  observers  have  maintained  that  the  beneficial  effects  are  due  to 
burning  with  the  .r-rays.  Dr.  Carl  Beck  thinks  that  they  are  obtained  only 
when  the  integument  alone  is  involved.  Dr.  A.  G.  Ellis  ("Amer.  Jour,  of 
Med.  Sciences"),  from  a  series  of  studies  made  in  the  laboratories  of  the  Jefl"er- 
son  Medical  College,  has  reached  the  conclusion  that  endarteritis  is  induced 
by  the  .v-rays;  but  that,  as  the  accompanying  tissue-necrosis  is  out  of  pro- 


1 066  Skiagraphy 

portion  to  the  vascular  changes,  it  is  possible  that  the  necrosis  does  not  result 
from  the  vascular  changes,  but  that  each  condition  results  from  the  same 
influence.  He  has  further  concluded  that  the  .r-rays  do  not  possess  any 
definite  germicidal  power.  Some  observers  attribute  to  actinic  action  the 
tissue-changes  wrought  by  the  .%--rays;  others,  to  phagocytosis  and  leuko- 
cvtosis.  It  is  certain  that  the  .%--rays  are  irritant  and  tend  to  produce  inflam- 
mation. In  an  inflamed  area  stasis  occurs  and  about  an  inflamed  area  leuko- 
cytes gather.  Hence,  degeneration  may  occur  or  actual  sloughing  take  place. 
The  embryonal  cells  of  cancer  are  acted  upon  more  strongly  than  normal 
tissue-cells.     Sarcoma  is  not  so  apt  to  be  benefited  as  carcinoma. 


Effects  Produced  by  Lightning^  1067 


XL.   INJURIES  BY   ELECTRICITY. 

Effects  Produced  by  Lightning.— An  individual  may  be  struck 
directl}-,  or  he  may  be  shocked  by  an  induced  current,  the  lightning  having 
struck  a  nearby  object.  A  person  can  be  struck  while  in  a  room,  but  there  is 
more  danger  when  exposed,  especially  in  the  open  country.  To  be  under  a 
single  tree  during  a  thunderstorm  is  dangerous,  but  to  be  in  a  wood  or  under  a 
hedge  is  reasonably  safe.  The  victim  of  hghtning  may  be  killed  instantly. 
Death  is  the  fate  of  over  one-third  of  those  struck.  Tidy  states  that  out  of 
54  cases,  21  died  and  t,;^  recovered.  Post-mortem  examination  may  fail  to 
reveal  a  lesion,  but  in  many  cases  severe  burns  are  discovered;  in  some  there 
are  laceration  of  tissue,  crushing  of  bones,  and  fearful  injury.  Burns  are 
especially  apt  to  occur  at  the  points  where  the  current  entered  and  emerged. 
The  clothes  are  usually  singed  and  torn.  The  typical  lightning-marks  are 
arborescent  tracings,  representing  the  course  of  blood-vessels,  produced  by 
disorganization  and  effusion  of  blood  as  the  fluid  travels  through  it.  Occa- 
sionally metal  objects,  such  as  buttons,  knives,  money,  keys,  etc.,  are  fused, 
and  spread  as  a  metallic  film  over  a  considerable  portion  of  the  surface  of  the 
body.  Bichat  stated  that  in  death  from  lightning  rigor  mortis  does  not  occur. 
This  statement  is  now  known  to  be  an  error  (see  the  three  cases  reported  by 
M.  Tourdes).  As  a  rule,  there  is  early  rigor  mortis,  retained  fluidity  of 
blood,  and  distention  of  the  brain  with  venous  blood.  The  cause  of  death 
by  lightning  was  supposed  by  Hunter  to  be  due  to  destruction  of  muscular 
contractility,  and  by  Richardson  to  the  resolution  of  the  blood  into  gases. 
It  seems  probable  that  some  deaths  are  due  to  actual  disorganization  of  vital 
structure  and  that  others  are  due  to  shock  or  inhibition.  An  individual 
struck  by  lightning  may  reco^•er  even  when  he  is  appareiUly  dead.  Sestier 
reported  77  cases  struck  by  lightning,  and  in  7  of  them  the  persons 
were  apparenth'  dead  for  a  number  of  hours.*  Brouardel  says  in  such 
cases  the  death-hke  state  may  be  ascribed  to  inhibition,  caused  by  a 
maximum  degree  of  stimulus.!  When  death  from  lightning  is  not  imme- 
diate, the  condition  may  be  as  above  outlined,  the  individual  being  apparenth' 
dead,  without  obvious  respiration  or  pulse.  He  may  be  insensible,  with  slow 
and  labored  respiration,  a  weak  and  irregular  pulse,  and  dilated  pupils,  and 
may  remain  in  this  condition  for  a  few  minutes  or  for  se^■eral  hours.  The 
above  condition  is  not  to  be  distinguished  from  severe  concussion  of  the 
brain.  Every  individual  sufi^ering  from  the  eftects  of  lightning  should  have 
his  entire  body  carefully  examined  to  see  if  physical  injuries  exist  (fractures, 
wounds,  burns,  ecchymoses,  arborescent  tracings).  The  consequences  of 
lightning-stroke  are  many  and  various.  There  may  be  rapid  and  complete 
recovery,  gradual  recovery,  traumatic  neurasthenia,  sloughing  burns,  partial 
paralysis,  which  is  usualh-  reco\-ered  from  (Nothnagel),  but  which  may  be 
permanent;  hysteria,  blindness,  change  of  character,  and  actual  insanity. 

Treatment. — Do  not  pronounce  a  person  dead  until  a  thorough  attempt 
at  resusciuuion  has  been  made.     Do  not  give  alcoholic  stimulants.     If  the 

*  Sestier,  "De  la  Foudre,"  Paris,  1866.  Quoted  by  Brouardel  in  his  lectures  upon 
"  Death  and  Sudden  Death." 

f  Benham's  translation  of  Brouardel's  lectures  upon  '*  Death  and  Sudden  Death." 


io68  Injuries  by  Electricity 

respiration  is  feeble  and  apparently  absent,  make  tongue  traction  and  em- 
ploy artiticial  respiration.  Apply  the  stream  of  a  cold  douche  to  the  head,  rub 
the  limbs  with  mustard,  put  a  mustard  plaster  over  the  heart  and  another  to 
the  back  of  the  neck,  wrap  the  individual  in  hot  blankets,  and  give  enemata  of 
hot  saline  fluid.  In  some  cases  venesection  has  seemed  to  be  of  benefit. 
When  the  individual  reacts,  treat  any  existing  condition  symptomatically, 
and  treat  particular  physical  injuries  according  to  their  character. 

Effects  of  Artificial  Currents. — Workmen  for  electric  companies, 
pedestrians-  in  the  streets  of  a  city  which  is  hghted  by  electricity  or  in  which 
trolley  cars  are  employed,  roofers,  and  firemen  are  liable  to  be  injured  by 
electricity.  An  alternating  current  is  decidedly  more  dangerous  than  a  con- 
tinuous current  of  equal  strength.  An  artificial  current  acts  like  Hghtning. 
It  may  produce  instant  death;  it  may  produce  unconsciousness,  delirium, 
stertorous  respiration,  Cheyne-Stokes'  breathing,  or  clonic  spasms.  Its 
effects  can  be  often  recovered  from.  Not  unusually  the  victim  is  apparently 
dead,  but  subsequently  recovers.  D'Arsonval  reports  the  case  of  a  man 
who  was  apparently  killed  by  the  passage  of  4500  vohs.  No  attempt  at  resus- 
citation was  made  for  one-half  hour,  and  yet  he  recovered  when  artificial 
respiration  was  employed.  Donnellan  reports  a  case  of  recovery  after  the 
passage  of  1000  volts.  Slight  shocks  may  cause  temporary  numbness,  and 
even  motor  paralysis.  An  electric  shock  frequently  causes  burns  or  ecchy- 
moses,  and  occasionally  wounds.  Wounds  caused  by  electricity  bleed  pro- 
fusely and  are  apt  to  slough.  An  electric  hum  looks  like  a  blackened  crust; 
it  is  surrounded  by  pale  skin,  and  for  twenty-four  hours  remains  dry,  when 
inflammatory  oozing  begins  and  the  skin  around  it  reddens.  These  burns 
are  not  as  painful  as  are  ordinary  burns,  but  recovery  requires  a  long  time. 
When  inflammation  begins  and  suppuration  occurs,  tissue  is  extensively 
destroyed;  tendons,  bones,  and  joints  may  suffer;  some  portions  become 
deeply  excavated,  and  other  portions  show  dry  adherent  masses  of  dead  and 
dying  tissue,  and  a  burn  which  was  at  first  small  may  be  followed  by  a  large 
area  of  moist  gangrene;  *  lack  of  tissue-resistance,  due  to  trophic  disturbance, 
is  largely  responsible  for  the  progress  of  the  sloughing. 

Treatment. — If  a  person  is  in  contact  with  a  live  wire,  the  first  thing  to  do 
is,  if  possible,  to  shut  off  the  current.  If  it  is  not  possible  to  shut  off  the  cur- 
rent, catch  a  portion  of  the  clothing  of  the  victim  and  pull  him  away  from  the 
wire,  but  do  not  touch  his  body  with  the  bare  hand.  If  a  pair  of  rubber 
gloves  can  be  obtained,  the  subject  can  be  moved  with  impunity  and  the  wires 
can  be  safely  cut.  If  it  is  not  possible  to  drag  a  person  away  from  electric 
wires,  the  surgeon  can  wrap  his  hands  in  dry  cloth  and  lift  the  portion  of  the 
body  in  contact  with  earth  or  wire,  and  thus  break  the  circuit  and  permit  of 
removal  of  the  body.f  A  dry  cloth  can  be  pushed  between  the  body  and  the 
ground,  and  the  body  can  then  be  removed  from  the  wires.  It  may  be  pos- 
sible to  push  the  wires  away  by  means  of  a  dry  piece  of  wood,  or  to  cut  them 
with  shears  which  have  wooden  handles  and  which  are  perfectly  dry.  Treat 
the  general  condition  in  the  manner  set  forth  in  the  article  on  lightning-stroke 
(page  1067).     Very  severe  burns  may  be  caused.     The  author  has  dressed  a 

*  See  the  article  by  N.  W.  Shari)e  on  "Peculiarities  and  'rreatnienl  of  Electrical  In- 
juries," in  Phila.  Med.  Jour.,  Jan.  29,  1898. 

t  See  the  directions  in  Med.  Record,  Dec.  28,  1895,  from  Med.  Press. 


Effects  of  Artificial  Currents  1 069 

number  of  electric  burns  with  hot  fomentations  of  salt  solution  during  the  first 
few  days.  This  facilitates  the  separation  of  the  sloughs  and  seems  to  aid  the 
weakened  tissues  in  resisting  microbic  invasion;  after  sloughs  separate,  the 
part  is  dressed  with  dry  sterile  gauze.  Antiseptic  dressings  can  be  used 
from  the  beginning,  but  they  often  fail  entirely  to  arrest  the  sloughing.  Iodo- 
form produces  much  irritation.  Ointments  are  very  unsatisfactory.  When 
the  dressings  are  changed,  the  part  should  not  be  washed  with  corrosive 
sublimate,  as  this  agent  produces  irritation;  peroxid  of  hydrogen  should 
be  employed,  followed  by  hot  normal  salt  solution.  Sharpe  removes  sloughs 
by  applying  the  following  mixture:  2  parts  of  scale  pepsin,  i  part  of  hydro- 
chloric acid,  U.S. P.;  120  part?  of  distilled  water.  This  mixture  is  washed  off 
after  two  hours  with  peroxid  of  hydrogen.  The  same  surgeon  treats  necrosis  of 
bone  by  injecting  every  few  hours  a  3  per  cent,  solution  of  hydrochloric  acid, 
using  every  second  day  the  pepsin  solution,  and  when  necrotic  areas  come 
away  packing  with  gauze.  Skin-grafting  by  Reverdin's  method  or  Thiersch's 
method  is  rarely  successful.  In  some  regions  it  is  possible  to  slide  a  large 
flap  in  place  to  cover  a  granulating  area  which  will  not  heal.  In  a  very  severe 
case  amputation  or  resection  may  be  necessary. 


INDEX 


Abbe's  method  of  intestinal  anastomosis, 
■     8ii 

operation  of  intracranial  neurectomy,  593 
Abdomen,  gunshot-wounds  of,  703 

operation  upon,  772 
Abdominal  aorta,  ligation  of,  362 
hernia,  824 
section,  772 
wall,  contusion  of,  695 

contusion  of,  muscular  rupture   from, 
696 

wounds  of,  701 
Abscess,  log 
acute,   112 

retropharyngeal,  ii6 

symptoms  of,   114 
alveolar,  117 
appendiceal,  115 
Brodie's,  367 
chronic,  of  bone,   125 
deep,   121 
diagnosis  of,  118 
dorsal,  124 
extradural,  620 
forms  of,  114 
heahng  of,  113 
iliac,  125 

ischiorectal,  117,  S55 
lumbar,  125 

of  antrum  of  Highmore,  117,  655 
of  bone,  chronic,  367 
of  brain,  115,  618 

from  ear  disease,  620 
of  breast,    117,   125,   1046 
of  frontal  sinus,  656 
of  kidney,  942 
of  larynx,  1 1 7 
of  liver,   116,  749 

tropical,  750 
of  lung,   117,  669 

pneumotomy  for,  676 
of  mediastinum,  117 
of  prostate  in  gonorrhea,  990 
of  scalp,  599 
of  spleen,  771 
orbital,   118 
painting  in,  1 13 
palmar,  559 
pericystic,  758 
perinephric,  117,  942 
postpharyngeal,   124 

treatment  (jf,  127 
})rognosis  of,   1  19 
prostatic,   1 1  7 
psoas,  125 


Abscess,  residual,  of  Paget,   183 

retromammary,   1047 

retropharyngeal,   124 

spinal,  643 

spontaneous  evacuation  of,  113 

subphrenic,    116,   746 

superficial,   121 

treatment  of,  119 
drainage  in,  122 

tuberculous,   122 
formation  of,   123 
large,  126 
of  breast,   126 
of  head,  124 
of  lymphatic  glands,  126 
prophylactic  membrane  in,  123 
symptoms  of,   123 
treatment  of,   125 
Senn's,  126 
Absorbent  cotton,  sterile,  54 
Absorptive  power  of  stomach,  714 
Accessory  adrenals,  267 
A.  C.  E.  mixture,  881 
Acetabulum,  fracture  of  brim  of,  442 
Acetanilid,  28 

Achard  and  Castaign's  test  of  kidneys,  933 
Achillodynia,  254 
Acne,  230 
Acromegaly,  375 
Acromion,  fractures  of,  415 
Actinomycosis,  18,  221 

of  bone,  364 
Active  clot,  295 
Actol,  29 
Acupressure  in  hemorrhage,  314 

in  treatment  of  aneurysm,  303 
Adams's  operation,  530 
Adenitis,  tuberculous,  183 
Adenocele  of  breast,  1049 
Adenoma,  269 

cystic,  269 

of  breast,  1049 
Adhesions,  perigastric,  711 
Adrenal  rests,  267 
Adrenals,  accessory,  267 
Air-embolism,  160 
Airol,  28 

Albert's  disease,  254 
Albuminous  expectoration  after  aspiration, 

672 
Alcohol  and  chloroform,  8S1 

as  antidote  for  carbolic  acid,  26 

in  inflammation,  89 
Aldehyd,  formic,  29 
Aleppo  boil,  897 


1071 


10/2 


Index 


Alexander's    operation    of    prostatectomy, 

1 013 
Alexins,  ^^ 

AKmentary  cana'    tuberculosis  of,  181 
Allingham's  decalcilied  bone  bobbin,  805 
Allis's  ether-inhaler,  874 

sign  of  fractures  of  femur,  441 
Almen's  test-for  blood  in  urine,  927 
Alopecia  of  syphilis,  231 
Ambulatory   dressing   apparatus    for   frac- 
ture of  thigh,  392 
of  plaster-of-Paris  for  fractured  bones 
of  leg,  392 
Amputation,   1023 

a  la  manchette,   1026 

at  ankle,   1037 

Pirogoff's  method,  1037 
Syme's  method,  1037 

at  elbow,  1031 

at  forearm,   1030 

at  hip-joint,   1041 

Jordan's  method,  1045 
Senn's  method,  1045 
Sheldon's  method,  1045 
Wyeth's  method,  1042 

at  knee,  1039 

at  metacarpophalangeal  joint,   1029 

at  shoulder,   1031 

Dupuytren's  method,  1033 
Kocher's  method,   1032 
Larrey's  method,  1032 
Lisfranc's  method,   1033 

at  wrist,    1029 

Berger's,  1033 

Bier's,  1038 

Chopart's,  of  foot,   1036 

circular,  1025 

classification  of,  1023 

Dupuytren's,  at  shoulder,  1033 

elliptical  method,  1027 

flap  method,  1027 

Gritti's,   1040 

hemorrhage  in,  1023 

Hey's,  of  foot,  1035 

intertarsal,  1036 

Jordan's  method,  1045 

Kocher's,  at  shoulder,   1032 

Larrey's,  of  shoulder,   1032 

Lisfranc's,  of  foot,   1034 

Liston's  method,  102ft 

mixed  method,  1027 

modified  circular  method,  1026 

oblique  circular  method,  1027 

of  arm,   1031 

of  breast,    1053 

of  finger,   1028 

of  foot,   1034 

of  hand,   1029 

of  leg,   1037 

of  penis,  1005 

of  thigh,  1040 

of  thumb,  1029 

of  toes,   1034 

of  upper  extremity,  1033 

Pirogoff's,   1037 

racket  method,   f02  7 

Sabanejeff's,  10.50 


Amputation,  Seddlot's,  1038 
Senn's  bloodless  method,  1045 
Sheldon's  method,  1045 
special,   1028 
subastragaloid,  1036 
Syme's,  1037 

through  femoral  condyles,   1039 
tarsometatarsal,  1034 
Teale's,   1038 
transverse  circular,  1025 
Wyeth's  bloodless  method,  1042 
Anastomosis,  intestinal,  813 

Abbe's  method,  Sii 

Horsley's  method,  812 

Laplace's,  S13 

lateral,  810 
ureteral,  951 

with  rings,  810 
Anderson's  method  of  tendon-lengthening, 

567 
Anel's  operation  for  aneurysm,  300 
Anesthesia,  869 

after-effects  of,  SSo 
local,  886 
mortality  in,  869 

of  spinal  cord,  Morton's  method,  889 
paralysis  after,  881 
preparation  of  patient  for,  869 
primary,  881 
reaction  from,  879 
renal  complications  after,  880 
respiratory  disorders  after,  880 
treatment  of  complications  in,  87 7 
vomiting  after,  880 
Anesthetic  successions,  885 
Aneurysm,  293 
active  clot  in,  295 
amputation  for.  303 
arteriovenous,  305 
by  anastomosis,  306 
causes  of,  295 
cirsoid,  259,  306 
diffuse  traumatic,  304 
distal  ligation  for,  302 
extirpation  of,  300 
forms  of,  293 
ligature  of,  300 
operation  for,  300 

Anel's,  300 

Antyllus',  300 

Brasdor's,  302 

Hunter's,  301 

Matas',  302 

Wardrop's,  302 
passive  clot  in,  295 
symptoms  of,  296 
treatment  of,  297 

by  acujjressure,  303 

by  electrolysis,  303 

by  extirpation,  300 

by  injecting  coagulating  agents,  303 

by  introduction  of  wire,  303 

by  ligature,  300 
•   by  manipulation,  303 

by  pressure,  299 
varicose,   305 
Aneurysmal  varix,  305 


Index 


1073 


Angina  Ludov'ici,  152 
Angioma,  258 

capillary,  258 

cavernous,  258 

of  breast,  1050 

plexiform,  259 
Angiosarcoma,  264 

Angle's  bands  for  fractured  lower  ja  .v,  403 
Ankle-joint  disease,  482 

dislocation  of,  526,  1037 

excision  of,  545 

Hancock's  method,  546 
Ankylosis,  496 

false  (extra-articular),  498 

fibrous,  497 

true  (intra-articular),  496 
Anodynes  in  inflammation,  86 
Anosacral  cysts,  635 
Anterior  tibial  artery,  ligation  of,  ^^2 
Anthrax,  216 

bacillus  of,  40 

benign,  897 

carbuncle,  217 

forms  of.  217 

treatment  of,  2:7 
Antinosin,  28 

Antipyretics  in  inflammation,  86 
Antisepsis,  42 

historic  note  on,  42 
Antiseptic  gauze  dressing,  53 
Antiseptics,  chemical,  24 

and  germicides,  miscellaneous,  30 
Antitoxins,  33 
Antrum  of  Highmore,  abscess  of,  117.  655 

inflammation  of,  655 
Antyllus'   operation  for  aneurysm,  300 
Anus,   fissure  of,  858 

fistula  in,  855 

gonorrhea  of,  994 

imperforate,  855 

prolapse  of,  862 

pruritus  of,  857 
Aorta,  abdominal,  ligation  of,  362 
Appendicitis,  725 

acute,  operation  for,  776 

diagnosis  of,  733 

etiology  of,  726 

forms  of,  728 

in  children,  736 

in  pregnant  women,  736 

McBurney's  point  in,  726 

operations  for,  mortality  of,  7S0 

pathology  of,  726 

prognosis  of,  732 

symptoms  and  signs  of,  729 

terminations  of,  732 

tuberculous,   736 
Appendix,  palpation  of,  732 

structure  of,  725 
Ardor  urin;u  in  gonorrhea,  989 
Argyrol,  29 
Aristol,  28 

Arm,  amputation  of,  1031 
Arterial  sedatives  in  inflammation,  85 
Arteries,  gunshot-wounds  of,  308 

ligation  of,  in  continuity,  334 

saline  infusion  in,  333 
68 


Arteries,  wounds  of,  306 

contused  and  incised,  306 
lacerated,  307 
punctured,  307 
Arteriocapillary  fibrosis,  29.2 
Arteriorrhaphy,  302 
Arteriosclerosis,  292 
Arteritis,  acute,  291 
Arthrcctomy,  537 
Arthritis,  472 

acute  rheumatic,  487 
suppurative,  484 

deformans,  489.     See  Osteo-arlliritis. 

gonorrheal,  485 

gouty,  489 

infective,  484 

neuropathic,  491.     See  Charcot's  disease. 

pneumococcus,  487 

rheumatoid,  489.     See  Osteo-arthritis. 

tuberculous,  472 

typhoid,  485 
Arthropathy,   tabetic,   401.     See   Charcot's 

disease. 
Arthrospores,  21,  22 

Artificial    respiration,    Laborde's    method, 
878 
Sylvester's  method,  S79 
Ascites    from    hepatic    cirrhosis,    surgical 

treatment,  815 
Ascococci,  20 
Asepsis,  42 

Aseptic  gauze  for  dressings,  54 
Aspiration,   672 

of  joints,  536 
Aspirator  and  injector,  536 
Astragalectomy,  547 
Astragalus,  dislocations  of,  527 

excision  of,  547 
Astringents  in  treatment  of   inflammation, 

78 
Atheroma,  292 
Atony  of  bladder,  95S 
Atrophy  of  bone,  364 

of  muscles,  554 

of  thyroid,  acquired,  900 
congenital,  900 
Autointoxication,  32 
Autotransfusion,  196 
Avulsion  of  limb,   203 

of  scalp,  203 
Axillary  artery,  ligation  of,  341 


Bacilli,  20 

miscellaneous,  41 
Bacillus  anthracis,  40 

coli  communis,  40 

Koch's,  39 

Lustgartcn's,  40 

mallei,  40 

Nicolaier's,  39 

of  Escherich,  40 

of  malignant  edema.  40 

of  Ncisser,  38 

of  syphilis,  40 

of  tetanus,  39 

of  typhoid  fever,  41 


I074 


Index 


Bacillus  pyocyaneus,  38 
pyogenes  foetidus,  38 
tuberculosis,  39 
Bacteria,  18 
aerobic,  22 
facultative,   22 
obligate,  22 
amotile,  19 
anaerobic,  22 
capsule  of,  19 
discovery  of,  17 
distribution  of,  30 
drum-stick,  22 

effect  of  motion,   sunlight,  x-rays,   cold, 
and  heat,  on,  22 
upon  bacteria,  23 
facultative,   19 
life-conditions  of,  22 
metachromatic  bodies  of,  19 
motile,   19 

multiplication  of,  20 
non-pathogenic,   19 
nuclei  of,  19 
obligate,  19 
parasitic,  19 
pathogenic,  19 
placental  transmission  of,  23 
Bacteriology,  17 

of  cholecystitis,   755 
of  thrush,  18 

Pasteur's  early  work  in,   17 
Balanitis.  989 
Balanoposthitis,  989 
Bandage,  56,  913 

American,  of  foot,  915 
Barton's,  916 
Borsch's,  of  eye,  916 
crossed,  of  angle  of  jaw,  917 

of  both  eyes,  916 
demi-gauntlet,  914 
Desault's,  919 
Esmarch's  elastic,  1023 
figure-of-8  of  breast,  918 

of  elbow,   shoulder,   neck,  and  axilla, 

918 
of  jaw  and  occiput,  916 
French,  of  foot,  915 
gauntlet,  914 
Gibson's,  916 
handkerchief,  920 
obhque,  of  jaw,  917 
of  foot  covering  heel,  915 
not  covering  heel,  915 
plaster-of-Paris,  921 
recurrent,  of  head,  920 

of  stump,  920 
Ribbail's,  915 
Selva's,  of  thumb,  914 
spica,  of  groin,  918 
of  instep,  915 
(if  shoulder,  918 
o*'  thumb,  914 
spiral,  of  all  fingers,  914 
of  foot,  covering  heel,  915 
of  palm,  914 

reversed,  of  lower  extremity,  915 
of  upper  extremity,  913 


Bandage,  T-,  of  perineum,  920 
Velpeau's,  918 

Barker's  operation  for  dislocation  of  carti- 
lages of  knee-joint,  551 

Barton's  bandage,  916 
fracture,  434 

Basedow's  disease,  904 

Bassini's  operation  in  hernia,  830 

Beast-mimic  rV;  219 

Beatson's   operation   for  cancer   of  breast, 

275 
of  oophorectomy,  1056 
Bed-sore,   135,  151 

acute,  of  Charcot,  151 
Bee,  stings  of,  214 

Belfield's  operation  of  prostatectomy,  1012 
Bellocq  cannula,  324 
Bell's  induction  balance  for  locating  bullets, 

211 
Berger's    amputation    of   upper   extremity, 

1033 
Beyea's  operation  for  gastroptosis,  800 
Bichat's  fissure,  location  of,  595 
Bichlorid  of  methylene,  8S5 
Bier's  amputation,  1038 

treatment  of  tuberculosis,   185 
Bigelow's  evacuator,  970 

lithotrite,  971 

operation  of  litholapaxy,  969 
Bile-ducts,  rupture  of,  700 
Billroth's  pylorectomy,  787 
Bites  and  stings,  214 
Bladder,  atony  of,  958 

congenital  defects  of,  956 

contusion  of,  956 

exstrophy  of,   756 

female,  growths  in,  976 

hernia  of,  849 

operation  on,  966 

rupture  of,  957 

stone  in,  959 

tumors  of,  966 

ulcer  of,  965 

wounds  of,  956 
Blastomycetes  dermatitis,  18 
Bleeding  by  leeching,  73 

by  puncture,  73 

by  scarification  or  incision,  73 

from  kidney -substance,  927 

in  inflammation,  73,  84 
Blisters  in  inflammation,  83 
Blood  in  urine,  tests  for,  927 

placques  in  inflammation,  62 

transfusion  of,  331 

vessels,  repair  of,  103 
Bloodgood's  operation  for  varicocele,  330 
Bobbins,  decalcified  bone,  805 
Bodine's  operation  of  inguinal  colostomy, 

818 
Boil,  896 

Aleppo,  897 

blind,  896 

endemic  tropical,  897 
Bond's  splint  in  Colles's  fracture,  436 
Bone,  abscess  of,  chronic,   125,  367 

actinomycosis  of,  3C4 

atrophy  of,  364 


Index 


1075 


Bone,  cysts  of,  364 

excision  of,  536 

ferrules.  533 

hypertrophy  of,  364 

necrosis  of,  369 

repair  of,  103 

tuberculosis  of,  364 

tuberculous  disease  of,  182 

tumors  of,  364 
Bone-chips,  decalcified,  Senn's,  56 
Bone-drills,   Brainard's,  with  Wyeth's  ad- 
justable handles,  534 

Hamilton's  improved,  534 
Bone-felon,  562 
Borsch's  eye-bandage,  916 
Bottini's  galvanocaustic  prostatotomy,  1013 
Bougie,  esophageal,  688 
Bougie-a-boule,  991 
Bowels,  ulcer  of,  722 
Bow-legs,  572 

Brachial  artery,  ligation  of,   340 
Bracketed  plaster-of-Paris  dressing,  396 
Brain,  abscess  of,  115,  618 
from  ear  disease,  620 

compression  of,  604 

concussion  of,  603 

disease  of,  from  suppurative  ear  disease, 
619 

fissures  and  convolutions  of,  595 

healing  of,  100 

hernia  of,  615 

laceration  of,  603 

operations  on,  technique,  631 

rupture  of  sinus  of,  608 

traumatic  inflammation  of,  615 

water  on,  617 

wounds  of,  613 
Brainard's    bone-drills    with    Wyeth's    ad- 
justable handles,  534 
Brain-sand  tumor,  252 
Branchial  cysts,  277 

fistula,  277 
Brandt's  operation  of  gastroplication,  799      i 
Brasdor's  operation  for  aneurysm,   302 
Braun's  method  of  gastro-enterostomy,  796  j 
Breast,  abscess  of,   117  i 

acute,  1047 
chronic,  125 
tuberculous,   126 

adenocele  of,  1049 

adenoma  of,  cystic,  1049 

angioma  of,   1050 

cancer  of,  105 1 

carcinoma  of,  105 1 

cysts  of,   1049 
hydatid,    1050 

fibro-adenoma  of,   1049 

fibroma  of,  cystic,  1050 

inflammation  of,  1046 

inoperable  diseases  of,  1056 

male,  cancer  of,  1053 

myxoma  of,    1049 

sarcoma  of,  105 1 

scirrhus  of,  105 1 
atrophic,   1052 

tuberculosis  of,   181 

tumors  of,  1049 


Breast,  tumors  of,  malignant,   1051 
Brodie's  abscess,  367 

joint,  492 
Bronchocele,  900 
Bronchus,  foreign  bodies  in,  658 
Brush-burn,   203 
Bryant's  extension  in  fracture  of  thigh  in 

children,  453 
Bryson's  operation  of  prostatectomy,   1013 
Bubo  in  gonorrhea,  990 

syphilitic,  227 
Buck's  extension  apparatus  in  fractures  of 

femur,  443 
Bullet-forceps,   211 
Bullet  probe,  Fluhrer's,  211 
Girdner's  telephonic,  213 
Lilienthal's,  211 
Nelaton's,  211 
Bul'ets,  description  of  modern,  206 

Dumdum,  209 
Bunion,  564 
Burns  and  scalds,  892 
of  epiglottis,  894 
of  esophagus,  894 
of  glottis,   894 
of  pharynx,  894 
of  tongue,  894 
x-ray,   1059 
Bursitis,  563 


Cable  twist  silk  for  sutures  and  ligatures, 

53 
Cachexia,  cancerous,  271 
Calculi  in  ureter,  941 

pancreatic,  768 

renal,  939 

vesical,  959 
Callus,  formation  of,  389 
Calyx-eyed  needle,   781 
Cancer,  269.     See  also  Carcinoma. 

colloid,  274 

contact,  271 

en  cuirasse,  105 1 

melanotic,  274 

of  breast,    105 1 
male,   1054 
treatment  of,    1053 

of  penis,   1005 

of  rectum,  865 

Kraske's  operation  in,  867 
Cancerous  cachexia,  271 
Cancnim  oris,   149 
Cannon-ball  wounds,  209 
Cannula  a  chemise,  325 

Bellocq,  324 
Capsule  of  bacteria,  19 
Caput  medusa-,  289 

succedaneum,  602 
Carbolic  acid,   25 
antidote  for,  26 
poisoning  by,  26 
Carboluria,  26 
Carbuncle,  S97 

of  anthrax,  217 
Carcinoma,  269.     See  also  Cancer. 

bacteriology  of,  271 


10/6 


Index 


Carcinoma,  classiacation  of,  272 

encephaloid,   274 

glandular,  274 

hematoid,  274 

increase  of,  272 

medullary,  274 

of  brain,  624 

of  breast,   1051 

of  esophagus,  690 

of  lower  lid,    682 

of  stomach,  704 

of  tongue,  684 

recurrence  of,  271 

scirrhous,  274 

telangiectatic,  274 

transplantation  of,  270 

treatment  of,   275 
Caries,  368 

necrotica,  368 

sicca,  368 

spinal,  640 

vertebral,  Treves's  operation  for,  535 
Carnot's  solution  for  treatment  of  aneurysm, 

-99. 
Carotid,  common,   ligation  of,  347 

external,  ligation  of,  349 
Carpus,   fractures  of,  437 
Cartilage,  inflammation  in,  64 
Castration,  1015,   1019 
Cataplasm,  81 
Catarrh,  chronic  urethral,  984 

venereal,  982 
Catgut,  chromicized,  51 

for  ligatures,  49 

method  of  tying,  52 

preparation  of,  49 

Boeckman's  method,  51 
cumol  method,   50 
formalin  method,  51 
Fowler's  method,  50 
Johnston's  method,  51 
Kronig's  method,  50 
Senn's  method,  51 
Cathartics  in  inflammation,  85 
Catheter,  disinfection  of,  953 

English  silk-web,  957 

Gouley's,  954 

Mercier's,  elbowed  and  curved,  955 

Nelaton's,  954 
Catheterization  of  ureter,  928 
Catlin,  1024 
Cautery,   actual,   in  hemorrhage,  318 

as  counterirritant,  83 

Paquclin,  318 
Celiotomy,  772 
Cell-division,  98 

Cell -proliferation  in  inflammation,  62 
Cellular  emphysema,  406 
Cellulitis,  169 

diffused,  1 1 1 

gangrenous,    1 69 
Celluloid  thread  for  sutures  and  ligatures, 

.5.3 
Cementome,  254 
Centipedes,  215 
Cephalodynia,  553 
Cerebellum,  tumors  of,  626 


Chancre,  225 

and  chancroid,  mixed  infection  of,  225 

diagnosis  of,  225 

redux,  226 

soft    1003 
Chancroid,   1003 
Charbon,  216 
Charcot's  acute  bed-sores,  151 

disease,  491 

joint,  491.     See  Charcot's  disease. 
Charriere's  tourniquet,   1024 
Cheiloplasty,  683 
Chemotaxis  in  inflammation,  61 

negative,  19 

positive,  19 
Chest,  contusions  of,  666 

wounds  of,  667 
Chilblain,  895 
Chlorid  of  calcium  in  hemorrhage,  318 

of  ethyl,  882 
anesthesia,  886 

followed  by  ether  or  chloroform,   885 
Chloroform,   871 

administration  of,  873 

and  oxygen,  874 

anesthetic  state  from,  876 
Chloroma,  262 
Cholangitis,  infective,  759 

suppurative,  759 
Cholecyst,  280 
Cholecystectomy,  764,  820 
Cholecystendysis,  763 
Cholecystenterostomy,  764,  820 
Cholecystitis,  754 

acute  phlegmonous,  75S 

bacteriology  of,  755 

catarrhal,  755 

simple  suppurative,  757 
Cholecystotomy,  819 
Choledochoduodenostomy,  764 
Choledocho-enterostomy,  764 
Choledocholithotomy,  821 
Choledocholithotrity,  763 
Choledochostomy,  764 
Choledochotomy,   764,  821 
Cholesteatoma,  252 

of  brain,  624 
Chondroma,  252 
Chopart's  amputation,   1036 
Chordee,  989 
Christian's   treatment  in  acute  gonorrhea 

.989. 
Cicatrization,  97 
Circular  amputation,   1025 
Cirsoid  aneurysm,  259 
Clap,  982 
Claret  stains,  258 
Claviceps  purpurea,  148 
Clavicle,  excision  of,  547 

fractures  of,  411 

traumatic  dislocations  of,  504 
Clavus,  899 
Claw-hand,  582,  583 
Cleft  palate,' 678 

operations  for,  680 
Cloaca,  369 
Clostridium    22 


Index 


1077 


Clot,  external,  307 

internal,  307 
Clover's  ether-inhaler,  875 
Club-foot,  572 

varieties  of,  572 
Club-hand,  572 

Cocain  hyclrochlorate  anesthesia,  886 
Cocainization  of  nerve-trunks,  887 

of  spinal  cord,  889 
Cocci,  20 

pyogenic,  20 

wool-sack,  20 
Coccyx,  fractures  of,  411 
Cock's  operation  in  urinary  fever,   1002 
Cohnheim's     inclusion     theory     of     tumor 

origin,  245 
Coin-catcher,   688 
Cold,  dry,  in  treatment  of  inflammation,  76 

effect  of,  894 

in  treatment  of  inflammation,  75 

wet,  in  treatment  of  inflammation,   76 
Coley's  treatment  for  sarcoma,  266 
Colic,  appendicular,  728 
Collapse,  193 
Colles's  fracture,  433 

law  in  syphilis,  241 
Collins's  apparatus  for  saline  infusion,  332 
Colon  bacillus,  40 
Colopexy,  862,  863 
Colostomy,  inguinal,  817 

lumbar,  818 
Common  carotid  artery,  ligation  of,  347 
Compression  in  treatment  of  inflammation, 
78 

of  spinal  cord,  648 
Concussion  of  brain,   603 

of  spinal  cord,  647 
Condyloma,  flat,  of  syphilis,  229 
Congestion  of  thyroid,  900 
Connell's  suture,  782 
Contact  cancer,  271 
Contraction  of  muscles,  558 
Contusions,  191 

and  wounds,  191 

of  bladder,  956 

of  spinal  cord,  647 
Cooper's  operation  on  abdominal  aorta,  362 
Coracoid  procesS;   fractures  of,  416 
Corn,  899 

Cornea,  inflammation  of,  63 
Corona  venerea  of  syphilis,   229 
Corpus  striatum,  tumors  of,  625 
Corrosive  sublimate,  24 
dilutions  of,  25 
poisoning  by,  25 
Cortical  motor  areas,  lesions  of,  625 
Counterirritants  in  inflammation,  82 
Cowperitis  in  gonorrhea,  990 
Coxa  vara,  576 
Coxalgia,  pain  of,  67 
Coxitis,  475 

Craniotomy,  linear,  634 
Crede's  ointment  cf  silver,  29 
Creolin,  27 
Cretinism,  900 

Cripp's  operation  in  rectal  cancer,  S67 
Cryoscopy,  933 


Cupjjing,  dry,  74 

wet,   74 
Curling's  ulcer,   722 
Cushing's  suture,  781 
Cyanid  gauze,  for  dressings,  54 
Cylindroma,   264 
Cyrtometcr,  Horsley's,  598 
Cysticotomy,  764 
Cystitis,  961 

acute,  962 

chronic,  963 

tuberculous,  063 

in  gonorrhea,  990 
Cystocele,  824 
Cystoma,  276 

atheromatous,  276 

mesoblastic,  277 

mucous,  277 

traumatic  epithelial,  276 
Cystoscopes,  Nitze's,  952 
Cystoscopy,  051 
Cystotomy,  974 

median,  976 

suprapubic,  975 
Cysts,  279 

anosacral,  635 

branchial,  277 

dentigerous,  254 

dermoid,   278 

from  softening,  280 

hydatid,  281 

lacteal,  280,   1050 

mucous,  280 

of  bone,   364 

of  breast,    1049 

of  liver,  748 
hydatid,  749 

of  nipple,   1048 

of  pancreas,   769 

of  vitello-intestinal  duct,  280 

oil,  280 

parasitic,  281 

retention,  279  , 

salivary,  280 

sebaceous,  279 

thyro-lingual,  684 

urachal,  281 
Czerny-Lembert  "suture,  7S2 
Czerny's  method  of  tendon-lengthening,  567 


Davy's  lever,   1041 
Death  by  inhibition,    103 
Decortication,  pulmonary,  676 
Decubitus,  135,  151 
Defecation  spermatorrhea,  980 
Degeneration  of  muscles,  554 

pulpy,  472.     See  Arthritis,  tuberculous. 
De  Guise's  operation,  677 
Demi-gauntlet  bandage,  914 
Deodorizers,  24 
Derbvshire  neck,  00 1 
Dermatitis,  malignant,  1049 

venenata,  896 
Dermoid  cysts,  278 
Desault's  bandage,  919 

sign  of  fractures  of  femur,  441 


1078 


Index 


Diabetes,  operations  in,  147 
Diapedesis  in  inflammation,  61 
Diaphoretics  in  inflammation,  86 
Diaphragm,  hernia  of,  849 

rupture  of,  666 
Diastasis,  381 
Diet  in  inflammation,  89 
Dilatation,  acute,  of  stomach,  714 

chronic,  of  stomach,  713 

of  pylorus,   digital,   784 

of  urethra,  rules  for,  994 
Dilators,  Gross's,  998 

Kollmann's,  993 

Oberlander's,  993 
Diplococci,  20 
Diplococcus  pneumonije,  40 
Disarticulation,  anterior  intertarsal,   1036 

at  ankle-joint,  1037 

at  elbow,  1031 

at  hip,  1041 

at  metacarpophalangeal  joint,   1029 

at  shoulder,  103 1 

at  wrist,    1029 

of  knee,   1039 

subastragaloid,  1036 

tarsometatarsal,  1034 
Disease  oroduction,  31 
Disinfection  of  catheters,  953 

of  instruments,  47 

of  mucous  membranes,  48 
Dislocation,  congenital,  500 

of  hip,  Hoffa's  operation  for,  552 
Lorenz's  bloodless  reduction  of,  551 
Lorenz's  operation  for,  552 

consecutive,  500 

of  muscles,  558 

of  spine,  648 

of  tendons,  558 

of  ulnar  nerve  at  elbow,  586 

pathological,  500 

spontaneous,  500 

traumatic,  499 
compound,  503 
of  ankle-joint,  526 
of  astragalus.  527 
of  carpal  bones,  516 
of  clavicle,  504 
of   clavicle,    Rhoads's    apparatus    for, 

of  elVjow-joint,  512 
of  femur,  51S 

anomalous,  521 

into  obturator  foramen,  520 

into  sciatic  notch,  520 

upon  dorsum  of  ilium,  519 

upon  pubis,  521 

with    catching   up    of   sciatic    nerve 
during  reductit^n,  521 

with  fracture  of  shaft,  522 
of  fibula,  525 
of  humerus,   506 

Kocher's  reduction  in,  509 

reduction  of,  by  extension,  510 

Smith's  reduction  in,  510 

symptoms  of,  508 

treatment  of,  509 
of  knee,  522 


Dislocation,  traumatic,  of  lower  jaw,  503 
of  metacarpal  bones,  516 
of  metacarpophalangeal  articulations, 

516 
of  metatarsals,  528 
of  patella,  524 
of  phalanges,  517,  528 
of  radius,  514 

and  ulna,  513 
of  ribs  and  cartilages,  517 
of  scapula,  506 
of  semilunar  cartilages  of  knee-joint 

524 
of  sternum,  517 
of  tarsals,  528 
of  ulna,  514 
of  wrist,  515 
old,  503 
pelvic,  517 
Displacement  in  plastic  surgery,  923 
Dissection  wounds,  213 
Distention  of  frontal  sinus,  656 
Diuretics  in  inflammation,  86 
Diverticula  of  esophagus,  691 
Diverticulum,  Meckel's,  280 

pharyngeal,  278 
Divulsors,  Gouley's,  999 

Thompson's,  999 
Dorsalis  pedis  artery,  ligation  of,  352 
Douche  in  treatment  of  inflammation,  79 
Downes'  hemostatic  instrument  for  hemor- 
rhage, 319 
Doyen's  vasotribe,  313 
Drainage,  55 

Drainage-tube,  Stevenson's,  976 
Dressings,  change  of,  55 
fixed,  921 
for  wounds,   53 

Mayer's,  for  Wolf's  skin-grafting,  925 
plaster-of-Paris,  920 
silicate  of  sodium,  921 
Drum-stick  bacteria,  22 
Dry-air  apparatus,  hot,  Sprague,  471 
Dumdum  bullet,  209 
Dunham's  apparatus  for  fractured  thigh  in 

children,  453 
Duodenocholedochotomy,  823 
Duodenostomy,  800 
Duodenum,   peptic  ulcer  of,   722 
Dupuytren's  amputation  at  shoulder,  1033 
contraction,  570 
suture,   781 
Duret's  operation  of  gastropexy,  Soo 


Ear,  affections  of,  in  syphilis,  : 
Ecchondroscs,  252 
Ecthyma,  230 
Ectopia   vesica;,  956 
Edema,   malignant,  214 
bacillus  of,  40 

of  glottis,  656 

of  larynx,   656 
Effusion,  pleuritic,  661 

miners',  564 
Elbow,  disarticulation  at,  1031 
Elbow-joint  disease,  483 


31 


Index 


1079 


Elbow-joint,     dislocations     of,    512.      See 
Dislocations  of  elbow-joint. 

fractures  in  or  near,  426 
Electricity,  effect  of,  1068 

injuries  by,   1067 
Electrohemostasis,  319 

Electrolysis  in  treatment  of  aneurysm,  303 
Elephantiasis,  gii 

Elliptical  method  of  amputation,  1027 
Embolism,  157 

air-,  160 

fat-,  158 

infarction  from,   158 
Emetics  in  inflammation,  87 
Emphysema,  cellular,  406 

gangrenous,   144,  214 
Empyema,  662 

acute,  662 

recurrent  simple,  of  gall-bladder,   758 
Encephalitis,  617 
Encephalocele,  601 
Endarteritis,  chronic,   2Q2 
Endospore,  21 
Endothelioma,  264 
Endspore,  21 

Enterectomy,   limits  of,   801 
Enterocele,  824 

partial,  849 
Entero-epiplocele,  824 
Enteroptosis,  739 
Enterorrhaphy,  781 

Halsted's  cylinder  in,  806 

Harris's,  805 
Enterostenosis,  715 
Enterostomy,  816 
Enzymes,  31 
Epidermization,  97 
Epididymectomy,   1019 
Epididymis,  hydrocele  of,   1022 
Epididymitis,   1020 

in  gonorrhea,  990 
Epiglottis,  burns  and  scalds  of,  894 
Epilepsy,  operative  treatment  of,  627 
Epiphyseal  separation,  381 
Epiplocele,  824 
Epiplopexy,  815 
Epispadias,  1002 

Epistaxis,  rule  for  treatment,  323 
Epithelioma,  272 

cylindrical-celled,  273 

s([uamous-celled,  272 
Epulides,  fibrous,  250 
Equinia,  220 
Erectile  tumors.  258 
Ergotism,  gangrene  from,   148 
Erosion,  537 

of  knee-joint,  537 
Erysipelas,  166 

cellulocutaneous,   168 

cutaneous,  166 

phlegmonous,   168 

varieties  of,  166 
Erysipele  salutaire,   167 
Erythema,  228 
Escherich,  bacillus  of,  40 
Esmarch"s  elastic  bandage,  1023 
Esophageal  instruments,  688 


Esophagismus,  691 
Esophagotomy,  external,  689 
Esophagus,  burns  and  scalds  of,  894 
carcinoma  of,  690 
diverticula  of,  691 
foreign  bodies  in,  692 
injuries  of,  692 
stricture  of,  687 
spasmodic,  691 
Estlander's  operation.  675 
Ether,  871 

administration  of,  874 

rectal,  876 
Allis's  inhaler  for,  874 
and  chloroform,  88 1 
and  gas,  885 
and  oxygen,  875 
anesthetic  state  from,  S76 
Clover's  inhaler  for,  875 
Etherization,  rectal,  876 
Ether-pneumonia,  8S0 
Ether-spray  anesthesia,  886 
Ethvl  bromid,  S82 
chlorid,  882 
anesthesia,  886 

followed  by  ether  or  chloroform,  885 
Eucain  hydrochlorate  anesthesia,  888 
Europhen,  28 
Evacuator,  Bigelow's,  970 

Thompson's,  972 
Ewald's    salol    test    for    motor    power    of 

stomach,  714 
Excision,  536 

of  ankle-joint,  545 

Hancock's  method,  546 
of  astragalus,  547 

by  subperiosteal  plan,  547 
of  clavicle,  547 
of  half  of  lower  jaw,  550 
of  half  of  upper  jaw,  54S,  549 
of   hip-joint,  543.     See    also   Hip-joint, 
excision  of. 
by  anterior  incision,  543 
by  Gross's  incision,  544 
by  lateral  incision,  544 
of  knee-joint,  544 

by  anterior  semilunar  flap,  544 
of  metacarpals,  543 
of  metatarsals  of  great  toes,  547 
of    metatarsophalangeal    articulation    of 

great  toe,  547 
of  OS  calcis,  546 
of  pylorus,  7S6 
of  rib,  548 
of  scapula,  547 
of  shoulder-joint.  530 
by  anterior  incision,  540 
by  deltoid  flap,  540 
Senn's  method,  540 
of  wrist-joint,  541 
Lister's  method,  542 
Exclusion,  intestinal,  local,  814 
Exfoliation,  369 
Exostosis,  253 

subungual,  254 
Expectoration,    albuminous,    after    aspira- 
tion, 672 


io8o 


Index 


Exstrophy  of  bladder,  956 

External   carotid   artery,    ligation   of,    349 

clot,  307 


Fabricius'  operation  in  hernia,  S41 
Facial  artery,  ligation  of,  351 
Facio-accessory  anastomosis,  594 
Faciohypoglossal  anastomosis,  594 
Farcy,  220 

Fascia,  tuberculous  disease  of,   182 
Fasciotomv,  subcutaneous,  of  plantar  fascia, 

566 
Fat-embolism,   158 
Fat-hernia,  249 
Fecal  fistula,  721 
Fell-O'Dwyer  apparatus,  666 
Felon,  561 

deep,  562 
Femoral  artery,  ligation  of,  356 
Femur,  dislocation  of,  traumatic,  518 

fractures  of,  438 

separation  of  lower  epiphysis  of,  455 
Fenestrated   plaster-of-Paris   dressing,   395 
Fergusson's  operation,  681 
for  varix  of  leg,   330 
in  hernia,  836 
Fever,  aseptic,  105 

emotional,  107 

hepatic,  762 

hysterical,  107 

intermittent  hepatic,  759 

malarial,   107 

of  morphinism,   107 

of  tension,  107 

post-operative,  105 

rheumatic,  487 

scarlet,  surgical,  105,  107 

surgical,  genuine,  106 

suppurative,   106 

traumatic,  105 
benign,  105 
true,  106 

urethral,  999 

urinary,   1000 
Fibro-adenoma,  269 

of  breast,   1049 
Fibroma,  250 

hard,  250 

nasopharyngeal,  250 

of  brain,  624 

of  breast,    1050 

soft,  250 

treatment  of,  252 
Fibrosis,  arteriocapillary,  292 
Fibrous  epulides,  250 
Fibula,  dislocations  of,  525 

fracture  of,   464.     See  also  Fracture  oj 
fibula. 
Finger,  amputation  of,  1028 

supernumerary,   571 

webbed,  571 
Finney's  method  (jf  jjyloroplasty,  785 
Finsen's  light  treatment  of  tuVjerculosis,  185 
Fissure,  intrajjarietal,  location  of,  596 

of  anus,  858 

of  Bichat,  location  of,  595 


Fissure  of  nipples,  1046 

of  Rolando,  location  of,  595 

of  Sylvius,   location  of,   596 
Fistula,  136 

branchial,  277 

fecal,  721 

Senn's  operation  in,  S16 

in  ano,  855 
Flail-joint,  576 

Flap  method  of  amputation,    1027 
Flat-foot,  574 

Flexion,  forced,  in  hemorrhage,  316 
Floating  cartilages,  498 

hepatic  lobe,  754 

liver,  753 
Fluhrer's  bullet-probe,  211 
Fluoroscope,  1057 

for  locating  bullets,  211 
Fomentation,  antiseptic.  Si 

in  treatment  of  inflammation,  80 
Foot,  amputation  of,  1034 

fractures  in,  468 
Forbes's  lithotrite,  971 
Forceps,  bullet-,  211 

curved  hemostatic,  310 

esophageal,  688 

Halsted's  straight  artery,  310 

Laplace's,  for  intestinal  anastomosis,  807 

O'Hara's  anastomosis,  808 

straight  hemostatic,  311 

Thompson's  vesical,  974 
Ford's  stitch,  781 
Forearm,  amputation  at,  1030 
Formaldehyd,  29 
Formalin,  29 
Formalin-gelatin,  29 
Formic  aldehyd,  29 
Fowler's  gastro-enterostomy,  798 
with  Murphy  button,  799 

method  of  gastro-enterostomy,   794 

operation,  676 
in  hernia,  835 
Fox's  apparatus  for  fractured  clavicle,  413 
Fracture  en  cain,  380 

en  rave,  380 

en  V,  of  Gosselin,  380 
Fracture-box  for  bones  of  leg,  464 
Fractures,  377 

Barton's,  434 

bent,  379 

by  contrecoup,  381 

capillary,  379 

causes  of,  382 

Colles's,  433 

Bond's  splint  in,  436 

comminuted,  380 

complete,  378 

complicated,  378 

complications  and  consequences  of,  388 
prevention  and  treatment  of,  393 

composite,  380 

compound,  377 
primary,  378 
secondary,  378 

cuneated    380 

cuneiform,  380 

delayed  union  of,  390 


Index 


1081 


Fractures,  dentate,  380 
depression,   379 
diagnosis  of,  386 

by  :\;-rays,   1064 
direct,  381 
fissured,  379 

from  muscular  action,  382 
from  violence,  direct,  382 

indirect,  382 
green-stick,  379 
hair,  379 
helicoidal,  381 
hickory-stick,  379 
impacted,  380 
incomplete,  379 
indirect,  381 
intra-uterine,  3S2 
linear,  379 
longitudinal,  379 
multiple,  380 
non-union  of,  390 
oblique,  379 

of  acetabulum,  at  brim,  442 
of  acromion,  415 
of  carpus,  437 
of  clavicle,  411 

at  acromial  end,  414 

at  shaft,  412 

at  sternal  end,  415 

Fox's  apparatus  for,  413 

Moore's  dressing  for,  414 

Sayre's  dressing  for,  413 
of  coccyx,  411 
of  coracoid  process,  416 
of  costal  cartilages,  407 
of  femur,  438 

above  condyles,   154 

at  neck,  in  children,  447 

at  shaft,  449 
in  children,  453 

at  upper  extremity,  438 

extracapsular,  446 

intracapsular,  439 

longitudinal,  455 

separating  cither  condyle,  455 

separation  of  upper  epiphysis,  448 

treatment  by  extension  in,  450 
of  fibula,  464 

at  upper  two-thirds,  464 

in  lower  third,  464 

Pott's,  465 
of  foot,  468 
of  glenoid  cavity,  415 
of  great  trochanter,  448 

separation  of  epiphysis,  449 
of  humerus,  416 

at  anatomical  neck,  416 

at  base  of  condyles,  425 

at  external  condyle,  423 

at  head,  419 

at  inner  cpicondyle,  424 

at  internal  condyle,  424 

at  lower  epiphysis,  429 

at  shaft,  420 

at  surgical  neck,  41S 

in  or  near  elbow-joint,  426 
separation  of  upper  epiphysis,  420 


Fractures  of  humerus,  T -fracture,  425 
of  hyoid  bone,  404 
of  inferior  maxillary  bones,  402 
of  lachrymal  bone,  399 
of  laryngeal  cartilages,  404 
of  metacarpals,  438 
of  metatarsal  bones,  468 
of  nasal  bones,  397 
of  patella,  455 

by  direct  force,  461 

transverse,  456 
treatment  of,  458 
treatment  of,  needle  for,  458 

ununited  and  badly  united,  462 
operative  treatment  of,   535 

wired,  461 
of  penis,  1005 
of  phalanges,  438 

of  toes,  469 
of  radius,  432 

above  insertion  of  pronator  radii  teres, 

432 
and  ulna,  433 

near  wrist,  437 
at  head,  432 
at  lower  extremity,  433 
at  neck,  432 
at  shaft,  432 
below  insertion  of  pronator  radii  teres 

433 
separation  of  lower  radial   epiphysis, 

437 
of  ribs,  405 
of  sacrum,  41  r 
of  scapula,  415 
of  skull,  608 
of  spine,  648 
of  sternum,  407 
of  superior  maxillary  bone,  399 
of  tibia,  462 
and  fibula,  467 
at  inner  malleolus,  464 
at  lower  end,  464 
at  shaft,   463 
at  upper  end,  462 
separation  of  epiphyses  of,  464 
of  tubercle  of,  463 
of  true  pelvis,  409 
of  ulna,  429 

at  coronoid  process,  429 
at  olecranon  process,  430 
at  shaft,  431 
at  styloid  process,  432 
of  zygomatic  arch,  401 
par  irradiation,  381 
pathological,  3S1 
Pott's,  465 
repair  of,  388 
secondary,  381 
spiral,  381 
splinter,  379 
spontaneous,  381 
stellate  or  starred,  381 
strain,  379 
symptoms  of,  384 
toothed,  380 
torsion,  381 


io8: 


Index 


Fractures,  transverse,  379 

treatment  of,  390 

T-shaped,  380 

ununited,  381 

operative  treatment  of,  535 

varieties  of,  377 

\'icious  union  of,  390 

V-shaped,  380 

wedge-shaped,  380 

willow,  379 

with  crushing,  381 

with  penetration,  381 
Frank's  method  of  gastrostomy,  792 
Frazier-Spiller    operation    of    intracranial 

neurotomy,  593 
Freezing  for  anesthesia,  586 
Fremitus,  hydatid,  281 
Frontal  sinus,  distention  and  abscess  of,  656 

trephining  of,  631 
Frost-bite,  gangrene  from,  149 
Fuller's  operation  of  prostatectomy,  1012 
Fungi,  budding,  18 

filamentous,  18 
Fungus  cerebri,  615 

of  testicle,  184 
Fiirbringer's  method  of  cleansing  hands  for 

operations,  45 
Furuncle,  896 


Galactocei.e,  1050 

Gall-bladder  and   bile-ducts,   inflammation 
of,   catarrhal,  755 
croupous,  756 
suppurative,  756 
empyema  of,  recurrent  simple,  758 
inflammation  of,   754 
removal  of  mucous  membrane  of,  821 
rupture  of,  700 
Gall-stones,  760 
Ganglia,  761 

Ganglion,  Gasserian,  removal  of,  591 
Gangrene,  acute,  142 
chronic,  140 
classification  of,  138 
decubital,  151 
diabetic,  146 

operations  for,   146 
dry,  139 

non-senile,  139 
senile,  140 

senile,  prevention  and  treatment  of,  141 
emphysematous,  144 
foudroyante,   144 
from  carfjolic  acid,   153 
from  ergotism,  148 
from  frost-bite,  149 
fulminating,   144 
hosf)ital,  145 
microbic,  144 
moist,  142 

from  inflammation,  143 
of  limb,  143 
treatment  of,    143 
of  lung,  669 
of  penis,  1005 


Gangrene,  post-febrile,  153 

Pott's,  140 

Raynaud's,  145 

rules  for  amputation  in,  154 

spreading,  144 

symmetrical,  145 

traumatic,  144 
Gangrenous  emphysema,  214 
Gas  and  ether,  885 
Gasoline,  commercial,   30 
Gasserian  ganglion,  removal  of,  591 
Hartley's  method,  592 
Horsley's  method,  593 
Gastrectomy,  total,  789 
Gastro-duodenostomy,  796 
Gastro-enterostomy,  792 

anterior,  794 

Braun's,  796 

complications  of,  793 

Fowler's,  794,  798 

Jaboulay's,   796 

Kocher's,  794,  795 

Lijcke's,  794 

Mayo's  method,  795 

McGraw's  method,  794,  796 

posterior,  796 

Senn's  method,  794 

vicious  circle  and  regurgitation  after,  793 

vomiting  after,  794 

von  Hacker's,  794 

with  Murphy  button,  797 

Wolfler-Liicke's,  794,  797 
Gastrogastrostomy,  799 

Wolfler's  method,  798 
Gastro-jejunostomy,  792 
Gastropexy,   800 
Gastroplication,  799 
Gastroptosis,  715 

Beyea's  operation  for,  800 

Brandt's  operation  for,   799 

Buret's  operation  for,   800 
Gastrostomy,  789 

Frank's,  792 

Kader's,  791 

Senn's  (Emanuel),  791 

Ssabanejew-Frank's,  791 

Witzel's,  790 
Gastrotomy,  789 
Gault's  trephine,  629 
Gauntlet  bandage,  914 
Gauze,   antiseptic,   for  dressings,  53 

cyanid,  54 

iodoform,  54 

sterilized  or  aseptic,  54 
Gebauer's  ethyl-chlorid  spray,  886 
Gelatin,  injection  of,  for  hemorrhage,  317 

in  treatment  of  aneurysm,  298 
Gelatinous  polyps,  255 
Genu  valgum,  572 

Ogston's  operation  for,  530 
osteotomy  for,  529 
Genu  varum,  572 
Germicides,  24 
Gibney's  method  of  strajjjjing  in  sprained 

ankle,  495 
Gibson's  bandage,  916 
Gila  monster,  216 


Index 


1083 


Girdner's  telephonic  bullet  probe,  211 
Glanders,  220 

bacillus  of,  40 
Glanduke  Pleiades  of  Ricord,  in  syphilis,  227 
Gleet,  9S4 

Glenard's  disease,  739 
Glenoid  cavity,  fractures  of,  415 
Glioma,  258 
of  brain,  624 
of  eyeball,  262 
Glottis,  burns  and  scalds  of,  894 

edema  of,  656 
Gloves  for  operation,  46 
Gluteal  artery,  ligation  of,  360 
Goiter,  goo 
causes  of,  901 
exophthalmic,  904 
pulsating,   904 
symptoms  of,  902 
treatment  of,  903 
varieties  of,  900,  901 
Gonococcus,  38 
Gonorrhea,  9S2 
abortive,  984 

acute  inflammatory,  complications  of,  983 
symptoms  of,  983 
treatment  of,  985 
catarrhal,  9S4 
chronic,   treatment  of,  991 
in  female,  995 
irritative,  984,  987 
of  anus  and  rectum,  994 
of  mouth,  995 
of  nose,  995 
subacute,  984 
uterine,  995 
Gonorrheal  arthritis,  485 
ophthalmia,  990 
rheumatism,  4S5 
Gouley's  divulsors,  999 
tunnelled  catheter,  954 
whalebone  guides,  054 
Gout,  rheumatic,  4S9.     Sec  Osleo-arlhritis. 
partial,  490 
progressive,  490 
Granny-knot,  311 
Grant's  operation,  531 

for  carcinoma  of  lip,  683 
Granulation  tissue  in  inflammation,  63 
Graves's  disease,  904 
Great  trochanter,  fracture  of,  44S 
Gritti's  amputation,  1040 
Gross's  dilators,  998 
Gumma  of  tertiary  syphilis,  233 

tuberculous,  181 
Gunshot  Vi-Qunds,  205 
amputation  fo.r,  212 
asepsis  in,  212 
from  Dumdum  bullet,  209 
of  abdomen,  703 
of  arteries,  308 
of  head,  614 
of  pregnant  uterus,  703 
symptoms  of,  209 
treatment  of,  210 
Gussenbauer's  suture,  782 
Guthrie's  rule  in  hemorrhage,  319 


Hagedorx's  needles,  312 
Hallux  valgus,  575 

osteotomy  for,  532 

varus,  575 
Halsted's  artery  forceps,  310 

cylinder  in  enterorrhaphy,  806 

operation  in  cancer  of  breast,   1053 
in  hernia,  833 

plus  Bloodgood's,  834 

suture,  782 
Hamilton's  bone-drills,  improved,  534 
Hammer-toe,  575 
Hancock's  method  of  excising  ankle-joint, 

546 
Hands,  cleansing  of,  for  operations,  45 
Harelip,  678 

operation  for,  679 
Harris's  method  of  enterorrhaphy,  805 

urine  segregator,  929 
Hartley's   operation    for    removal    of    Gas- 

serian  ganglion,  592 
Head,  contusions  of,  603 

gunshot-wound  of,  614 

topography  of,  595 

tuberculous  abscess  of,   124 
Healing  by  blood-clot,  95 

by  first  intention,  92 

by  immediate  union,  93 

by  second  intention,  95 

exuberant  granulations  in,  97 

by  third  intention,  97 

cell-division  in,  98 

in  non-vascular  tissue,  97 

karyokinesis  in,  98 

of  abscess,   113 

of  blood-vessels,  103 

of  bone,  103 

of  brain,   100 

of  muscle,  10 1 

of  nerve  fiber,  98 

of  skin,  104 

of  spinal  cord,   roo 

of  subcutaneous  wounds,  97 

of  tendon,   103 

of  various  internal  organs,  104 
Heart,  rupture  of,  283 

wounds  of,  2^7^ 
operation  for,  328 
suture  of,  284 
Heat  as  germicide,  30 

in  treatment  of  inflammation,  77,  80 
Heberden's    nodosities    in    osteo-arthritis, 

490 
Heineke-Mikulicz's  pyloroplasty,  784 
Heller's  test  for  blood  in  urii\e,  927 
Hemangioma.  258 
Hematemcsis,  326 
Hematocele  of  spermatic  cord,  1022 

of  testicle,  1022 

vaginal,   1022 
Hcmatomyelia,  648 
Hematuria,  927 
Hemophilia,   t^t,!. 
Hemoptysis,  326 
Hemorrhage.  308 

actual  cautery  in,  318 

acupressure  in,  314 


io84 


Index 


Hemorrhage,  capillary,  323 

cerebral,  608 

chlorid  of  calcium  in,  318 

compression  in,  314 

Do'wnes'  instrument  for,  319 

electrohemostasis  in,  319 

extradural,  322,  607 

extramedullary  spinal,  322 

forced  flexion  in,  316 

from  artery,  319 

from  cancellous  bone,  321 

from  cerebral  sinus,  322 

from  diploe,  321 

from  ear,  324 

from  extremity,  320 

from  femoral  vein,  321 

from  gunshot-wounds,  324 

from  intercostal  artery,  321 

from  internal  mammary  artery,  321 

from  large  bowel,  326 

from  lateral  lithotomy,  325 

from  leech -bite,  324 

from  lung,  326 

from  nose,  323 

from  palmar  arch,  319 

from  prostate,  325,  931 

from  rectum,  324 

from  small  bowel,  326 

from  stomach,  326 

from  tooth-socket,  322 

from  umbilical  cord,  324 

from  urethra,  931 

from  urethral  meatus,  324 

from  varicose  vein,  323 

from  vein,  319,  321 

gelatin  injections  in,  317 

Guthrie's  rule  in,  319 

in  amputation,  1023 

intra-abdominal,  309,  322 

intracranial,  606 

primary,  320 

rules  for  procedure,  319-326 

reactionary  or  recurrent,  326 

renal,  325 

secondary,  327 

styptics  in,  316 

subcutaneous,  308,  324 

subdural,  608 

suprarenal  extract  in,  318 

torsion  in,  314 

treatment  of,  309 

uterine,  325 

vaginal,  325 

vesical,  325,  931 
Hemorrhagic  diathesis,  333 
Hemorrhoids,  289,  858 

capillary,  859 

external,  858 

connective-tissue,  859 
thrombotic,  858 
varicose,  859 

inflammatory,  859 

interna],    859 

treatment,  operative,  860 
palliative,  860 
Hepatic  fever,  762 
intermittent,  759 


Hepatitis,  pain  of,  67 
Hepatoptosis,  753 

partial,  754 
Hereditation  in  tumor  growth,  245 
Hernia,  abdominal,  824 
causes  of,  824 
cecal,  848 
diaphragmatic,  849 
epigastric,  848 
Fabricius'  method  in,  841 
fat-,   249 
femoral,  847 

Ferguson's  operation  in,  836 
Fowler's  operation  in,  835 
gluteal,  849 

Halsted's  operation  in,  833 
plus  Bloodgood's,  834 
in  childhood,  846 
incarcerated,  841 
infantile,  847 

encysted,  847 
inflamed,  842 
inguinal,  congenital,  S47 
indirect,  847 
interstitial,  848 
Macewen's  method  in,  829 
oblique,  Bassini's  operation  in,  830 
superficial,  848 
interna],  849 

into  foramen  of  Winslow,  849 
into  funicular  process,  847 
irreducible,  841 
Kocher's  operation  in,  S35 
Littre's,  849 
lumbar,  849 

Mayo's  operation  in,  838 
obturator,  848 
of  bladder,  849 
of  brain,  615 
of  muscles,  558 
perineal,  849 
preperitoneal,  848 
pudendal,  849 
reducible,  825 

Lannelongue's  method  in,  828 
treatment  of,  palliative,  826 
radical,  826 
Richter's,  849 

Rokitansky's  diverticula,  S49 
sciatic,  849 
strangulated,  842 
tuberculosis  of,  824 
umbilical,  848 

radical  cure  of,  838 
varieties  of,  847 
ventral,  848 
Herniotomy,  844 
Herpes,   226 

Hewitt's  nitrous  oxid  and  oxygen  apparatus, 
884 
inhaler,  883 
Hey's  amputation  of  foot,  1035 
Hip  disease,  475 

Hip-joint,   disarticulation  at,    1041 
disease  of,  475 

excision  of,   543.      See  also  Excision  oj 
hip-joint. 


Index 


1 08: 


Hip-joint,      excision      of,»     Langenbeck's 
method,  544 
Parker's  method,  543 
traumatic  dislocations  of,  518 
tuberculosis  of,  475 
Hodgen's  apparatus  in  fracture  of  femur, 

Hodgkin's  disease,  911 

Hoffa's    operation    for   congenital    disloca- 
tion of  hip,  552 

Hollow-foot,  575 

Horsehair  for  sutures,  53 

Horsley's  cyrtometer,  598 

method  of  intestinal  anastomosis,  812 
operation     for     removal     of     Gasserian 
ganglion,  593 

Hour-glass  stomach,  712 

Housemaids'  knee,  564 

Humerus,  dislocations  of,  traumatic,  506 
fractures  of,  416 
traumatic  dislocations  of,  subclavicular, 

507 
subcoracoid,  507 
subglenoid  (axillary),  507 
subspinous,  508 
supracoracoid,  508 
Hunter's  operation  for  aneurysm,  301 
Hutchinson  teeth,  242 

knee  splint,  4S1 
Hydatid  fremitus,  281 

toxemia,  282 
Hydrencephalocele,  60  r 
Hydrocele,  chronic,  1021 

congenital,  102 1 

encysted,  of  spermatic  cord,  102 1 

funicular,  1022 

infantile,   102 1 

of  neck,  277 
Hydrocephalus,   602 

acute,  617 
Hydronephrosis,  280,  943 
Hydrophobia,  218 

Pasteur  treatment  for,  220 

spurious,   21Q 
Hydrorrhachitis,  635 
Hydrosalpinx,  280 
Hyoid  bone,  fractures  of,  404 
Hyperemia,  active,  57 
retardation  after,  58 
signs  of,  58 
Hypertrophy  of  bone,  364 

of  muscles,  554 

of  prostate,   1008 

of  thyroid,  congenital,  900 
Hvpnotics  in  inflammation,  86 
Hypodermoclysis,  195 
Hypospadias,  1002 

Hysteria  and  tetanus,  differential  points  of, 
172 

traumatic,  646 
Hysterical  joini,  41)2 


ICHTHYOL  in  inflammation,  7( 
Ileus,  715 

Iliac  arteries,  ligation  of,  35S 
Immediate  union,  9^ 


Immunity,  32 

Ehrlich's  theory  of,  33 

humcjral  theory  of,  33 
Impetigo,  230 

Incontinence  of  retention,  953 
Infarction  from  embolism,  158 
Infection,  mixed,  23 

septic,  162 
Infiltration,  purulent,   11 1 
Infiltration-anesthesia,  Schleich's,  888 
Inflammation,  57 

active  hyperemia  in,  57 

acute,  local  symptoms  of,  6b 
symptoms  of,  66 
treatment  of,  71 

alcohol  in,  89 

anodynes  in,  86 

antipyretics  in,  86 

arterial  sedatives  in,  85 

bleeding  in,  84 
treatment  of,  73 

blood  plaques  in,  62 

catarrhal,  64 

of  gall-bladder  and  bile-ducts,  755 

cathartics  in,  85 

causes  of,  66 

changes  in  perivascular  tissue  in,  62 

chronic,  71 

treatment  of,  90 

classification  of,  64 

constitutional  symptoms  of,  70 

counterirritants  in,  82 

croupous,  64 

of  gall-bladder  and  bile-ducts,  756 

delitescence  in,  63 

derangement  of  absorbents  in,  7c 
secretions  in,  70 

diaphoretics  in,  86 

diet  in,  89 

diphtheritic,  64 

discoloration  in,  68 

disordered  function  in,  70 

diuretics  in,  86 

dry  heat  in,  82 

emetics  in,  87 

extension  of,  65 

exudation  of  fluids  in,  60 

heat  in,  66 

hot-water  bath  in,  82 

hypnotics  in,  86 

impairment   of   special    function    in,    70 

in  cartilage,   64 

in  non-vascular  tissue,  63 

iodids  in,  87 

irritants  in,  82 

leukocytosis  in,  71 

local  treatment  of,   72 

mercury  in,  87 

migration  and  diapedesis  in,  61 

new  growth  in,  66 

of  antrum  of  Highmore,  655 

of  brain,  traumatic,  615 

of  breast,  1046 

of  cornea,  63 

of  gall-bladder,  754 

of  mucous  membranes,  64 

of  thvroid,  qoo 


io86 


Index 


Inflammation  of  urethra,  980 

oscillation  and  stagnation  in,  59 

pain  in,  67 

phlebotomy  in,  84 

plastic,  60 

pustulation  in,  83 

redness  as  sign  of,  69 

resolution  in,  66 

rest  in  treatment  of,  72 

retardation  of  blood-current  in,   58 

serous,  60 

suppurative,   64 

of  gall-bladder  and  bile-ducts,  756 

swelling  or  tumefaction  in,  69 

temperature  in,  90 

termination  of,  65 

tonics  in,  89 

treatment  of,  constitutional,  84 

vascular  and  circulatory  changes  in,  57 

venesection  in,  84 
Infra-orbital  nerve,  neurectomy  of,  589 
Infusion,  intravenous,  of  saline  fluid,  332 
Ingrown  toe-nail,  899 
Inhibition,  death  by,   193 
Injection,  subcutaneous,  of  paraffin,  925 
Innominate  artery,  ligation  of,  345 
Inoculation,  protective  and  preventive,  35 
Inoculation-tuberculosis,  178 
Instruments,  disinfection  of,  47 
Internal  carotid,  ligation  of,  349 

clot,  307 

pudic  artery,  ligation  of,  362 
Interpolation  in  plastic  surgery,  923 
Intertarsal  disarticulation,  1036 
Intestinal  exclusion,  local,  814 

obstruction,  715 
Intestines,  approximation  of,  813 

foreign  bodies  in,   704 

identification  of  small  and  large,  699 

malignant  tumor  of,  724 

primary  tuberculosis  of,  724 

rupture  of,  698 

suture  of,  781 

tuberculosis  of,  181 
Intoxication,  septic  or  putrid,  161 
Intubation  of  larynx,  661 
Intussusception  of  intestines,   716 

operation  for,  816 
Involucrum,  369 
lodids  in  inflammation,  87 
lodin,  tincture  of,  30 

in  inflammation,  79 
Iodoform,  27 

gauze  for  dressings,  54 

poisoning  by,  27 
Iritis  of  syphilis,  231 
Irrigation  of  wounds,  49 
Irritants  in  inflammation,  82 
Ischiorectal  abscess,  855 
Itrol,  29 


Jaboulay's  method  of  gastro-enterostomy, 

796 
Jacob's  ulcer,  273 
Jaw,  lower,  excision  of  half  of,  550 
traumatic  dislocations  of,  503 


Jaw,  upper,  excision  of  half  of,  548 

Jejunostomy,  800 

Jerk-finger,  571 

Joints,  aspiration  of,  536 

Brodie's,  492 

excision  of,  536 

hysterical,  492 

loose  bodies  in,  498 

neuralgia  of,  493 

tuberculous  disease  of,  183 

wounds  and  injuries  of,  493 
Jones'  nasal  splint,  398 
Jonnesco's  operation,  588 
Jordan's  method  of  hip-amputation,   1045 
Justus's  test  for  syphilis,  235 


Kader's  method  of  gastrostomy,  791 
I    Kangaroo-tendon,  52 
j        preparation  of,  52 
I  Truax's  method,  52 

Karyokinesis  in  healing,  98 
Keen's  siphonage  apparatus,  969 
Keith's  operation  of  lithotrity,  974 
Kelly's    method    of    catheterizing    female 
ureter,  929 
rectal  specula,  851 
Keloid,  251 

spontaneous  or  true,  251 
Kidney,  abscess  of,  942 
calculus  in,  939 
determination  of  excretory  capacity  of, 

932 

laceration  of,  937 

mobile,  934 

operation  on,  945 

perforations  of,  938 

prolapse  of,  934 

rupture  of,  937 

surgical,  944 

tuberculosis  of,  chronic,  944 

tumors  of,  933 
Kidney-substance,  bleeding  from,  927 
Klemperer's     test     for     motor     power     of 

stomach,   714 
Knee,  dislocations  of,  522 

housemaids',  564 
Knee-joint,  amputation  at,  1039 

disease,  481 

erosion  of,  537 

excision  of,  544.     See    also   Excision   of 
knee-joint. 

Sayre's  double  extension  for,  482 
Knock-knee,  572 
Knot,  granny-,  311 

reef-,  311 

surgeons',  312 
Kocher's  amputation  at  shoulder,  1032 

elliptical  method,  1027 

method  of  gastro-enterostomy,  794,  795 
of  pylorectomy,  787-789 
reduction  in  dislocated  humerus,  509, 

510 
modified  circular  amputation,  1025 
operation  for  removal  of  tongue,   686 
in  hernia,  835 
Koch's  bacillus,  39 


Index 


1087 


Koch's  circuit,  31 

tuberculin,  185 
Koenig's  tracheotomy  tube,  904 
Kollmann's  dilators,  993 

gland  syringe,  994 
Korayni's  test  of  excretory  powers-  of  kid- 
^  neys,  933 

Kraske's  operation  in  rectal  cancer,  867 
Kronlein's     method     of     locating     cranial 

points,  598 


Laborde's  method  of  artificial  respiration, 

■878 
Laceration  of  kidneys,  937 
Lachrymal  bone,  fractures  of,  399 
Lagoria's  sign  of  fracture  of  femur,  441 
Laminectomy,  644,  653 
Langenbeck's    method    of    excising    hip- 
joint,  544 
Lannelongue's  method  in  hernia,  828 

operation  to  expose  liver,   748 
Laparotomy,  772 

Laplace's  forceps,  for  intestinal  anastomo- 
sis, S07 

method  of  intestinal  anastomosis,  813 
Larrey's  amputation  of  shoulder,    1032 
Laryngotomy,  quick,  661 
Larynx,  abscess  of,   117 

edema  of,  656 

foreign  bodies  in,  657 

intubation  of,  661 

wounds  and  injuries  of,  656 
Le  Dentu's  tendon-suture,  567 
Leeching,  73 

Le  Fort's  tendon-sutures,  567 
Leg,  amputation  of,  1037 

fractures  of  both  bones  of,  467 

ulcer  of,  acute,   129 
chronic,  130 
complications  of,  131 
syphilitic,  130 
tuberculous,  130 

varix  of,  operation  for,  329 
Lejars'  tendon-suture,  567 
Lembert's  suture,  781 
Leontiasis  ossium,  376 
Leptomeningitis,  acute,  6r6 

chronic,  617 
Leptothrix,  20 
Leucomains,  32 

Leukocytosis  in  inflammation,  71 
Le\as's  radius-splints,  436 

splint  for  dislocated  phalanges,  516 
Lewis's  ureter-cystoscope,  930 
Ligation  in  tabatiere,  338 

of  anterior  tibial  arten,-,  352 

of  arteries  in  continuity,  334 

of  axillary  artery,  341 

of  brachial  artery,  340 

of  common  carotid  arten.-,  347 

of  dorsalis  pedis  artery,  352 

of  external  carotid  artery,  349 

of  facial  artery,  351 

of  femoral  artery,  356 

of  gluteal  artery,  360 

of  iliac  arteries,  358 


Ligation  of  inferior  thyroid  artery,  345 

of  innominate  artery,  345 

of  internal  carotid  artery,  349 
pudic  artery,  362 

of  lingual  artery,   350 

of  occipital  artery,  351 

of  popliteal  artery,  355 

of  posterior  tibial  artery,  354 

of  radial  artery,  336 

of  sciatic  artery,  361 

of  subclavian  artery,  343 

of  superior  thyroid  artery,  350 

of  temporal  artery,  351 

of  ulnar  artery,  339 

of  vertebral  artery,  344 
Ligatures,  310 

and  sutures,  49 

for  aneurysm,  300 
Lightning,  effects  of,   1067 
LilienthaTs  bullet  probe,  211 
Lingual  artery,  ligation  of,  350 
Liomyoma,  255 
Lip,  lower,  carcinoma  of,  682 

cheiloplasty  on,  683 
Lipoma,  248 

cavernous,  249 

dififuse,  249 

nevoid,  259 

telangiectodes,  249 

treatment  of,  250 
Lisfranc's  amputation  of  foot,  1034 
Lister's  method  of  excising  wrist-joint,  542 
Liston's   modified   method   of  amputating, 

1026 
Litholapaxy,  969 

in  male  children,  973 
Lithotomy,  lateral,  966 

suprapubic,  968     ■ 
Lithotrite,  Bigelow's,  971 

Forbes's,  971 

Thompson's,  971 
Lithotrity,  perineal,  974 

rapid,  969 
Littre's  hernia,  849 
Liver,  abscess  of,  116,  749 
tropical,  750 

cysts  of.  748 
hydatid,  749 

floating,  753 

rupture  of,  700 

and  wounds  of,  747 

tuberculosis  of,  182 

tumors  of,  748 
Lizard,  poisonous,  216 
Lloyd's  symptom  of  stone  in  kidney,  040 
Lockjaw,  170.     See  also  Tetanus. 
Lorenz's  bloodless  reduction  of  congenital 
dislocation  of  hip,  551 

operation   for   congenital    dislocation  of 
hip,  552 
Loreta's  operation,  784 
Loretin,  28 

Liicke's  method  of  gastro-enterostomy,  794 
Ludwig's  angina,  152 
Lumbago,  553 
Lumbar  puncture,  634 
Lumpy  jaw,  221 


io88 


Index 


Lung,  abscess  of,  117,  669 

contusion  of,  666 

gangrene  of,  669 

rupture  of,  666 

tuberculous  ca^•ity  in,  670 
Lupus,  180 

syphilitic,  233 
Lustgarten's  bacillus,  40 
Lymph  scrotum,  260 
Lymphadenitis,  acute,  910 

cervical,  183 

chronic,  910 
Lymphadenoma,  911 
Lymphangiectasis,  260,  910 
Lymphangioma,  260,  911 

cavernous,  260 

circumscriptum,  910 
Lymphangitis,  910 

infective,  910 
Lymphatics,  varicose,  910 
Lymphoma,  malignant,  911 
Lymphosarcoma,  262 
Lysol,  29 
Lyssa,  218 


Macewen's    method    of   compressing    ab- 
dominal aorta,  1041 

operation,  529 

for  inguinal  hernia,  829 
Macroglossia,  260 

Madelung's  operation  for  varix  of  leg,  330 
Madura-foot,   18 
Maisonneuve's  urethrotome,  997 
Malgaigne's  operation,  679 
Malignant  edema,  214 
bacillus  of,  40 

pustule,  216 
Malingering,  647 

Mallet,  rawhide,  for  osteotomy,  528 
Mallet-finger,  572 
Mammae,     diseases    of,     1046.      See    also 

Breasts. 
Mammary  gland,  1046.    See  also  Breast. 
Mammillitis,  1046 
Marie's  disease,  492 
Marsupialization,  282 
Mason's  pin  for  nasal  fractures,  398 
Massage  in  treatment  of  inflammation,  80 
Mastitis,  acute,  and  abscess,   1046 

chronic,   1048 
lobular,  1048 
Mastodynia,  1048 

Mastoid  suppuration,  operation  for,  632 
Matas'  operation  for  aneurysm,  302 
Mathew's    self-retaining    rectal    speculum, 

851 
Maunsell's  method  of  anastomosis,  804 
Maxillary  bone,  inferior,  fractures  of,  402 

superior,   fractures  of,  399 
Maydl's  operation  of  colostomy,  817 
Mayer's  dressing  in   Wolf's  skin-grafting, 

925 
Mayo's  method  of  gastro-enterostomy,  795 

in  hernia,  83S 
McBurney's  method  of  controlling  bleed- 
ing, 1041 


McBurney's  operation,  823 

point  in  appendicitis,   726,   731 
McGill's  operation  of  prostatectomy,  1012 
McG  raw's  method  of  gastro-enterostomy, 

794>  796 
Mclntyre's  splint,  452 
Meckel's  diverticulum,  280,  715 
Mediastinum,  abscess  of,   117 

operation  on,  694 
Medulla,  tumors  of,  626 
Melanosis,  274 

Meniere's  disease  from  syphilis,   231 
Meningitis,  tuberculous,  617 
Meningocele,  601,  635 

spurious,  601 
Meningomyelocele,   635 
Mercier's  catheter,  elbowed  and  curved,  955 
Mercurials  in  inflammation,  79 
Mercury  in  inflammation,  87 
Mesenteric  arteries,  rupture  of,  701 
Metacarpals,  excision  of,  543 

fractures  of,  438 
Metacarpophalangeal  joint,  amputation  at, 

1029 
Metachromatic  bodies  of  bacteria,  19 
Metatarsal  bones,  dislocations  of,  528 

fractures  of,  468 
Metatarsalgia,  576 
Methylene-blue  test  for  kidneys,  932 
Microbes,   17 

pyogenic,  37 

useful  functions  of,  30 
Microcephalus,  600 
Micrococcus  pyogenes  tenuis,  38 

tetragenus,  38 
Micro-organisms,  17 
Microphyta,   17 

Microscopic  test  for  blood  in  urine,  927 
Microzoaria,   17 
Micturition,  frequency  of,  931 
Middle  lobe,  1009 
Milzbrand,  216 
Miner's  elbow,  564 
Mixed  infection,   23 
Mole,  251 

MoUities  ossium,  375 
Molluscum  fibrosum,  251 
Monococci,  20 
Morbus  coxarius,   475 
Morphia,  251 
Morris's  measurement  in  fracture  of  femur, 

441 
Mortification,  13S.     See  also  Gangrene. 
Morton's  disease,  576 

method  of  spinal  cord  anesthesia,  889 
Mother's  marks,  258 
Motor  power  of  stomach,   714 
Moulds,  18 
Mouth,  gonorrhea  of,  995 

preparation  of,  for  operation,  49 
Mucous  membranes,  disinfection  of,  48 
Miiller's  law  in  tumors,  244 
Mumps,  67S 

Murphy  button  in  gastro-enterostomy,  797 
Murray  operation  on  abdominal  aorta,  362 
Musc;e  volitantes,  308 
Muscles,  atrophy  of,  554 


Index 


1089 


Muscles,  contractions  of,  558 

degeneration  of,  554 

dislocations  of,  558 

healing  of,   loi 

hernia  of,  558 

hypertrophy  of,  554 

ossification  of,  554 

rupture  of,  557 

strains  of,  557 

syphilis  of,  554 

tuberculosis  of,   182 

tumors  of,  554 

Volkmann's  contractures  of,  555 

wounds  and  contusions  of,  556 
Mustard,  29 
Myalgia,  553 
Mycetoma,   18 
Mycosis  fungoides,  265 
Myoma,  255 

uterine,  256 
Myositis,  infective,  554 

ischemic,  555 

ordinary,  554 

ossificans,  554 
Myxoma,  254 

of  breast,  1049 
Myxosarcoma,  255 


Natiform  skulls  of  syphilis,  242 
Necrosis,  128 
of  bone,  369 
central,  370 
quiet,  370 
Needle,  calyx-eyed,  781 
Neisser,  bacillus  of,  38 
Nelaton's  bullet  probe,  211 

catheter,  954 
Neoplasms,  244 
Nephrectomy,  948 
abdominal,  949 
in  children,  949 
lumbar,  948 
partial,  949 
Nephritis,  operation  for,  945 
Nephrolithotomy,  947 
Nephropexy,  937,  949 
Nephroptosis,  934 
Nephrorrhaphy,  937,  949 
Nephrotomy,  946 
Nerves,  contusion  of,  586 
healing  of,  08 
inflammation  of,  577 
pressure  upon,  585 
punctured  wounds  of,   586 
section  of,  578 

symptoms  of,  in  anterior  crural,  583 
in  brachial  plexus,  579 
in  circumflex,  579 
in  external  po[)litcal,  584 
in  great  sciatic,  5S4 
in  internal  po[)liteal,  584 
in  lumbar  plexus,  582 
in  median,   5S0 
in  musculocutaneous,  580 
in  musculospiral,  380 
in  obturator,  583 
69 


Nerves,  section  of,  svmptoms  of,  in  plan- 
tar, 585 
in  posterior  thoracic,  579 
in  radial,  580 
in  sacral  plexus,  583 
in  small  sciatic,  584 
in  superior  gluteal,  583 
in  suprascapular,  579 
in  ulnar,  581 
treatment  of,  585 
tuberculosis  of,  loi 
Nerve-suture,  586 
Nerve-trunk,  cocainization  of,  887 
Neuralgia,  578 
intercostal,  553 
of    fifth     nerve,     extracranial    operation 

for,  589 
of  joints,  493 
of  stumps,  578 
Neurectasy,  587 
of  sciatic,  588 
Neurectomy,  588 

intracranial.  Abbe's  method,  593 
of  inferior  dental,  589 
of  infra-orbital,  589 
of  supra-orbital,   589 
Rose's  method,  590 
Neuritis,  577 
Neurofibroma,  257 
Neuroma,  257 
false,  257 
malignant,  257 
plexiform,  257 
traumatic,  257 
true,  257 
Neurorrhaphy,  586 
Neurotomy,  58 7 

intracranial,       Frazier-Spiller      method, 

593 
Nevi,  258 

lymphatic,  260 

venous,  258 
Nevoid  lipoma,  259 
Nevolipoma,  249 
Nicolaier's  bacillus,  39 
Nicoll's       operation       of      prostatectomv, 

1013 
Nipples,  cysts  of,   1048 

fissure  of,   1046 

inflammation  of.  1046 

Paget's  disease  of.    1049 

tumors  of,  1048 
Nitrate  of  silver  in  inflammation,  79 
Nitrous  oxid  gas,  883 

followed  by  ether,  885 
Hewitt's  inhaler  for,  883 
Nitze's  catheter,  92S 

cystoscopes,  952 
Noli  me  tangere,  135 
Noma,  149 

pudendi,    140 
Nose,  foreign  bodies  in,  655 

fractures  of,  307 

gonorrhea  of,  995 
Nosophen,  28 
Nuclei  of  bacteria,  19 
Nucleins,  30 


lOQO 


Index 


Oberlander's  dilators,  993 
Obturator,  Valentine's,  992 
Occipital  artery,  ligation  of,  351 

lobe,  tumors  of,  625 
Occlusion  of  thoracic  ducts,  909 
Odontoma,  254 

composite,  254 

compound  follicular,  254 

epithelial,  254 

fibrous,   254 

follicular,   254 

radicular,  254 
O'Dwyer's  operation,  661 
Ogston's  operation,  530 
O'Hara's  anastomosis  forceps;  808 
Oidium  albicans,  18 
Ollier-Thiersch    method    of    skin-grafting, 

924 
Omphalectomy,  838 
Onychia,  899 

of  syphihs,  231 
Oophorectomy,  double,   1056 
Operation,    Abbe's,    of    intestinal    anasto- 
mosis, 811 
of  intracranial  neurectomy,  593 

abdominal,   772 

Alexander's,  of  prostatectomy,  1013 

antiseptic  method,  43 

aseptic  method,  42 

Barker's,  for  dislocation  of  cartilages  of 
knee-joint,  551 

Bassini's,  in  hernia,  830 

Beatson's,  of  oophorectomy,   1056 

Belfield's,  of  prostatectomy,  1012 

Beyea's,  for  gastroptosis,  Soo 

Bigelow's,  of  litholapaxy,  969 

Bloodgood's,  330 

Bodine's,  of  inguinal  colostomy,  818 

Bottini's,  of  galvanocaustic  prostatotomy, 
1013 

Brandt's,  for  gastroplication,  799 

Braun's,  of  gastro-enterostomy,  796 

Bryson's,  of  prostatectomy,  1013 

cleansing  hands  for,  45 

Cock's,  in  urinary  fever,   1002 

Cooper's,  on  abdominal  aorta,  362 

Cripp's,  of  excision  of  rectum,  867 

De  Guise's,  677 

Buret's,  for  gastropexy,  800 

Estlander's,   675 

Fabricius',  in  hernia,  841 

Ferguson's,  in  hernia,  836 

Fergusson's,  330,  681 

Finney's,  of  pyloroplasty,  785 

for  appendicitis,  acute,  776 
mortality  of,  780 

for  cleft  palate,  680 

for  facial  paralysis,  594 

ffjr  harelip,  679 

for  intussusception,  816 

for  mastoid  supfjuration,  632 

for  nephritis,  945 

for  neuralgia  of  fifth  nerve,  extracranial, 

589 
for  pericardial  effusion,  328 

suppuration,  328 
for  spina  bifida,  653 


Operation  for  stone  in  women,  974 

for  varicocele,  330 

for  varix  of  leg,  329 

for  wound  of  heart,  328 

Fowler's,  676 
in  hernia,  835 
of  gastro-enterostomy,  794,  798 

Frank's,  of  gastrostomy,  792 

Frazier-Spiller.    of    intracranial    neurot- 
omy, 593 

Fuller's,   of  prostatectomy,    1012 

Grant's,  for  carcinoma  of  lip,  683 

Halsted's,  in  cancer  of  breast,  1053 
in  hernia,  833 

plus  Bloodgood's,  834 

Harris's,  of  enterorrhaphy,  805 

Hartley's,     for     removal     of     Gasserian 
ganglion,_  592 

Heineke-Mikulicz,  of  pyloroplasty,  784 

Hoffa's,  for  congenital  dislocation  of  hip, 

552 
Horsley's,     for     removal     of     Gasserian 
ganglion,  593 

intestinal  anastomosis,  812 
Jaboulay's,  of  gastro-enterostomy,  796 
Jonnesco's,  588 
Kader's,  of  gastrostomy,  791 
Keith's,  of  lithotrity,  974 
Kocher's,  for  removal  of  tongue,  686 

in  hernia,  835 

of  gastro-enterostomy,  794,  795 
Kraske's,  in  rectal  cancer,  867 
Lannelongue's,  for  hernia,  828 

to  expose  liver,   748 
Laplace's,  of  intestinal  anastomosis,  813 
Lorenz's,    for   congenital    dislocation    of 

hip,  551.  552 
Loreta's,  784 

Liicke's,  of  gastro-enterostomy,  794 
Macewen's,  for  inguinal  hernia,  829 
Madelung's,  330 
Malgaigne's,  679 
Mayal's,  of  colostomy,  817 
Mayo's,  for  gastro-enterostomy,  795 

in  hernia,  83S 
McBurney's,  823 
McGill's,  of  prostatectomy,  1012 
McG raw's,    of  gastro-enterostomy,    794, 

796 
Murrav,  for  ligation  of  abdominal  aorta, 

362' 
Nicoll's,  of  prostatectomy,   1013 
O'Dwyer's,  661 
on  bladder,  966 
on  diabetics,  147 
on  kidney  and  ureter,  945 
on  larynx  and  pharynx,  659 
on  spine,  653 
on  stomach,   783 
on  thyroid,  905 
Ovi'en's,  682 
Phelps',  330 
{^reparation  for,  44 

of  mouth  for,  49 

of  patient  for,  48 

of  rectum   for,  49 

of  urethra  for,  49 


Index 


1 09 1 


Operation,  Schede's,  330,  675 
Senn's,  for  cancer  of  breast,  1055 

for  fecal  fistula,  S16 

of  gastro-enterostomy,  794 

of  gastrostomy,   791 

of  nepihropexy,  950 
Socin's,   on  thyroid,  905 
Ssabanejew-Frank,  of  gastrostomy,  791 
sterilization  of  instruments  for,  47 
Syme's,  for  urinary  fever,    looi 
Trendelenburg's,  329 
Van    Hook's,     of    uretero-ureterostomy, 

■    950 

von  Hacker's,  of  gastro-enterostomy,  794 
Wheelhouse's,  in  urinary  fever,  looi 
Whitehead's,  for  removal  of  tongue,  686 
Witzel's,  of  gastrostomy,  790 
Wolfler's,  of  gastro-enterostomy,  794 

of  gastrogastrostomy,  798 
Wolfler-LiJcke's,  of   gastro-enterostomy, 

794-  797 
Ophthalmia,  gonorrheal,  990 
Orchidectomy,  1019 
Orchitis,  1018 
Orrhotherapy,  36 
Os  calcis,  excision  of,  546 
Osteitis,  364 

deformans,  376 

tubercular,  182 
Osteo-arthritis,  489 

Heberden's  nodosities  in,  490 
Osteo-arthropathie   hypertrophiante   pneu- 

mique,  492 
Osteocopic  pains  of  syphilis,  231 
Osteoma,  253 

of  brain,  624 
Osteomalacia,  375 
Osteomyelitis,  acute,  372 
of  vertebrae,  636 

chronic,  374 
Osteoperiostitis,  365 

of  syphilis,  231 
Osteoplastic  resection  of  skull,  630 
Osteotome,  529 
Osteotomy,  .528 

for  bent  tibia,  530 

for  faulty  an'^ylosis  of  hip-joint.  530 
of  knee-joint,  531 

for  genu  valgum,  529 

for  hallux  valgus,  532 

for  talipes  equino-varus,  532 
equinus,  532 

for  vicious  union  of  fracture,  ^^2 

mallet  for,  539 

through  neck  of  femur,  530 

through  shaft  of  femur  below  trochanter, 

531 
Owen's  operation,  682 


Pachymf.xixgitis,  615 

interna,  616 
Paget's  disease,  273,  376,  4S9 
of  nipple,   T049 

residual   abscess,   183 
Pain,  expression  of,  68 

of  coxaigia,  67 


Pain  of  hepatitis,  67 

of  inflammation,  67,  68 

results  of,  68 

sympathetic,  67 

value  of,  68 
Painful  subcutaneous  tubercle,   250 
Palate,  cleft,  678.     See  also  Clejl' palate. 

soft,  suture  of,  681 
Palmar  abscess,  559 
Pancoast's  tourniquet,   1041 
Pancreas,  calculi  in,  768 

cysts  of,  769 

injuries  of,  764 

movable,   765 

tumors  of,  770 
Pancreatic  cysts,  769 
Pancreatitis,  765 

chronic,  768 

forms  of,  767 

subacute,  767 
Papilloma,  267 

villous,  268 
Paquelin  cautery,  318 
Paracentesis  auriculi,  32S 

pericardii,  32S 

thoracis,  672 
Paraffin,  subcutaneous  injection  of,  925 
Paralysis,  post-anesthetic,  88 1 
Paraphimosis,  989 
Parasites,  facultative,  19 

obligate,  19 
Paratrimma,   152 

Parieto-occipital  lobe,  tumors  of,  625 
Parker's  method  of  excising  hip-joint,  543 
Parkhill's  bone-clamp,  396 
Paronychia  of  syphilis,  231 
Parotitis,  678 
Passive  clot,  295 
Patella,  dislocations  of,  524 

fracture  of.   455.     See  also  Fractures  of 
patella. 
ununited,  operative  treatment  of,  535 
Pearl  tumor,  252 
Pelvis,  true,  fractures  of,  409 
Penis,  amputation  of,   1005 

cancer  of,   1005 

fracture  of,  1005 

gangrene  of,   1005 

injuries  of,  076 
Peptic  ulcer  of  duodenum,  722 

of  stomach,  707 
Peptones,  7,2 
Pericardial  effusion,  operation  for,  328 

suppuration,  operation  for,  32S 
Pericarditis,  286 
Pericardium,  tuberculosis  of,   182 

wounds  of,  283 
Pericystic  abscess,  758 
Perigastric  adhesions,  711 
Perinephric  abscess,  942 
Perinephritis,  942 
Perineum,  injuries  of,  976 
Periostitis,  366 

osteoplastic,  366 
Peritoneum,  rupture  of,  606 
Peritonitis,  acute,   740 

circumscribed  suppurative,   741 


1092 


Index 


Peritonitis,  diffuse  septic,  741 
suppurative,   742 

tuberculous,   743 
Peri-urethritis  in  gonorrhea,  990 
Pernio,  895 

Peroxid  of  hydrogen,  27 
Pes  cavus,  575 

planus,  574 
Petit's  spiral  tourniquet,   1024 
Phagedena,   151,  226 
Phagoc)'tes,  34 
Phagocytosis,  34 
Phalanges,  dislocations  of,  528 

fractures  of,  438 

of  toes,  fractures  of,  469 
Pharyngeal  diverticulum,  278 
Pharynx,  burns  and  scalds  of,  894 

foreign  bodies  in,  657 
Phelps'  operation  for  varix  of  leg,  330 
Phimosis,  989,   1004 
Phlebectases,  287 
Phlebectasia,  2S7 
Phlebitis,   286 

acute,  286 

chronic,  287 
Phlebolith,   156 
Phlebotomy,  331 

in  inflammation,  84 
Phloridzin  test  of  kidneys,  932 
Phthisis,  syphilitic,  234 
Piles,  289,  858.     See  also  Hemorrhoids. 
Pirogoff's  amputation,  1037 
Plastic  surgery,  922 
Pleura,  tuberculosis  of,   182 
Pleural  sac,  exploratory  puncture  of,  671 
Pleurectomy,   676 
Pleuritic  effusion,   661 
Pleurodynia,  553 
Pneumectomy,  671 
Pneumonia,  diplococcus  of,  40 

ether-,  880 
Pneumothorax,  acute  traumatic,   665 

non-traumatic,  664 
Pneumotomy,  669 
4>       for  abscess,  676 

Pointing  in  abscesses,  113 
Polydactylism,  571 
Polyps,  255 

gelatinous,  255 

mucous,  255 
Pons,  tumors  of,  625 
Popliteal  artery,  ligation  of,  355 
Port-wine  stains,  258 
Posterior  tibial  artery,  ligation  of,354 
Pott's  disease,  640 

fracture,  465 

puffy  tumor,  601 
Poultice,  81 

antiseptic,  81 
Prefrontal  region,  tumors  of,  625 
Pregnancy,  ap[)endicitis  in,  736 
Primary  union,  92 
Probang,  horsehair,  688 
Proctoscope,  Tuttle's  pneumatic,  853 
Prolapse  of  anus  and  rectum,  862 

of  kidney,  934 
Prostate,  abscess  of,  in  g(jiKjrrhea,  990 


Prostate,  hemorrhage  from,  931 

hypertrophy  of,   1008 

malignant  disease  of,   1016 

middle  lobe  of,   1009 

tuberculosis  of,  1017 
Prostatectomy,  perineal,  1013 

suprapubic,  1012 
Prostatitis,   acute,    1006 
in  gonorrhea,  990 

chronic,   1007 

in  gonorrhea,  990 
Prostatorrhea,  1008 
Prostatotomy,  loii 

Bottini's  galvano-caustic,  1013 

Young-Freudenberg  galvano-cautery  for, 
1014 
Protargol,  29 
Protectives,  54 
Proteid,  32 
Protonuclein,  30 
Protozoa,  41 
Proud  flesh,  97 
Pruritus  of  anus,  857 
Psammoma,  252,  264 
Pseudo-leukemia,  911 
Psoriasis,  palmar  and  plantar,  of  syphilis, 

229 
Psorosperm,  247 
Ptomains,  32 
Ptyalism,  acute,  from  mercurial  treatment, 

238 
Pulmonary  decortication,  676 
Puncture,  lumbar,   654 

of  pleural  sac,  671 
Pus,  no 

aseptic,   109 

constituents  of,  no 

forms  of,  no 

microbes,  37 

spurious,  109 
Pustulation,  production  of,  83 
Pyelitis,  942 

in  gonorrhea,  990 
Pyelonephritis,  942 
Pyemia,   164 

arterial,   165 
Pylorectomy,    786 
Pyloroplasty,  784 
Pylorus,  digital  dilatation  of,  784 

excision  of,   786 
Pyogenic  microbes,  37 
Pyonephrosis,  944 


Quincke's  lumbar  puncture,  654 


Rabies,  218 

Rachitic  beads,    187 

Rachitis,  187 

Racket  amputation,  1027 

incision,  1025 
Radial  artery,   ligation  of,  336 
Radius,  dislocation  of,  traumatic,  514 

fractures  of,  432 
Railway  spine,  646 


Index 


1093 


Ranula,  280,  684 
Raynaud's  gangrene,   145 
Rectum,  851 

cancer  of,  865 

Cripp's  operation  in,  867 

examination  of,  851 

foreign  bodies  in,  854 

gonorrhea  of,  994 

preparation  of,   for  operation,   49 

prolapse  of,  862 

stricture  of,  non-cancerous,  864 

ulcer  of,   863 

wounds  of,  854 
Reef-knot,  311,  336 
Renal  calculus,  939 
Renipuncture,  949 
Repair,  92 

Respiration,   artificial,   Laborde's   method, 
878 

Sylvester's  method,  879 
Retardation  after  active  hyperemia,  58 
Retention,  incontinence  of,  953 

of  urine,  953 

in  gonorrhea,  990 
Retention-cysts,  279 

Reverdin's  method  of  skin-grafting,  924 
Rhabdomyoma,  255 

Rheumatic  gout,  489.     See  Osteo-arthritis. 
Rheumatism,  acute,  487 

gonorrheal,  485 

muscular,   553 
Rhigolcne  anesthesia,  886 
Rhinoplasty,  926 

Indian  method,  926 

Tagliacotian  method,  926 
Rhoads's  apparatus  for  dislocated  clavicle, 

505 
Rib,  excision  of,  548 

fractures  of,  405 

traumatic  dislocations  of,  517 
Richter's  hernia,  849 
Rickets,  187 

Robson's  decalcified  bone  bobbins,  805 
Rodent  ulcer,  273 
Rokitansky's  hernia,  S40 
Rolando's  fissure,  location  of,  50:; 
Rontgcn  rays,  1057.     See  also.  X-rays. 
Rontgen-ray  burns,  1059 
Rosenthal's  test  for  blood  in  urine,  927 
Rose's  method  of  neurectomy,  590 
Rouge's  operation  for  myxoma,   255 
Rupia,  230 
Rupture,  abdominal,  S24 

muscular,  from  abdominal  contusion,  696 

of  bladder,  957 

of  dia])hragm,  666 

of  gall-bladder  and  bile-ducts,  700 

of  intestines,  698 

of  kidney,  937 

of  liver,   700,   747 

of  lung,  666 

of  mesenteric  arteries,   701 

of  muscles,  557 

of  peritoneum,  696 

of  sinu--  of  brain,  608 

of  spleen,  700,  770 

of  stomach,   697 


Rupture  of  tendons,  559 
of  thoracic  ducts,  909 
of  urethra,  977 


Sabaneieff's  amputation,   1040 
Sacrococcygeal  tumors,  635 
Sacro-iliac  disease,  474 

joint,  tuberculosis  of,  474 
Sacrum,  fractures  of,  411 
Saline  infusion  in  arteries,  333 
Salivary  concretions,  678 

glands,  wounds  of,  677 
Salivation  from  mercurial  treatment,  238 
.Salol  test  for  motor  power  of  stomach,  714 
Salt  solution,  infusion  of,  332 
Sapremia,   i6t 
Saprophytes,  19 
Sarcinae,  20 

.Sarcocele,  syphilitic,  232 
Sarcoma,  260 

alveolar,  263 

black,  264 

Coley's  treatment  for,  266 

erysiyjelas  serum  in  treatment  of,  266 

giant-celled,  263 

hemorrhagic,  264 

melanotic,  264 

myeloid,  263 

of  brain,  623 

of  breast,    105 1 

of  stomach,   707 

plexiform,  264 

round-celled,  262 

spindle-celled,  262 

treatment  of,  265 

varieties  of,  262 
Sayre's  double  extension  of  knee-joint,  482 

dressing  for  fractured  clavicle,  413 

knee-splint,  481 
Scalds,  892.     See  also  Burns  and  scalds. 
Scalp,  abscess  of,  599 

diseases  of,  599 
Scalp-wounds,  602 
Scapula,  dislocation  of,  traumatic,  506 

excision  of,  547 

fractures  of,  415 
Scarlet  fever,  surgical,  107 
Schede's  operation,  675 

for  varix  of  leg,  330 
Schizomycetcs,  18 
Schleich's  anesthetic  agent,  882 

infiltration-anesthesia,  888 
Sciatic  artery,  ligation  of,  361 

nerve,  stretching  of,  588 
Scirrhus  of  breast,   105 1 
Scoliosis,  638 
Scorbutus,  188 
Scorpion,  215 
Scrofula,   179 

angelic,    179 

phlegmatic,   iSo 

sanguine,  171) 
Scrofuloderma,  i8r 
Scrotum,  Ivmph,  260 
Scurvy,  18S 

infantile,   189 


I094 


Index 


Secondary  suturing,  gy 

Sedillot's  amputation,  1038 

Selva's  thumb-bandage,  gi4 

Seminal  vesicles,  tuberculosis  of,  1006 

Senn's    apparatus    for   fracture    of    femur, 

445 
bloodless  method  of  hip  amputation,  1045 

bullet-probe,  615 

entero-anastomosis  with  bone  plate,   807 

invagination  method,  804 

method  in  fracture  of  femur,  444 

method  of  excision  of  shoulder-joint,  540 
of  gastro-enterostomy,  794 
of  gastrostomy,  791 

operation  for  fecal   fistula,   816 
in  cancer  of  breast,   1055 
of  nephropexy,  950 

silver  tube,  975 
Septic  infection,  162 
Septicemia,  161 

cryptogenetic,  161 

true,   162 
Sequestrotomy,  371 
Sequestrum,  369 

Serpiginous  ulcers  of  tertiary  syphilis,  233 
Serum-therapy,  36 

Sheldon's  method  of  hip-amputation,    1045 
Shock,  192 

delirious,  193 

diagnosis  of,  194 

prevention  of,  in  operations,  194 

secondary  or  delayed,   194 

symptoms  of,  193 

treatment  of,  195 
Shoulder-joint,  amputation  at,  103 1 

disease,  483 

dislocations  of,  506.     See  Htimerus,  dis- 
locations of,  506. 

excision  of,  539 

Senn's  method,  540 
Sigmoidopexy,  862,  863 
Silk  for  ligatures  and  sutures,  52 

Tait's,  53 
Silkworm-gut  for  sutures,  53 
Silver  as  antiseptic,  29 

Crede's  ointment  of,  29 

foil  for  dressings,   54 

nitrate  of,  in  inflammation,   79 

wire  for  suture,  53 
Sinuses,   136 

thyro-lingual,  684 
Sinus-thrombosis,  infective,  620 
Skene's  electrohemostasis    in    hemorrhage, 

319 
Skiagraph  for  locating  bullets,  211 
Skiagraphy,  1057 
Skin  diseases,  syphilitic,  228 

repair  of,  104 

tuberculosis  of,   180 
Skin-grafting,  923 

Ollier-Thiersch  method,  924 

Revcrdin's  method,  924 

Wolf's  method,  925 
Skin-taVjs,  859 
Skull,  fractures  of,  608 

osteoplastic  resection  of,  630 
Sloughing,  150 


Smith's  anterior  splint  in  fracture  of  femur, 

450 
method      of      reduction     in      dislocated 
humerus,  510 
Snake-bites,  215 

serum-therapy  for,  216 
treatment  of,   216 
Snufifles  in  hereditary  syphilis,  241 
Socin's  operation  on  thyroid,  905 
Sorbefacients  in  treatment  of  inflammation, 

Spectroscope  test  for  blood  in  urine,  927 
Specula,  Kelly's,  851 

Mathews',  851 
Spencer's    apparatus     for    saline    infusion, 

332 
Spermatic  cord,  hydrocele  of,  102 1 

strangulation  of,   1020 
Spermatorrhea,  defecation,  980 
Sphacelus,  138.     See  also  Gangrene. 
Spider,  poisonous,  bite  from,  215 

of  New  Zealand,  215 
Spina  bifida,  635 

operations  for,  653 
j    Spinal  caries,  640 

cord  anesthesia,  Morton's  method,  889 
cocainization  of,  88g 
compression  of,  648 
concussion  of,  647 
contusion  of,  647 
healing  of,  100 
tumors  of,  636 
wounds  of,  648 
curvatures,  637 
meninges,  puncture  of,  654 
Spine,  abscess  of,  643 
caries  of,  640 

congenital  deformities  of,  635 
curvature  of,  angular,   640 
anteroposterior,  639 
lateral,  638 
dislocations  of,  648 

forcible  correction  of  deformity  of,   644 
fractures  of,  648 

injuries  to  ligaments  and  muscles  of,  645 
railway,  646 
typhoid,  637 
Splanchnoptosis,  739 
Spleen,  abscess  of,  771 
rupture  of,  700,  770 
tumors  of,  771 
wandering,  771 
Splenectomy,  771,  823 
Splenic  fever,  216 
Splenopexy,  771 
Splenoptosis,  771 

Splint,  anterior  angular,  for  fractures  about 
elbow-joint,  427 
Strohmeyer's,  483 
Bond's,  in  Colles's  fracture,  436 
bracketed,  396 
hard-rubber,  400,  401 

aj)y)Iied,  402 
interdental,  404 

internal  angular,  for  fractured  humerus, 
418,  422 
I        Jones's  nasal,  398 


Index 


1095 


Splint,  knee,  Hutchinson's,  481 
Sayres',  481 

Levis's,  for  dislocated  phalanges,  516 
radius-,  for  fractured  radius,  436 

Mclntyre's,  452 

Senn's,  for  fractured  femur,  445 

Smith's  anterior,  in  fracture  of  thigh,  450 

straight,  two,  for  fracture  of  both  bones 
of  forearm,  432 

Thomas's,    in    intracapsular    fracture    of 
femur,  445 

Van  Arsdale's,  diagram  and  application 

.  of'  454 

vulcanite,  403 

Watson's   plaster-of-Paris  swing-,   545 
Spondylitis,  640 

deformans,  645 
Sponges,  artificial,  56 

marine,  56 
Spores,  21 

Sprague  hot  dry-air  apparatus,  471 
Sprains,  494 

of  ankle,  Gibney's  dressing  for,  405 
Ssabanejew-Frank  method  of  gastrostomy, 

791 
St.  Anthony's  fire,  166.    See  also  Erysipelas. 
Staphylococci,  20 
Staphylococcus  cereus  albus,  37 
flavus,  37 

fiavescens,  38 

pyogenes  albus,  37 
aureus,  37 
citreus,  37 
Staphylorrhaphy,  681 
Stellwagen's  trephine,  630 
Steno's  duct,  wounds  of,  677 
Stenosis,  cicatricial,  of  orifices  of  stomach, 

710 
Step-mother,  ulcerated,  562 
Sterilized  gauze  for  dressings,  54 
Sternum,  fractures  of,  407 

traumatic  dislocation  of,  517 
Stevenson's  drainage-tube,  976 
Stings  and  bites,  214 
Stomach,  absorptive  powers  of,  714 

bilocular,  712 

carcinoma  of,  704 

chronic  dilatation  of,   713 

cicatricial  stenosis  of  orifices  of,  710 

dilatation  of,  acute,  714 

foreign  bodies  in,   704 

hour-glass,  712 

motor  power  of,   714 

operations  upon,  783 

pe])tic  ulcer  of,   707 

ru])ture  of,  697 

sarcoma,  707 
Stone  in  bladder,  959 
Strains  of  muscles,  557 
Strangulation  of  s])ermatic  cord,  1020 
Strcptobacilli,  20 
Streptococci,  20,  3() 
Streptococcus  articulorum,   38 

of  erysipelas,  38 

of  septicemia  and  pyemia,  38 

pyogenes,  38 
malignus,  ^8 


Streptococcus  septicus,  38 
Streptothrix  Madura?,  18 
Stricture  of  esophagus,  687 
spasmodic,  691 

of  rectum,  non-cancerous,  864 

of  urethra,  095 
Strongylus  armatus  in  aneurism  in  horses, 

295 
Strumous  joint,  472.     See  Ar/hri/is,  luber- 

culoits. 
Struve's  test  for  blood  in  urine.  927 
Strychnin-pois(5ning,  and  tetanus,  differen- 
tial j)oints  of,   172 
Stum])s,  neuralgia  of,  578 
Stv])tics  in  hemorrhage,  316 
Subastragaloid  disarticulation,   1036 
Subclavian  artery,  ligation  of,  343 
Subphrenic  abscess,   746 
Superior  thyroid  artery,  ligation  of,  350 
Suppuration,  37,   109 

causation  of,  109 

mastoid,   operation  for,   632 

pericardial,  operation  for,  328 

phlegmonous,   iii 

pointing  in,  1 13 

signs  of,  1 1 1 
Supra-orbital  nerve,  neurectomy  of,  589 
Suprarenal  extract  in  hemorrhage,  318 
Surgeon's  knot,  312 
Surgery,  plastic,  922 
Suture-ligature,  313 
Sutures,   199-202 

Connell's,   782 

Cushing's,  781 

Czerny-Lembert,   782 

Dupuytren's,  7S1 

Gussenbauer's,  782 

Halsted's,  782 

Lembert's,  781 

ligature  and,  49 

of  intestine,   781 

removal  of,   q6 

Wolfler's,  782 
Suturing,  secondary,  07 
Sweet's     jL-ray     apparatus     for     locating 

foreign  bodies,  1061 
Svlvester's  method  of  artificial  respiration 

'  S79 
Sylvius'  fissure,  location  of,  506 
Syme's  amputation,  1037 

through  femoral  condyles,  1039 

operation  for  urinary  fever,   looi 

stalT,  997 
Svmpathectomy,   588 
.Syncytioma  malignum,  275 
Syndactylism,  571 
Synovitis,  469 

acute  simple,  460 

chronic,  470 
Syphilides,  228 

erythematous,  229 

papular,  229 

pustular,   230 

tubercular,  230 
Syphilis,  223 

affections  of  bones  and  joints  from,  231 
of  car  in,  2^1 


1096 


Index 


Syphilis,  affections  of  eye  in,  231 

of  hair  in,  231 

of  mucous  membranes  in,  230 

of  nails  in,  231 

of  testes  in,  232   - 
bubo  of,  227 
Colles's  law  in,  241 
corona  venerea  of,  229 
fever  of,   227 
flat  condylomata  of,  229 
general,   227 
hereditary,  241 

diagnosis  of,  242 

evidences  of,  241 

Hutchinson  teeth  in,  242 

natiform  skulls  of,  242 

snufHes  in,   241 

treatment  of,  243 

Virchow's  sign  of,  242 
in  muscles,  554 
initial  lesions  of,  225 
intermediate  period  of,  232 
Justus's  test  for,   235 
lichen  of,  229 
marriage  in,  240 
Meniere's  disease  from,  231 
nervous,  234 

palmar  and  plantar  psoriasis  of,  229 
primary,  224 

treatment  of,  235 
ptyalism   from    mercurial    treatment   of, 

■238 
reminders  of,  223 
rules  of  inheritance  in,  241 
secondary,  228 

treatment  of,  235 

complications  in,  239 
tertiary,  232 

gumma  of,  233 

serpiginous  ulcers  of,  233 

treatment  of,  240 
transmission  of,  223 
transmitted,  congenital,  241 
treatment  of,  by  fumigation,  237 

dietetic  and  general,  236 

medicinal,  236 

serum-therapy  method,  36 
visceral,  234 
Syphiloderma,  228 
Syringe,  Kollmann's  gland,  994 
Syringomyelocele,  635 


Tabatiere  anatomique  of  Cloquet,  338 

ligation  of,  338 
Tabes  mesenterica,  183 
Tabetic    arthropathy,  491.      See   Charcot's 

disease. 
Tache  cerebrale,  617 
Tagliacozzi's  method  of  rhinoplasty,  926 
Talipes,  572 

equinus,  osteotomy  for,  532 

equino-varus,  osteotomy  for,  532 

varieties  of,  572 
Tarantula,  215 
Tarsals,  dislocations  of,  528 
Tarsometatarsal  amputation,  1034 


Teale's  amputation,  1038 

Telangiectasis,  258 

Temperature  in  inflammation,  90 

Temporal  artery,  ligation  of,  351 

Temporosphenoidal  lobe,  tumors  of,  625 

Tenaculum,  311 

Tendo  Achillis,  subcutaneous  division  of, 

565 
Tendon  lengthening,  567 

rupture  of,  559 

suture  of,  567 
Tendons,  dislocations  of,  558 

repair  of,  103 

transplantation  of,  568 

wounds  of,  559 
Tenosynovitis,  559 
Tenotomy,  565 

subcutaneous,  of  tendo  Achillis,  565 
of    tendons    of    peroneus    longus    and 

brevis  muscles,  566 
of  tendon  of  tibialis  anticus  muscle,  566 
of  tendon  of  tibialis  posticus  muscle, 
566 
Teratoma,  277 

Testes,  affections  of,  in  syphilis,  232 
Testicle,  excision  of,  1019 

fungus  of,  184 

hematocele  of,  1022 

hydrocele  of,  1022 

retained  and  malplaced,   1018 

tuberculosis  of,   183,   1019 
Tetanus,  170 

and  hysteria,  differential  points  of,  172 

and      strychnin-poisoning,       differential 
points  of,  172 

antitoxin  serum  for,  175 

bacillus  of,  39 

cephalic  or  head,  172 

chronic,  172 

fecal  theory  in,   170 

girdle  pain  in,  171 

hydrophobic,  172 

treatment  of,  173 
Tetany,   173 
Tetracocci,  20 
"T-fractures  of  humerus,  425 
Thecitis,  559 

acute,  559 

chronic,  560 
Thigh,  amputation  of,  1040 
Thomas's  splint  in  fractures  of  femur,  445 
Thompson's  calculus  sound,  959 

diagnostic  questions,  932 

divulsor,  999 

evacuator,  972 

lithotrite,  971 

vesical  forceps,  974 
Thoracic  ducts,  occlusion  of,  909 
rupture  of,  909 
wounds  of,  909 
Thoracoplasty,  675 
Thoracotomy,   673 
Thrombosis,  155 

causes  of,   155 
Thrombus,  propagated,  156 
Thrush,  bacteriology  of,   18 
Thumb,  amputation  of,  1029 


Index 


1097 


Thyroid  artery,  inferior,  ligation  of,  345 

atrophy  of,  goo 

congestion  of,  900 

enucleation  of,  905 

extirpation  of,  complete  and  partial,  907 

hypertrophy  of,  900 

inflammation  of,  900 

operations  on,  905 

Socin's  operation  on,  905 

wounds  of,  900 
Thyroidectomy,  complete  and  partial,  907 
Thyro-lingual  cysts  and  sinuses,  684 
Thyrotomy,  658 

Tibia,  fractures  of,  462.    See  also  Fractures 
of  tibia. 

separation  of  epiphysis  of,  464 
Tibial  artery,  anterior,  ligation  of,  352 

posterior,  ligation  of,  354 
Tinnitus  aurium,  309 
Toe-nail,   ingrown,   899 
Toes,  amputation  of,   1034 
Tongue,  burns  and  scalds  of,  S94 

carcinoma  of,  684 

removal  of,  complete,  686 
partial,  685 
Tongue-tie,  684 
Tonics  in  inflammation,  89 
Torsion  in  hemorrhage,  314 
Torticollis,  569 

division  of  sternocleidomastoid  for,  565 

rheumatic,  553 

treatment  of,  570 
Tourniquet,  application  of,  1023 

Charriere's,  1024 

Pancoast's,  1041 

Petit's,  1024 

Von  Esmarch's,  1042 
Toxalbumins,  32 
Toxemia,  hydatid,  282 
Toxins,  31 

Trachea,  foreign  bodies  in,  658 
Tracheotomy,  659 

high,  660 

Koenig's  tube  for,  904 
Transfusion  of  blood,  331 
Trendelenburg's  operation,  329 

position,  773 
Trephine,  crown,  629 

Gault's,  629 

Stellwagen's,   630 
Trephining,  628 

frontal  sinus,  631 
Trevcs's  operation  for  caries  of  vertebrae, 

535 
Trichiniasis,  555 
Trichinosis,  555 
Trigger-finger,  571 
Tripper,  982 

Trismus  neonatorum  or  nascentium,  172 
Tropacocain  anesthesia,  889 
Tubercle,  177 

anatomical,  181 

bacillus  of,  178 

primitive,  177 
TubercuHn,  185 

Hunter's  modification  of,  186 
Tuberculosis,    177 


Tuberculosis,  bacillus  of,  39 
disseminata,  iSo 
Finsen's  light  treatment  of,  185 
hereditary  transmission  of,  178 
infection  with,  through  air  and  food,  178 
inoculation-,  178 
intestinal,  181 

primary,   724 
of  alimentary  canal,  181 
of  blood-vessels,  181 
of  bone,  364 
of  breasts,   181 
of  connective  tissue,  181 
of  heart  muscle,  182 
of  hernia,  824 
of  hip-joint,  475 

complications  of,  478 

diagnosis  of,  476 

symptoms  of,  475 

treatment  of,  479 
of  kidney,  chronic,  944 
of  liver,   182 

of  lymphatic  glands,  183 
of  muscle,  182 
of  nerve,  181 
of  pericardium,   182 
of  pleura,  182 
of  prostate,  1017 
of  seminal  vesicles,  1006 
of  sacro-iliac  joint,  474 
of  skin,  180 
of  testicle,  183,  10 19 
peritoneal,  182 
predisposing  causes  of,   179 
prognosis  of,  1S4 
pulmonary,  181 
surgical,  diagnosis  o.,  184 
treatment  of,  1S4 

Bier's  method,  185 
ulcerosa,  180 
verrucosa,  181 
Tubulo-cysts,  280 

Tuffnell's  treatment  for  aneurysm,  298 
Tumors,  244 
adrenal,  267 
brain-sand,  252 
causes  of,  245 
classification  of,  24S 
Cohnheim's  theory  of  origin  of,   245 
erectile,  258 
fibrofatty,  24S 
heredity  in,  245 

injurv  and  inflammation  as  causes  of,  245 
innocent,  247 

epithelial,  267 
intracranial,  622 
malignant,  247 

connective  tissue,  260 

epithelial,  269 

of  intestine,  724 
mixed,  264 
Miiller's  law  in,  244 
multilocular  cystic,  254 
of  bladder,  966 
of  bone,  364 
of  breast,  1049 
of  cerebellum,  626 


1098 


Index 


Tumors  of  corpus  striatum,  625 

of  cortical  motor  area,  625 

of  kidney,  933 

of  liver,   748 

of  medulla,  626 

of  muscles,  554 

of  nipple,  1048 

of  pancreas,  770 

of  parieto-occipital  lobe,  625 

of  pons,  625 

of  prefrontal  region,  625 

of  prostate,  1016 

of  spinal  cord,  636 

of  spleen,   771 

of  teniporosphenoidal  lobe,  625 

painful  subcutaneous,  250 

parasitic  theory  of,  246 

pearl,  252 

psorosperm  in,  247 

puffy,  of  Pott,  601 

sacrococcygeal,  635 

Virchow's  law  in,  244 
Tuttle's  pneumatic  proctoscope,  853 
Typhoid  arthritis,  485 

fever,  bacillus  of,  41 

spine,  637 

ulcer,  perforated,  723 


Ulcer,  128 
callous,  134 
cancroid,  135 
classification  of,  128 
Curling's,  722 
edematous,   134 
erethistic,  133 
exuberant,  133 
fungous,  133 
healthy,  133 
hemorrhagic,  134 
indolent,   134 
irritable,  133 
Jacob's,  135,  273 
Marjolin's,  135 
neuroparalytic,  135 
of  bladder,  965 
of  bowel,  722 
of  leg,  acute,  129 

chronic,  130 

complications  of,  131 

syphilitic,   130 

tuberculous,  130 
of  rectum,  863 
painful,  133 
peptic,  of  duodenum,  722 

of  stomach,   707 
perforated  typhoid,  723 
-    perforating,   135 
phagedenic,  134 
rodent,   135,  273 
scorbutic,  136  , 

trophic,  135 
varicose,  133 
Ulna,  fractures  of,  429 

traumatic  dislocations  of,  514 
Ulnar  artery,  ligation  of,  ;^;^C) 

nerve,  dislocation  of,  at  elbow,  586 


Unna's  dressing  for  ulcer,  131 
Uranoplasty,  681 
Ureter,  calculus  in,  941 

intestinal  implantation  of,  951 

operation  on,  945 
Ureter-catheterization,    928 

in  females,  929 
Ureter-cystoscope,  Lewis's,  930 
Ureterolithotomy,  950 
Uretero-ureterostomy,  950 
Ureters,  wounds  of,  939 
Urethra,  dilatation  of,  rules  for,  994 

foreign  bodies  in,  979 

hemorrhage  from,  931 

inflammation  of,  980 

preparation  of,  for  operation,  49 

rupture  of,  977 

stricture  of,  995 
Urethral  catarrh,  chronic,  984 

discharge,  chronic,  984 
examination  in,  983 

fever,  999 
Urethritis,  980 

acute  posterior,  in  gonorrhea,  990 

chronic,    after  gonorrhea,   treatment  of, 
991 

eczematous,  981 

gouty,  981 

simple,  981 

specific,  982 

traumatic,  981 

treatment  of,  995 

tuberculous,  981 
Urethrorrhea,  980 
Urethroscope,  Valentine's,  992 
Urethrotome,  Maisonneuve's,  997 
Urinary  fever,   1000 
Urine,  post-operative  suppression  of,  197 

retention  of,  953 
in  gonorrhea,  990 

segregation  of,  929 

Harris'  instrument  for,  929 
Uterine  fibroid,  256 
Uterus,  gonorrhea  of,  995 

pregnant,  gunshot-wound  of,  703 


Vagina,  hematocele  of,  1022 

Vaginitis,  995 

Valentine's  light-carrier,  992 

method  of  examination  in  urethral  dis- 
charge, 982 
obturator,  992 

table  for  urethral  irrigation,  987 
urethral  irrigator,  986 
urethroscope,  992 

Van  Arsdale's  splint,  applied,  454 
diagram  of,  454 

Van  Hook's  operation  of  uretero-ureteros- 
tomy, 950 

Varicocele,  289,  1022 
open  operation  for,  330 
subcutaneous  ligature  for,  330 

Varicose  lymphatics,  910 
veins,  287 

complicating  ulcer  of  leg,   132 

Varix,  287 


Index 


1099 


Varix,  aneurysmal,  305 

of  leg,  operation  for,  329 
Vasectomy,  1015 
Vasotribe,  Doyen's,  313 
Veins,  inflammation  of,  286 

varicose,  287 
Velpcau's  bandages,  918 
Venesection,  331 

in  inflammation,  84 
Verruca  necrogenica,  181 
Vertebrae,  acute  osteomyelitis  of,  636 
Vertebral  artery,  ligation  of,  344 
Vesical  calculus,  959 

hemorrhage,  931 
Vesicles,  seminal,  tuberculosis  of,   1006 
Vesiculitis,  acute,  in  gonorrhea,  990 

seminal,  1005 
Vibrione  septique  of  Pasteur,  40 
Vicious  circle  after  gastro-enterostomy,  793 
Vienna  paste  for  causing  pustulation.  83 
Virchow's  disease,  376 

law  in  tumors,  244 

sign  of  hereditary  syphilis,  242 
Viscera,  syphilis  of,  234 
Volkmann's  contracture,  555 
Volvulus,  716 
Vomiting  after  anesthesia,  880 

after  gastro-enterostomy,  794 
Von  Esmarch's  tourniquet,   1042 
Von    Hacker's    method    of   gastro-enteros- 
tomy, 794 


Wardrop's  operation  for  aneurysm,  302 
Wart-horn,  268 
Warts,  267 

lymphatic,  910 

venereal,  267 
Watson's  plaster-of-Paris  swing-splint,  545 
Weavers'  bottom,  564 
Webbed  fingers,  571 
Weir-Stimson   method  of  cleansing   hands 

for  operations,  46 
Welch-Kelly  method  of  cleansing  hands  for 

operations,  46 
Wens,  279 
Wheelhouse's   operation   in   urinary    fever, 

lOOI 

staff,  1 00 1 
White    swelling,    1S3,  472.      See   Arthritis, 

tuberculous,  472 
Whitehead's     operation     for     removal     of 

tongue,  686 
Whitlow,    561 


\\'ire  in  treatment  of  aneurysm,  303 
Witzel's  method  of  gastrostomy,  790 
Wolfler-Lucke  operation  of  gastro-enteros- 
tomy, 794,  797 
Wolfler's  method  of  gastrogastrostomy,  798 

operation  of  gastro-enterostomy,  794 

suture,  782 
Wolf's  method  of  skin-grafting,  925 
Wool-sack  cocci,  20 
Wool-sorter's  disease,  216 
Wounds,  192 

by  blank  cartridge,  209 

by  cannon-balls,  209 

by  small  shot,  209 

contused,  203 

dissection-,  213 

gunshot,  205 

incised,  199 

lacerated,  203 

of  mucous  membranes,  203 

poisoned,  213 

punctured,  204 

septic,  213 

stab-,  205 

treatment  of,  197,  200 
^^'ris^  disarticulation  at,   1029 

dislocations  of,  traumatic,  515 
^^'rist-drop,  580 
Wrist-joint  disease,  483 

excision  of,  541 

Lister's  method,  542 
Wry-neck,  569 

division  of  sternocleidomastoid  for,  565 
W}-eth's  bloodless  amputation,  1042 


X.'\NTHOM.\,  250 

X-rays,  1056 

apparatus,   Sweet's,  for  locating  foreign 

bodies,  1061 
burns,  1059 

diagnosis  of  fractures  by,   1064 
locating  foreign  bodies  by,   1061 
treatment  of  malignant  disease  by,  1065 


Yeasts,  iS 

Young's  galvano-cautery  for  prostatotorhy, 

1014 


ZooGLEA  masses,  20 

Zygomatic  arch,  fractures  of,  401 


SAUNDERS'  BOOKS 


on 


GYNECOLOGY 


and 


OBSTETRICS 


W.  B.  SAUNDERS  &  COMPANY 

925  WALNUT  STREET  PHILADELPHIA 

NEW   YORK  LONDON 

Fuller  Building',  5th  Ave.  and  23d  St.  9,  Henrietta  Street,  Covent  Garden 


"SAUNDERS'   IMPRINT  ENSURES  SUCCESS." 

'l^HAT  the  degree  of  excellence  obtained  by  the  Saunders 
publications  is  a  high  one  is  evidenced  by  the  fact  that 
in  every  one  of  the  190  Medical  Colleges  in  the  United 
States  and  Canada,  Saunders'  text-books  are  used  as  reci- 
tation books  or  books  of  reference.  In  the  list  of  recom- 
mended books  published  by  172  of  these  colleges  (the  other 
18  colleges  do  not  publish  such  lists)  Saunders'  books  are 
mentioned  2644  times.  These  figures  really  mean  that 
in  each  of  the  medical  colleges  in  this  country  an  average 
of  1 5 ^^3  of  the  teaching  books  emplo)ed  are  publications 
issued  by  W.  B.  Saunders  &   Company. 

A  Complete  Catalogue  of  our  Publications  will  be  Sent  upon  Request 


SAUNDERS'   BOOKS    ON 


Barton  and  Well^* 
Medical  Thesaurus 

A   NEW   WORK— JUST   ISSUED 


A  Thesaurus  of  Medical  Words  and  Phrases.  By  Wilfred  M. 
Barton,  A.  M.,  Assistant  to  Professor  of  Materia  Medica  and  Thera- 
peutics, and  Lecturer  on  Pharmacy,  Georgetown  University,  Washing- 
ton, D.  C. ;  and  Walter  A.  Wells,  M.  D.,  Demonstrator  of  Laryn- 
gology and  Rhinology,  Georgetown  University,  Washington,  D.  C. 
Handsome  octavo  of  about  650  pages.  Cloth,  ^0.00  net ;  Sheep  or 
Half  Morocco,  $0.00  net. 

THE   ONLY   MEDICAL  THESAURUS   EVER   PUBLISHED 

This  work  is  the  only  Medical  Thesaurus  ever  published.  It  aims  to  perform 
for  medical  literature  the  same  services  which  Roget's  work  has  done  for  literature 
in  general  ;  that  is,  instead  of,  as  an  ordinary  dictionary  does,  supplying  the 
meaning  to  given  words,  it  reverses  the  process,  and  when  the  meaning  or  idea 
is  in  the  mind,  it  endeavors  to  supply  the  fitting  term  or  phrase  to  express  that 
idea.  To  obviate  constant  reference  to  a  lexicon  to  discover  the  meaning  of 
terms,  brief  definitions  are  given  before  each  word.  As  a  dictionary  is  of  service 
to  those  who  need  assistance  in  interpreting  the  expressed  thought  of  others,  the 
Thesaurus  is  intended  to  assist  those  who  have  to  write  or  to  speak  to  give  proper 
expression  to  their  own  thoughts.  In  order  to  enhance  the  practical  application 
of  the  book  cross  references  from  one  caption  to  another  have  been  introduced, 
and  terms  inserted  under  more  than  one  caption  when  the  nature  of  the  term 
permitted.  In  the  matter  of  synonyms  of  technical  words  the  authors  have  per- 
formed for  medical  science  a  service  never  before  attempted.  Writers  and 
speakers  desiring  to  avoid  unpleasant  repetition  of  words  will  find  this  feature 
of  the  work  of  invaluable  service.  Indeed,  this  Thesaurus  of  medical  terms  and 
phrases  will  be  found  of  inestimable  value  to  all  persons  who  are  called  upon 
to  state  or  explain  any  subject  in  the  technical  language  of  medicine.  To  this 
class  belong  not  only  teachers  in  medical  colleges  and  authors  of  medical  books, 
but  also  every  member  of  the  profession  who  at  some  time  may  be  required  to 
deliver  an  address,  state  his  experience  before  a  medical  society,  contribute  to 
the  medical  press,  or  give  testimony  before  a  court  as  an  expert  witness. 


GYNECOLOGY  AND    OBSTETRICS. 


The  American 
Text-Book  of  Obstetric./* 

Second  Edition,  Thoroughly  Revised  and  Enlarged 


The  American  Text=Book  of  Obstetrics.  In  two  volumes.  Edited 
by  Richard  C.  Norris,  M.  D.  ;  Art  Editor,  Robert  L.  Dickinson,  M.D. 
Two  handsome  imperial  octavo  volumes  of  about  600  pages  each ; 
nearly  900  illustrations,  including  49  colored  and  half-tone  plates.  Per 
volume:  Cloth,  ^^3.50  net;  Sheep  or  Half  Morocco,  ^4.00  net. 

JUST   ISSUED  — IN  TWO  VOLUMES 

Since  the  appearance  of  the  first  edition  of  this  work  many  important  advances 
have  been  made  in  the  science  and  art  of  obstetrics.  The  results  of  bacteriologic 
and  of  chemicobiologic  research  as  apphed  to  the  pathology  of  midwifery  ;  the  wider 
range  of  the  surgery  of  pregnancy,  labor,  and  of  the  puerperal  period,  embrace 
new  problems  in  obstetrics.  In  this  new  edition,  therefore,  a  thorough  and  critical 
revision  was  required,  some  of  the  chapters  being  entirely  rewritten,  and  others 
brought  up  to  date  by  careful  scrutiny.  A  number  of  new  illustrations  have  been 
added,  and  some  that  appeared  in  the  first  edition  have  been  replaced  by  others 
of  greater  excellence.  By  reason  of  these  extensive  additions  the  new  edition 
has  been  presented  in  two  volumes,  in  order  to  facilitate  ease  in  handling.  The 
price,  however,  remains  unchanged. 


PERSONAL  AND   PRESS  OPINIONS 


Alex.  J.  C.  Skene.  M.  D., 

Laic  Professor  of  Gynecology,  Long  Island  College  Hospital,  Brooklyn. 
"  Permit  me  to  say  that  '  The  American  Text-Book  of  Obstetrics  '  is  the  most  magnificent 
medical  work  that  I  have  ever  seen.     I  congratulate  you  and  thank  you  for  this  superb  work, 
which  alone  is  sufficient  to  place  you  first  in  tlic  ranks  of  medical  publishers." 

Matthew  D.  Mann,  M.  D., 

Professor  of  Obstetrics  and  Gynecology  in  the  University  of  Buffalo. 

"  I  like   it  exceedingly  and  have   recommended   the  first  volume  as  a  text-book  for  our 
sophomore  class.     It  is  certainly  a  most  excellent  work.     I  know  of  none  better." 

American  Journal  of  the  Medical  Sciences 

"  As  an  authority,  as  a  book  of  reference,  as  a  'working  book'  for  the  student  or  practi- 
tioner, we  commend  it  because  we  believe  there  is  no  better." 


SAUNDERS'    BOOKS   ON 


Hirst's 
Text-Book  of  Obstetrics 

Fourth  Edition,  Thoroughly  Revised  and  Enlarged 


A  Text=Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  Handsome 
octavo,  873  pages,  with  704  illustrations,  36  of  them  in  colors.  Cloth, 
;g5.oo  net;  Sheep  or  Half  Morocco,  ;^6.oo  net. 

JUST   ISSUED 

Immediately  on  its  publication  this  work  took  its  place  as  the  leading  text-book 
on  the  subject.  Both  in  this  country  and  in  England  it  is  recognized  as  the  most 
satisfactorily  written  and  clearly  illustrated  work  on  obstetrics  in  the  language. 
The  illustrations  form  one  of  the  features  of  the  book.  These  are  numerous  and 
are  works  of  art,  most  of  them  being  original.  In  this  edition  the  book  has  been 
thoroughly  revised.  New  matter  has  been  added  to  almost  every  chapter,  notably 
those  treating  of  Diagnosis  of  Pregnancy,  the  Pathology  of  Pregnancy,  the 
Pathology  of  Labor,  and  Obstetric  Operations.  More  than  fifty  new  illustra- 
tions,  including  three  colored  plates,   have  been  introduced. 


OPINIONS  OF  THE  MEDICAL  PRESS 


British  Medical  Journal 

"  The  popularity  of  American  text-books  in  this  country  is  one  of  the  features  of  recent 
years.  The  popularity  is  probably  chiefly  due  to  the  great  superiority  of  their  illustrations 
over  those  of  the  English  text-books.  The  illustrations  in  Dr.  Hirst's  volume  are  far  more 
numerous  and  far  better  executed,  and  therefore  more  instructive,  than  those  commonly 
found  in  the  works  of  writers  on  obstetrics  in  our  own  country." 

Bulletin  of  Johns  Hopkins  Hospital 

"The  work  is  an  admirable  one  in  every  sense  of  the  word,  concisely  but  comprehensively 
written." 

The  Medical  Record,  New  York 

"The  illustrations  are  numerous  and  are  works  of  art,  many  of  them  appearing  for  the  first 
time.  The  author's  style,  though  condensed,  is  singularly  clear,  so  that  it  is  never  necessary 
to  re-read  a  sentence  in  order  to  grasp  the  meaning.  As  a  true  model  of  what  a  modern  text- 
book on  obstetrics  should  be,  we  feel  justified  in  affirming  that  Dr.  Hirst's  book  is  without  a 
rival." 


DISEASES    OF    IVOMEX. 


HirstV 
Diseases  of  Women 


A  Text=Book  of  Diseases  of  Women.  By  Barton  Cooke  Hirst, 
M.  D.,  Professor  of  Obstetrics,  University  of  Pennsylvania  ;  Gynecolo- 
gist to  the  Howard,  the  Orthopedic,  and  the  Philadelphia  Hospitals. 
Handsome  octavo  of  nearly  750  pages,  sumptuously  illustrated,  with 
entirely  original  illustrations.  Cloth,  $0.00  net;  Sheep  or  Half  Mo- 
rocco, $0.00  net. 

WITH    ENTIRELY   ORIGINAL   ILLUSTRATIONS— JUST   ISSUED 

This  new  book  of  Dr.  Hirst's  will  be  on  the  same  lines  as  his  Text-Book  of 
Obstetrics.  The  work  of  a  practical  teacher,  it  will  be  concise  and  practical. 
As  diagnosis  and  treatment  are  of  the  greatest  importance  in  considering  diseases. 
of  women,  particular  attention  has  been  devoted  to  these  divisions.  To  this  end, 
also,  the  work  has  been  magnificently  illuminated  with  a  wealth  of  illustrations,, 
for  the  most  part  original  photographs  and  water-colors  of  actual  clinical  cases 
accumulated  during  the  past  fifteen  years.  The  palliative  treatment,  as  well  as 
the  radical  operative,  is  fully  described,  enabling  the  general  practitioner  to  treat 
many  of  his  own  patients  without  referring  them  to  a  specialist.  An  important 
feature  of  the  work  is  the  thorough  manner  in  which  the  author  has  treated 
modern  technic  of  gynecic  surgery.  An  entire  section  is  devoted  to  a  full 
description  of  all  modern  gynecologic  operations,  illuminated  and  elucidated 
by  numerous  photographs  taken  especially  for  this  work.  The  author's  training 
in  the  subject  of  diseases  of  women  has  been  like  that  of  the  specialist  in  the 
Teutonic  countries  of  Europe,  where  gynecology  has  reached  the  highest  level 
of  perfection  :  namely,  specialization  in  the  diagnosis  and  treatment  of  diseases 
of  women  has  followed  a  thorough  special  training  in  the  recognition  and  treat- 
ment of  the  complications  and  sequels  of  childbirth,  wMch,  in  fact,  constitute 
the  vast  majority  of  the  diseases  of  women.  This  special  training,  together  with 
the  author's  extensive  experience,  renders  the  work  of  unusual  value,  not  only  to 
the  general  practitioner  and  student,  but  also  to  the  specialist. 


SAUNDERS'    BOOKS   ON 


GET  i^ •  THE  NEW 

THE  BEST  /\  m  6  r  1  C  Sin         standard 

Illustrated   Dictionary 

Third  Revised  Edition— Just  Issued 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surger>%  Dentistry, 
Pharmacy,  Chemistry,  and  kindred  branches;  with  over  lOO  new  and 
elaborate  tables  and  many  handsome  illustrations.  By  W.  A.  Newman 
Borland,  M.  D.,  Editor  of  "  The  American  Pocket  Medical  Diction- 
ary." Large  octavo,  nearly  8oo  pages,  bound  in  full  flexible  leather. 
Price,  ;^4.50  net ;  with  thumb  index,  $5.00  net. 

Gives  a  Mzkximum  Amount  of  Matter  in  a  Minimum  Space,  and  at  the  Lowest 

Possible  Cost 

THIRD  EDITION  IN  THREE  YEARS— 12,500  COPIES 

The  immediate  success  of  this  work  is  due  to  the  special  features  that  distin- 
guish it  from  other  books  of  its  kind.  It  gives  a  maximum  of  matter  in  a  mini- 
mum space  and  at  the  lowest  possible  cost.  Though  it  is  practically  unabridged, 
yet  by  the  use  of  thin  bible  paper  and  flexible  morocco  binding  it  is  only  i  )i 
inches  thick.  The  result  is  a  truly  luxurious  specimen  of  book-making.  In  this 
new  edition  the  book  has  been  thoroughly  revised,  and  upward  of  one  hundred 
important  new  terms  that  have  appeared  in  recent  medical  literature  have  been 
added,  thus  bringing  the  book  absolutely  up  to  date.  The  book  contains  hun- 
dreds of  terms  not  tp  be  found  in  any  other  dictionary,  over  100  original  tables, 
and  many  handsome  illustrations,  including  24  colored  plates. 


PERSONAL    OPINIONS 


Howard  A.  Kelly,  M.  D., 

Professor  of  Gynecology,  Johns  Hopkins  UniversUy,  Baltimore. 

"  Dr.  Dorland's  dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 

Roswell  Park,  M.  D., 

Professor  of  Principles  and  Practice  of  Surgery  and  of  Clinical  Surgery,  University  of 
Buffalo. 

"  I  must  acknowledge  my  astonishment  at  seeing  how  much  he  has  condensed  within  rela- 
tively small  space.  I  find  nothing  to  criticize,  very  much  to  commend,  and  was  interested  in 
finding  some  of  the  new  words  which  are  not  in  other  recent  dictionaries." 


OBSTETRICS. 


Webster's 
Text-Book  of  Obstetrics 


A  Text=Book  of  Obstetrics.  By  J.  Clarence  Webster.  M.  D., 
F.  R.  C.  P.  E.,  Professor  of  Obstetrics  and  Gynecology  in  Rush  Medical 
College,  in  Affiliation  with  the  University  of  Chicago ;  Obstetrician  and 
Gynecologist  to  the  Presbyterian  Hospital,  Chicago.  Handsome  octa\^o 
volume  of  nearly  800  pages,  with  over  400  beautiful  illustrations.  Cloth, 
$0.00  net ;  Sheep  or  Half  Morocco,  $0.00  net. 

JUST   ISSUED  —  BEAUTIFULLY   ILLUSTRATED 

This  entirely  new  work  is  written  for  the  student  of  obstetrics  as  well  as  for 
the  active  practitioner.  The  anatomic  changes  accompanying  pregnancy,  labor, 
and  the  puerperium  are  described  more  fully  and  lucidly  than  in  any  other  text- 
book on  the  subject.  The  exposition  of  these  sections  is  based  mainly  upon 
studies  of  frozen  specimens,  in  which  department  the  author  has  had  a  larger 
experience  than  any  other  worker.  Unusual  consideration  is  given  to  embryo- 
logic  and  physiologic  data  of  importance  in  their  relation  to  obstetrics,  many  of 
them  having  been  investigated  in  special  research  by  the  author.  The  practical 
aspects  of  the  subject  are  presented  in  such  a  manner  as  to  be  of  direct  assistance 
to  the  clinical  worker.  Diagnosis  is  accorded  the  prominence  due  it  from  its 
primal  importance,  and  treatment  is  presented  with  rare  exactitude  and  clearness, 
emphasis  being  given  to  those  methods  that  have  proved  successful  by  experience. 
The  illustrative  feature  of  the  work  is  far  above  the  a\erage.  (ireat  care  was 
taken  in  the  selection  of  the  illustrations,  aiming  to  meet  the  varied  requirements 
of  both  the  undergraduate  and  the  practising  physician.  Many  of  the  illustrations 
have  never  before  appeared  in  any  text-book,  having  been  made  especially  for 
this  work.  The  text  has  been  rendered  as  concise  as  possible — never,  however, 
to  the  sacrifice  of  clearness.  The  book  throughout  expresses  the  most  advanced 
thought  of  the  day,  and  its  statements  can  be  relied  upon  as  being  accurate. 


SAUNDERS'    BOOKS   ON 


Penrose's 
Diseases  of  Women 

Fourth   Revised   Edition 


A  Text=Book  of  Diseases  of  Women.  By  Charles  B.  Penrose, 
M.  D.,  Ph.  D.,  formerly  Professor  of  Gynecology  in  the  University  of 
Pennsylvania ;  Surgeon  to  the  Gynecean  Hospital,  Philadelphia.  Oc- 
tavo volume  of  539  pages,  with  221   fine  original  illustrations.     Cloth, 

$3.75  net. 

FOUR  EDITIONS  IN  AS  MANY  YEARS 

Regularly  every  year  a  new  edition  of  this  excellent  text-book  is  called  for, 
and  it  appears  to  be  in  as  great  favor  with  physicians  as  with  students.  Indeed, 
this  book  has  taken  its  place  as  the  ideal  work  for  the  general  practitioner.  The 
author  presents  the  best  teaching  of  modern  gynecology,  untrammeled  by  anti- 
quated ideas  and  methods.  In  every  case  the  most  modern  and  progressive 
technique  is  adopted,  and  the  main  points  are  made  clear  by  excellent  illustra- 
tions. The  new  edition  has  been  carefully  revised,  much  new  matter  has  been 
added,  and  a  number  of  new  original  illustrations  have  been  introduced.  In  its 
revised  form  this  volume  continues  to  be  an  admirable  exposition  of  the  present 
status  of  gynecologic  practice. 


PERSONAL   AND   PRESS  OPINIONS 


Howard  A.  Kelly.  M.  D., 

Professor  of  Gynecology  and  Obstetrics,  Johns  Hopkins  University,  Baltimore. 
"  I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  of  Women '  received.     I  have 
already  recommended  it  to  my  class  as  THE  BEST  book." 

E.  E.  Montgomery,  M,  D., 

Professor  of  Gynecology,  Jefferson  Medical  College,  Philadelphia. 
"  The  copy  of '  A  Text-Book  of  Diseases  of  Women  '  by  Penrose,  received  to-day.     I  have 
looked  over  it  and  admire  it  very  much.     I  have  no  doubt  it  will  have  a  large  sale,  as  it  justly 
merits." 

Bristol  Medico-Chirurgical  Journal 

"  This  is  an  excellent  work  which  goes  straight  to  the  mark.  .  .  .  The  book  may  be  taken 
as  a  trustworthy  exposition  of  modern  gynecology." 


GYNECOLOGY  AND    OBSTETRICS. 


Garrigues* 
Diseases  of  Women 

Third  Edition,  Thoroughly  Revised 


A  Text=Book  of  Diseases  of  Women.  By  Hexry  J.  Garrigues, 
A.  M.,  M.  D.,  Gynecologist  to  St.  Mark's  Hospital  and  to  the  German 
Dispensary,  New  York  City.  Handsome  octavo,  756  pages,  with  367 
engravings  and  colored  plates.  Cloth,  34.50  net;  Sheep  or  Half 
Morocco,  $5.50  net. 

INCLUDING  EMBRYOLOGY  AND   ANATOMY   OF  THE  GENITALIA 

The  first  two  editions  of  this  work  met  with  a  most  appreciative  reception  by 
the  medical  profession  both  in  this  country  and  abroad.  In  this  edition  the  entire 
work  has  been  carefully  and  thoroughly  revised,  and  considerable  new  matter 
added,  bringing  the  work  precisely  down  to  date.  JNIany  new  illustrations  have  been 
introduced,  thus  greatly  increasing  the  value  of  the  book  both  as  a  text-book  and 
book  of  reference.  In  fact,  the  illustrations  form  a  complete  atlas  of  the  embry- 
ology and  anatomy  of  the  female  genitalia,  besides  portraying  most  accurately 
numerous  pathologic  conditions  and  the  various  steps  in  the  gynecologic  opera- 
tions detailed.  The  work  is,  throughout,  practical,  theoretical  discussions  being 
carefully  avoided. 


PERSONAL  AND   PRESS  OPINIONS 


Thas.  A.  Reamy,  M,  D. 

Professor  of  Clinical  Gynecology,  Medical  College  of  Ohio. 
"  One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in  the 
English  language  ;    it  is  condensed,  clear,  and  comprehensive.     The  profound   learning  and 
great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a  most 
attractive  and  instructive  form." 

Bache  Emmet,  M.  D. 

Professor  of  Gynecology  in  the  Neiu  York  Post-Graduate  Medical  School. 
"  I  think  that  the  profession  at  large  owes  you  gratitude  for  having  given  to  the  medical 
world  so  valuable  a  treatise.     I  shall  certainly  put  it  forward  to  my  classes  as  one  of  the  best 
guides  with  which  I  am  familiar,  not  only  with  which  to  study,  but  for  constant  consultations." 

American  Journal  of  the  Medical  Sciences 

"  It  reflects  the  large  experience  of  tlic  author,  both  as  a  clinician  and  a  teacher,  and  com- 
prehends much  not  ordinarily  found  in  text-books  on  gynecology.  The  book  is  one  of  the 
most  complete  treatises  on  gynecology  that  we  have,  dealing  broadly  with  all  phases  of  the 
subject." 


SAUNDERS'   BOOKS    ON 


Saunders' 
American  Year-Book 


The  American  Year=Book  of  Medicine  and  Surgery  for  1903.     A 

Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  foreign  authors  and  inves- 
tigators. Arranged  with  critical  editorial  comments  by  eminent  Amer- 
ican specialists,  under  the  editorial  charge  of  George  M.  Gould,  M.  D. 
Year-Book  of  1903  in  two  volumes — Vol.  I.,  including  General  Medicine  ; 
Vol.  II.,  General  Surgery.  Per  volume:  Cloth,  ^$3.00  net;  Half  Mo- 
rocco, ^3.75  net.     Sold  by  Sztbscription. 

EQUIVALENT  TO  A  POST-GRADUATE  COURSE 

The  contents  of  these  volumes,  critically  selected  from  leading  journals,  mono- 
graphs, and  text-books,  is  much  more  than  a  compilation  of  data.  The  extracts 
are  carefully  edited  and  commented  upon  by  eminent  specialists,  the  reader  thus 
obtaining  not  only  a  yearly  digest  of  scientific  progress  and  authoritative  opinion 
in  all  branches  of  medicine  and  surgery,  but  also  the  invaluable  annotations  and 
criticisms  of  the  Editors,  all  leaders  in  their  several  specialties.  The  work,  more- 
over, is  not  lacking  in  its  illustrative  feature  ;  for,  besides  a  large  number  of 
text-cuts,  the  volumes  contain  several  full-page  plates  of  exceptional  merit. 


OPINIONS  OF  THE   MEDICAL  PRESS 


The  Lancet,  London 

"  It  is  much  more  than  a  mere  compilation  of  abstracts,  for,  as  each  section  is  entrusted  to 
experienced  and  able  contributors,  the  reader  has  the  advantage  of  certain  critical  commen- 
taries and  expositions  .   .  .  proceeding  from  writers  fully  qualified  to  perform  these  tasks." 

Boston  Medical  and  Surgical  Journal 

"  An  immense  deal  of  work  has  been  put  into  it,  and  the  editor,  seconded  by  a  large  corps 
of  competent  collaborators,  has  succeeded  in  satisfactorily  covering  the  extended  field  which 
he  has  set  himself  the  task  of  cultivating.  It  is  a  very  desirable  book  for  the  general  practi- 
tioner." 

British  Medical  Journal 

"  It  is  unrivaled  among  similar  publications  in  the  English  language." 


G  YNECOL  OG  V  AND    OBSTETRICS. 


American 
Text-Book  of  Gynecology 

Second  Edition,  Thoroughly  Revised 


American  Text=Book  of  Gynecology :  Medical  and  Surgical. 
By  lO  of  the  leading  Gynecologists  of  America.  Edited  by  J.  M. 
Baldy,  M.  D.,  Professor  of  Gynecology  in  the  Philadelphia  Polyclinic. 
Handsome  imperial  octavo  volume  of  718  pages,  with  341  illustrations 
in  the  text,  and  38  colored  and  half-tone  plates.  Cloth,  $6.00  net ; 
Sheep  or  Half  Morocco,  ^7.00  net. 

MEDICAL  AND  SURGICAL 

This  volume  is  thoroughly  practical  in  its  teachings,  and  is  intended  to  be  a 
working  text-book  for  physicians  and  students.  Many  of  the  most  important 
subjects  are  considered  from  an  entirely  new  standpoint,  and  are  grouped  together 
in  a  manner  somewhat  foreign  to  the  accepted  custom.  In  the  revised  edition 
of  this  book  much  new  material  has  been  added  and  some  of  the  old  ehminated 
or  modified.  More  than  forty  of  the  old  illustrations  have  been  replaced  by  new 
ones.  The  portions  devoted  to  plastic  work  have  been  so  greatly  improved  as 
to  be  practically  new.  Hysterectomy,  both  abdominal  and  vaginal,  has  been 
rewritten,  and  all  the  descriptions  of  operative  procedures  have  been  carefully 
revised  and  fully  illustrated. 


OPINIONS  or  THE   MEDICAL  PRESS 


The  Lancet,  London 

"  Contains  a  large  amount  of  information  upon  special  points  in  the  technique  of  gyne- 
cological operations  which  is  not  to  be  found  in  the  ordinary  text-book  of  gynecology." 

British  Medical  Journal 

"  The  nature  of  the  text  may  be  judged  from  its  authorship;  the  distinguished  authorities 
who  have  compiled  this  publication  ^lave  done  their  work  well.  This  addition  to  medical 
literature  deserves  favorable  comment." 

Boston  Medical  and  Surgical  Journal 

"  The  most  complete  exponent  of  gynecology  which  we  have.  No  subject  seems  to  have 
been  neglected  .  .  .  and  the  gynecologist  and  surgeon,  and  the  general  practitioner  who  has 
any  desire  to  practise  diseases  of  women,  will  find  it  of  practical  value.  In  the  matter  of  illus- 
trations and  plates  the  book  surpasses  anything  we  have  seen." 


SAUNDERS'    BOOKS   ON 


Dorland's 
Modern   Obstetrics 


Modern  Obstetrics:  General  and  Operative.     By  W.  A.  Newman 

Borland,  A.  M.,  M.  D.,  Assistant  Demonstrator  of  Obstetrics,  Univer- 
sity of  Pennsylvania ;  Associate  in  Gynecology  in  the  Philadelphia 
Polyclinic.  Handsome  octavo  volume  of  797  pages,  with  201  illustra- 
tions.    Cloth,  ^4.00  net. 

Second  Edition,  Revised  and  Greatly  Enlarged 

In  this  edition  the  book  has  been  entirely  rewritten  and  very  greatly  enlarged. 
Among  the  new  subjects  introduced  are  the  surgical  treatment  of  puerperal  sepsis, 
infant  mortality,  placental  transmission  of  diseases,  serum-therapy  of  puerperal 
sepsis,  etc.  By  new  illustrations  the  text  has  been  elucidated,  and  the  subject  pre- 
sented in  a  most  instructive  and  acceptable  form. 

Journal  of  the  American  Medical  Association 

"  This  work  deserves  commendation,  and  tliat  it  has  received  what  it  deserves  at  the  hands 
of  the  profession  is  attested  by  the  fact  that  a  second  edition  is  called  for  within  such  a  short 
time.     Especially  deserving  of  praise  is  the  chapter  on  puerperal  sepsis." 

Davis*  Obstetric  and 
Gynecologic  Nursing 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.  M., 
M.  D.,  Professor  of  Obstetrics  in  the  Jefferson  Medical  College  and 
Philadelphia  Polyclinic ;  Obstetrician  and  Gynecologist,  Philadelphia 
Hospital.      i2mo   of  400  pages,  illustrated.     Buckram,  $1.75   net. 

This  volume  is  designed  for  the  obstetric  and  gynecologic  nurse.  Obstetric 
nursing  demands  some  knowledge  of  natural  pregnancy  and  of  the  signs  of 
accidents  and  diseases  which  may  occur  during  pregnancy.  It  also  requires 
knowledge  and  experience  in  the  care  of  the  patient  and  child.  Gynecologic 
nursing  is  really  a  branch  of  surgical  nursing>  and  as  such  requires  special 
instruction  and  training.  This  volume  presents  this  information  in  the  most  con- 
venient form. 

The  Lancet,  London 

"  Not  only  nurses,  but  even  newly  qualified  medical  men,  would  learn  a  great  deal  by  a 
perusal  of  this  book.  It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can  recom- 
mend." 


GYNECOLOGY  AND    OBSTETRICS. 


Schaffer  and  Edg^ar's 

I^abor  and  Operative  Obstetrics 

Atlas  and  Epitome  of  Labor  and  Operative  Obstetrics.     Bv  Dr. 

O.  Schaffer,  of  Heidelberg.  From  the  Fifth  Revised  and  Enlarged 
Gcrr,ian  Edition.  Edited,  with  additions,  by  J.  Clifton  Edgar,  M.  D., 
Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medi- 
cal School,  New  York.  With  14  lithographic  plates  in  colors,  139  other 
illustrations,  and  1 1 1  pages  of  text.  Cloth,  ^2.00  net.  In  Saunders' 
Hand-Atlas  Series. 

This  book  presents  the  act  of  parturition  and  the  various  obstetric  operations 
in  a  series  of  easily  understood  illustrations,  accompanied  by  a  text  treating  the 
subject  from  a  practical  standpoint.  The  author  has  added  many  accurate  repre- 
sentations of  manipulations  and  conditions  never  before  clearly  illustrated. 

American  Medicine 

"  The  method  of  presenting  obstetric  operations  is  admirable.  The  drawings,  representing 
original  work,  have  the  commendable  merit  of  illustrating  instead  of  confusing.  It  would  be 
difficult  to  find  one  hundred  pages  in  better  form  or  containing  more  practical  points  for 
students  or  practitioners." 

Schaffer  and  Edgar's 

Obstetric  Diagnosis  and  Treatment 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and  Treatment.     By 

Dr.  O.  Schaffer,  of  Heidelberg.  From  the  Second  Revised  Gernian 
Edition.  Edited,  with  additions,  by  J.  Clifton  Edgar,  M.  D.,  Professor 
of  Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medical  School, 
N.  Y.  With  122  colored  figures  on  56  plates,  38  text-cuts,  and  315 
pages  of  text.     Cloth,  $3.00  net.     ///  Sannders'  Hand-Atlas  Series. 

This  book  treats  particularly  of  obstetric  operations,  and,  besides  the  wealth 
of  beautiful  lithographic  illustrations,  contains  an  extensive  text  of  great  value. 
This  text  deals  with  the  practical,  clinical  side  of  the  subject.  The  symptoma- 
tology and  diagnosis  are  discussed  with  all  necessary  fullness,  and  the  indications 
for  treatment  are  definite  and  complete. 

New  York  Medical  Journal 

"The  illustrations  are  admirably  executed,  as  they  are  in  all  of  these  atlases,  and  the  text 
can  safely  be  commended,  not  only  as  elucidatory  of  the  plates,  but  as  expounding  the  scien- 
tific midwifery  of  to-day." 


14  SAUNDERS'   BOOKS   ON 

Schaffer  and  Norris* 
Gynecology 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Schaffer,  of 
Heidelberg.  From  the  Second  Revised  and  Enlarged  German  Edition. 
Edited,  with  additions,  by  Richard  C.  Norris,  A.  M.,  M.  D.,  Gynecolo- 
gist to  Methodist  Episcopal  and  Philadelphia  Hospitals.  With  207 
colored  figures  on  90  plates,  65  text-cuts,  and  308  pages  of  text. 
Cloth,  ;$3.50  net.     In  Saunders'  Hand-Atlas  Series. 

The  value  of  this  atlas  to  the  medical  student  and  to  the  general  practitioner 
will  be  found  not  only  in  the  concise  explanatory  text,  but  especially  in  the  illus- 
trations. The  large  number  of  colored  plates,  reproducing  the  appearance  of 
fresh  specimens,  give  an  accurate  mental  picture  and  a  knowledge  of  the  changes 
induced  by  disease  of  the  pelvic  organs  that  cannot  be  obtained  from  mere 
description. 

American  Journal  of  the  Medical  Sciences 

"  Of  the  illustrations  it  is  difficult  to  speak  in  too  high  terms  of  approval.  They  are  so 
clear  and  true  to  nature  that  the  accompanying  explanations  are  almost  superfluous.  We 
commend  it  most  earnestly." 

Galbraith's 
Four  Epochs  of  Woman's  Life 

Second  Revised  Edition — Just  Issued 

The  Four  Epochs  of  Woman's  Life :  A  Study  in  Hygiene.  By 
Anna  M.  Galbraith,  M.  D.,  Fellow  of  the  New  York  Academy  of 
Medicine,  etc.  With  an  Introductory  Note  by  John  H.  Musser, 
M.  D.,  Profe.s.sor  of  Clinical  Medicine,  University  of  Pennsylvania. 
1 2mo  of  200  pages.     Cloth,  ^0.00  net. 

MAIDENHOOD.    MARRIAGE.    MATERNITY,    MENOPAUSE 

In  this  instructive  work  are  stated,  in  a  modest,  pleasing,  and  conclusive  manner, 
those  truths  of  which  every  woman  should  have  a  thorough  knowledge.  Written, 
as  it  is,  for  the  laity,  the  subject  is  discussed  in  language  readily  grasped  even  by 
those  most  unfamiliar  with  medical  subjects. 

Birmingham  Medical  Review,  England 

"  We  do  not  as  a  rule  care  for  medical  books  written  for  the  instruction  of  the  ]:)ublic.  But 
we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is  in  the  main  wise  and  wholesome." 


GYNECOLOGY  AND    OBSTETRICS.  15 

American  Pocket  Dictionary  '^^"I'usutue'd''''*'" 

The  American  Pocket  Medical  Dictionary.  Edited  by  W. 
A.  Newman  Borland,  A.  M.,  M.  D.,  Assistant  Obstetrician  to  the 
Hospital  of  the  University  of  Pennsylvania ;  Fellow  of  the  American 
Academy  of  Medicine.  Over  500  pages.  Full  leather,  limp,  with 
gold  edges.     $1.00  net;  with  patent  thumb  index,  Si.25  net. 

James  W.  Holland.  M.D.. 

Professor  of  Medical  Chemistry  and  Toxicology,  and  Dean,  Jefferson  Medical  College, 

Philadelphia. 
"  I  am  struck  at  once  with  admiration  at  the   compact  size  and  attractive   exterior.     I 
can  recommend  it  to  our  students  without  reserve." 

Long's  Syllabus  of  Gynecolo^ 

A  Syllabus  of  Gynecology,  arranged  in  conformity  with 
"American  Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D., 
Emeritus  Professor  of  Diseases  of  Women  and  Children,  Medical 
College  of  Virginia,  etc.     Cloth,  interleaved,  31.00  net. 

Brooklyn  Medical  Journal 

,  "  The  book  is  certainly  an  admirable  resume  of  what  every  gynecological  student  and 

practitioner  should  know,  and  will  prove  of  value." 

Crag»in*s  Gynecology.  Fifth  Revised  Edition 

Essentials  of  Gynecology.  By  Edwin  B.  Cragin,  ^I.  D., 
Professor  of  Obstetrics,  College  of  Physicians  and  Surgeons,  New 
York.  Crown  octavo,  200  pages,  62  illustrations.  Cloth,  $1.00 
net.     lii  Saunders'   Question- Conipoid  Scries. 

The  Medical  Record,  New  York 

"  A  handy  volume  and  a  distinct  improvement  on  students'  compends  in  general. 
No  author  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the 
student's  needs  so  thoroughly  as  Dr.  Cragin  has  done." 

Boisliniere's   Obstetric   Accidents,   Emergencies,   and 
Operations 

Obstetric  Accidents,  Emergencies,  and  Oper.\tions.  By 
the  late  L.  Ch.  Boisliniere,  M.  D.,  Emeritus  Professor  of  Ob- 
stetrics, St.  Louis  Medical  College  ;  Consulting  Physician.  St.  Louis 
Female  Hospital.      381  pages,  illustrated.     Cloth,  $2.00  net. 

British  Medical  Jotimal 

'■  It  is  clearly  and  concisely  written,  and  is  evidently  the  work  of  a  teacher  and  practi- 
tioner of  large  experience.    Its  merit  lies  in  the  judgment  which  comes  from  experience." 

AshtOn*S    Obstetrics.  Fifth  Edition,  Revised  and  Enlarged 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.D., 
Professor  of  Gynecology  in  the  Medico-Chirurgical  College,  Phila- 
delphia. Crown  octavo,  252  pages,  75  illustrations.  Cloth,  $1.00 
net.     In  Saunders"  Qnestion-Conipcnd  Series. 

Southern  Practitioner 

"  .\n  excellent  little  volume  containing  correct  and  practical  knowledge.  An  admir- 
able compend,  and  the  best  condensation  we  have  seen." 


RD31  D11  1903  C.1 

'  ■  ,,  :■'•■('  rmprativP 


2002144336 


>  - 


Mm 

'/Aw 
.■.■■/M'M 


/Awv 


■i  -i 
i  i 


